NATIONAL LIBRARY OF MEDICINE
Washington
Founded 1836
U. S. Department of Health, Education, and Welfare
             Public Health Service 
 
 
u>
SYSTEM  OF SURGERY.
            BY
      J. M. CHELIUS.
   TRANSLATED FROM THE GERMAN

       JOHN F. SOUTH.
VOL. III. 
 
                              A
                                                           *

SYSTEM   OF    SURGERY,
BY
            J.  M.  CHELIUS,

DOCTOR IN MEDICINE AND SURGERY, FUDLIC PROFESSOR OF GENERAL AND OPHTHALMIC
      SCRGERY^ DIRECTOR OF THE CHIRURGICAL AND OPHTHALMIC CLINIC
              IN THE UNIVERSITY OF HEIDELBERG,
                     &C. &C. &C.
TRANSLATED FROM  THE GERMAN,
                              AND


ACCOMPANIED WITH ADDITIONAL NOTES AND OBSERVATIONS,
BY
         JOHN  P.  SOUTH,

LATE PROFBSSOR OF SURGERY TO THE ROYAL COLLEGE OF SURGEONS OF ENGLAND,
       AND ONE OF THE SURGEONS TO ST. THOMAS'S HOSPITAL.
IN THREE VOLUMES.
       PHILADELPHIA;
LEA   &  B.L AN CHARD,
1847, 
Entered according to the Act of Congress, in the year 1847, by Lea & Blanchard, in
     the Clerk's Office of the District Court of the Eastern District of Pennsylvania.


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                             /  a 4-•)<>.

                            v.  2>
Griggs & Co., Printers. 
THIRD  DIVISION.
DISEASES DEPENDENT ON UNNATURAL COHERENCE.
    First Section—ON UNNATURAL COHERENCE IN GENERAL.

   1550.  The unnatural coherence of organic parts consists either in the
union of neighbouring parts, which naturally are distinct;  or in the for-
mation of bad scars which diminish or destroy the  movements  of parts,
by preventing their extensibility; or in  a narrowing or closing of their
outlets, by which their functions are considerably disturbed or  rendered
quite  impossible.  They are specially either consequences of  previous
inflammation, or vices of the original formation and congenital.
   1551.  In  order that parts, which in  their natural state  are distinct,
should unite together, a proper degree of inflammation, destruction of the
skin, and long continued close contact are required.  The union is either
immediate, by means  of a scarcely perceptible, interposed layer  of plastic
lymph, into which the vessels shoot; or it  is fleshy, and depending on
the development of granulations, and the formation of an intermediate
substance, oftentimes having perfect resemblance to the parts it connects;
or the connecting interposed  matter is  fibrous, membranous, in which
case it would seem that there  had  been  previously a more intimate  con-
nexion, which, in consequence of the movements of the connected organs,
had formed these membranous lengthenings.  For example, in the band-
like adhesions between the peritonceum and the surface  of the intestines,
between  the  pulmonary and costal pleura.   All organs are, under the
above-mentioned conditions, capable of union;  the serous structures and
synovial  membranes  are most prone to it, the mucous  membranes  least
so, and only when their surface is destroyed, and the  underlying cellular
tissue laid bare.
   1552. When in a wound  accompanied with loss of substance, especially
in a severe burn, the treatment has not been conducted with due  care, and
the parts kept in proper position, the edges of the skin either greatly contract
towards the centre, and a tough cord-like scar often connected with the
underlying parts, or  a superficial, prominent, knotty, misshapen scar is
produced.  In consequence of this the  position and movements of the
part are in various ways damaged or completely destroyed, or  great de-
formity is produced.   It must not however be forgotten,*that in  long
continued unnatural position of a  part,  consequent on  a scar formed in
one of these ways, secondary  contraction of the muscles, and alterations
in the joints may be produced, by  which the movements are still farther
restricted; and this condition may even become incurable.
   1553.  All  the outlets  are  peculiarly  constituted.   They are either
furnished with a true muscular apparatus, or at least are endowed  with
a special contractility, upon which their alternate expansion and  con-
traction depend.  Their inner surface is always overspread with mucous
  Vol. hi.—2 
14
UNNATURAL COHERENCE
  membrane, in  consequence of which  they  can, exclusive of the cases
  from compression by neighbouring swellings and the like, be narrowed
  or closed in a variety of ways: thus, first, by spasmodic  contraction,
  sometimes transient, sometimes continued ; second, by hypertrophy, thick-
  ening and swelling  of  the parenchyma of the  mucous  tissue lining the
  outlet, consequent on previous inflammation, and on an unnatural vege-
  tative process; third, by actual growing together, when for instance the
  mucous membrane of the outlet is destroyed;  and, fourth, by scars which
  form at the edge of the outlet, or in its neighbourhood.
    1554. The congenital  closure of outlets, {Atresia, Imperforatio,) as
  well as the congenilal  union  of parts, which should be  separate Irom
  each other, {Synechia,)  are arrested formations, in which the foetus, at  an
  early stage of its development, remains  stationary, when the openings
  and  clefts on the outer surface of the  body do not yet exist, and parts
  which at a later period  become separate, are still united together.  The
  skin' originally overspreads  the whole  surface of the  body, and  has on
  the parts where it closes the openings and clefts, the same character as
  elsewhere;  it  thins  gradually,  appears then  as  a  peculiar secreting
  membrane, and is lastly removed by the  process of absorption.   As the
 Mresice are  in  the earlier stages of development of  the  foetus, natural
 formations, so also are  the Synechice; for instance, union  of the eyelids
 with each other and  with  the eyeball; the  union of the tongue, of the
 glans penis with the prepuce, and the like.
    1555.  If  the closure  of the outlets be a  vicious  primary formation,
 either the organization of the outlet is natural, and its opening only closed
 by a mere skin, though sometimes by a tough fleshy mass, or no  trace of
 an outlet can be perceived externally.  When the congenital closure  of
. an outlet by which matters pass exists, it shows itself soon after birth, as
 in closure of the anus, urethra, and the like ; but if it occur in those which
 only at a  later  period assume the peculiar condition  of outlets,  as, for
 example, the vagina, the closure is generally then first observable.
    1556.  The treatment of union of parts, which in the natural state are
 free and  moveable, requires division with the  knife, together with the
 prevention of reunion,  and all contact  of the divided parts, by careful
 insertion  of  folds  of linen, or lint besmeared with mild, and afterwards
 with drying ointments.   The parts must also at the same time be  kept in
 proper position, and during the period of granulation  prevented  by  due
 application of caustic, from coining to that state in which they can again
 unite from the angle of the division ; for which purpose, usually, pressure
 properly employed, is most efficient.
    1557. In shapeless scars, which, by contracting parts, interfere with
 their position and movement, only in rare  cases can any considerable
 relaxation be effected by the continued use of softening ointments, baths
 and  the like; usually,  by  operation alone can improvement or  perfect
 cure be effected ;  the management of which is different according to the
 condition and seat of the scar.   If the  scar  be  cord-like, tense, and by
 its shortness destroy motion, several transverse cuts may be made throu£>h
 its whole mass, and afterwards an apparatus  put on, by which the parts
 shall be retained in natural posture, so that the formation of a broad scar
 may be effected.  When the scar is broad, or united with the underlying 
IN GENERAL.                        15
parts, so however that its release is possible without injury to important
parts, it must be cut out.   The scar must be included between two cuts,
and separated by careful dissection from the parts beneath, or the cellu-
lar membrane.   If the skin in the neighbourhood of the wound be yield-
ing, the edges of the wound, if it be not of very great extent, must be
set free so far, that they may be united with the interrupted, or with the
twisted suture.  Although the edges of the wound«be thus much stretched,
and the skin also in the subsequent healing be still so, yet in a short time
it yields, and all deformity disappears.   When, as is commonly the case,
this union is impossible, the wound must be treated as one suppurating,
and retained by a proper apparatus in its straight posture.   For the pur-
pose of making the scar sufficiently broad, frequent touching with lunar
caustic must be  resorted to.   I have, however, always found that, in
consequence, correspondent condition  of  the  scar is produced, that is,
the tough, knotty projection can be prevented; but the special contrac-
tion of the edges of the skin towards the  centre is encouraged.  In all
cases,  therefore, in which I wish to form a broad scar, I only cover the
suppurating parts with softening poultices or washes, and  but rarely use
caustic.   When  the  scarring goes on- tediously, there is always least
disposition to contract, and the easier is it to produce a broad scar.  If
the scar  project in knots and  thereby be disfiguring, it  must either be
removed with the knife held flat, from its base, and the wound healed
up  in the usual wTay; or it must be cut completely out, and treated ac-
cording to circumstances, after the above-mentioned rules.
  On the different modes of treating deformed scars, compare
  Beck ; in Heidelb. klinisch. Annalen, vol. v. p. 213.
  Dupuytren; in his Lecons Orales de Clinique Chirurg., vol. ii. p. 1.
   1558.  The narrowing and closure of the outlets require, according to
their several causes, a different treatment.  In  spasmodic contraction,
both local and general, corresponding  antispasmodic remedies  must be
employed.  If the narrowing  result from  an organic change of the
mucous membrane, it must be specially ascertained whether, and what
is the cause of the inflammation, which must be met with corresponding
treatment.  Should this,  however, not  be  sufficient to get rid of the nar-
rowing, the employment of mechanical means, which gradually  widen
the outlet, is required; or the removal of the hardened part of the mucous
membrane must be attempted with the knife, with caustic, and  the like.
In these various modes of treatment, it must always be remembered, that
should the natural calibre of the outlet be restored, the  mucous  mem-
brane has always a peculiar disposition to reproduce tue narrowing.
   1559.  The cure of imperforation is more or less difficult, in proportion
as the  seat of the closure  is more or less deep, and depends on a mem-
brane, or a fleshy mass.   The closed  part must  be cut into, and  its
reunion prevented by the introduction of mechanical bodies.   In closure
of an outlet by membrane, if the  latter be thrust down, in  a flask-like
form, by the collection of the excreted  matters, the division is easy, and
the skin  must be divided with a crucial cut.   But if the union be inti-
mate and  fleshy, the division is more difficult, and so much more so, in
proportion to the greatness of its extent; it must always be made  in the
middle line of the union.  If there be scarce  any trace of the  external
opening of the outlet, the  cut must be made in the direction in which it
should open, and  the  outlet there sought for. 
[   16   ]
Second Section—OF UNNATURAL COHERENCE  IN PARTICULAR.
    I.—OF THE UNION OF THE FINGERS AND OF THE TOES.

  Earle, Henry, On Contractions after Burns or  extensive Ulcerations; in Med.
Chir. Trans., vol. v.
  ----Further Observations on Contractions succeeding to ulceration of the Skin,
in Med. Chir. Trans., vol. vii.
  Beck, K. J., Ueber die angeborne Verwachsungder Finger.  Freiburg, 1819. 8vo.
  Seerig, Ueber die angeborne Verwachsung der Finger und Zehen, und Ueberzahl
derselben.  Breslau.  4to; with two lithographed plates.
   1560. The union of  the fingers with each other has different degrees
of intensity  and extent, and is  either congenital or accidental, especially
after burning the fingers.  The congenital union arises, first, from bridges
of skin ; second, from connexions of skin and flesh ; and, third, from run-
ning together of bone.   The first kind  of union is  the most frequent.
The natural formation of the finger may also  be variously degenerated in
these unions.
   1561. The single mode  of getting rid  of these deformities consists, in
dividing the union, which  is alone contra-indicated, when the soft parts
of the hand are grown together in an unshapely mass (1), and the bones
of the fingers so run  together, that there is  scarcely  any connexion by
joints;  Diseased  condition  of the  skinny  covering of the ill-formed
hand, a highly scrofulous condition of the constitution, still existing in-
flammation, or  great plastic activity, and  the age of the party, may render
the delay of an  operation requisite.   The time generally considered most
suitable for operation, is the  end  of the first year of the child's life, and
beyond that time, except for very special  reasons, it  should not be de-
ferred.   The fact, however, that even  after the operation-wound has
been perfectly healed, the fingers will again grow together, which depends
partly on the deficiency of the skin, and its production not corresponding
with the formation and growth of the finger, partly on the incompletely
divided union stretching on with the  enlargement of the finger  is of the
greatest  importance,  and must, if the union of growth do not prevent
seem most  properly to put off the operation, till the complete develop-
ment of the finger {a).  The painfulness of the operation, as well as the
ensuing inflammatory reaction, depend on the degree  and extent of the
union, on which account only  one hand should be operated on at  once
and the other at a more distant time.
  (1)  In a case in which the hands of a child presented only two lumps of flesh with
a single undivided nail, five moveable fingers were made, by cutting through the
common cartilaginous mass {b).                                     s
   1562. The result of the  operation is often  unsatisfactory, as reunion of
the divided parts will occur, under the most careful treatment.   This is
to be  especially feared  at  that period when the  granulations rise from
the hinder  angle of the wound,  and  the  edges of the wound  draw
together from both sides.  To prevent this,  various modes of operation
have been proposed.
(a) Seerig, above cited.       (6) Leroux ; Journal de Med., vol. xiv. p. 275 
TREATMENT OF UNITED FINGERS.
17
   1563. In a simple, merely skinny union, after properly fixing the hand,
a pointed bistoury is thrust, either with its edge towards the operator,
somewhat above the angle of  the  natural junction of the fingers, verti-
cally, through the connecting skin, and then divides it in the mesial line
to the finger-tips; or the knife is  carried from the points of the fingers
backwards through the connexion.  The  irregularities of the edges of
the wound are to be trimmed with  the scissors.   If the bones  be  also
connected, the  soft parts  must be first divided with the bistoury, and
afterwards the bony union, through the mesial line, with a little watch-
spring saw.   The dressings must be  most carefully applied: a strip of
linen, spread, at its ends only, with adhesive plaster, must be placed in
the angle of the wound, and the two ends respectively fixed on the  front
and back of the hand.  Over this a small long pad is placed, the surface
of the wound covered with some  folds of  linen, spread with ointment,
each several finger enveloped in a bandage, and the finger, by means of
a piece of card-board or wood attached to  the hand, kept as straight as
possible ; this may also be  effected by particular contrivances (a).  The
dressing should be daily  and very cautiously  renewed once or under
particular circumstances even twice, with strips of linen laid close in the
angle of the wound;  and towards the end of  the cure, by a moderate
application of caustic, the growth of the granulations there must be
repressed.
  Dupuytren (&) applied a narrow long pad with its middle on the angle of the
wound, carried with its ends to the fore-arm, and fastened  them to an arm-bandage.
He could not, however, by these means prevent the reunion.  And he did not suc-
ceed any better with'a narrow strap which he buckled to the arm-bandage.
   1564. To prevent the reunion of the angle of the wound, which espe-
cially in firm  union, is to  be  dreaded, Rudtorffeb, (c) thrusts a  steel
needle fourteen lines in length, the point  of which  is lancet-shaped, and
its other  end having  a hole, for  the  reception of a leaden thread two
inches long, vertically between the two  united fingers, and thus intro-
ducing the leaden thread, bends and leaves it there.  Cold water checks
the bleeding and pain, and the sticking of the leaden thread is diminished
by smearing the edges of the wound with oil.  The  thread is to be fre-
quently moved, and the drying up and scarring hastened by use of  lead
wash.   Beck {d) uses a lancet-needle ten lines broad with a leaden thread
of equal width,  w7hich is left for some  time, till the scarring of the edges
of the wound.   The leaden thread has  a decided preference to the leaden
plate, as by fixing its turned ends, pressure is always kept up against the
angle of the wound, for with the leaden plate, with which this cannot be
done, the  growth at the angle of the wound goes  on, and the lead is
thrust out, as I  saw in one  instance.
   1565. If the skin upon  the back of the united fingers be sound and
natural, it should be divided, according to Zeller(c), a little beyond the

  (a) Zang ; Darstellung, u. s. w., vol. iv. pi. Theil der Wundarzneikunst sich bezienden
iii.                                 Beobachtungen, vol. ii. p. 478.
  (6) Legons Orales, vol. ii. p. 36.           (d) Above cited.
  (c) Abhandlung ilber die einfachste und   (e) Abhandlung fiber die ersten Erschein-
sicherste Operationsmethode ein gesperrter ungen venerischer Local-krankheitsformen,
Leisten und Schenkelbruche; nebst einem p. 109. Wien, 1810.
Anhange merkwurdiger, auf den operativen 
18
GROWING TOGETHER
second phalanx ; a V-shaped cut should then be made in the skin on the
dorsal surface, with its point on the middle of the connecting substance.
The skin  should be  detached, turned  back, and, after  the  complete
division of the union, this flap should be  carried down between  the
fingers towards the palm, and fixed with  sticking plaster.   This  treat-
ment is rarely  possible,  as  the skin is most commonly  hard, callous,
morbidly changed, and the  flap commonly dies (a).   Krimber {b) has,
however, given some  satisfactory reports of this  operation.
   1566. If the reunion of the  fingers cannot be prevented, the  operation
mustjDe repeated, but the inflammatory reaction and plastic activity must
have completely subsided.
II.—OF  GROWING  TOGETHER OF THE JOINT  ENDS OF BONES,
                        OR ANCHYLOSIS (c).

  Muller, Diss, de Anchylosi.  Lugd. Batav., 1707.
  Van Doeveren, Diss, de Anchylosi.  Lugd. Batav., 1783.
  Murray, Diss, de Anchylosi.  Upsal, 1787.
  Delpech, Precis Elementaire, vol. i.
  Barton, On the Treatment of Anchylosis, etc.  Philadelphia, 1827.
  Lacroix, De l'Anchylose ; in Annales de l'Anatomie et de la Physiologie patholo-
giques, publ. par Pigne, 1843.

  1567. Every intimate  union of two bones, which  naturally are  con-
nected together in a joint, produces complete loss of motion in the joint
{Anchylosis, Lat. ;  Gelenksteifigheit, Germ.; Ankylose, Fr.)

  Anchylosis is commonly divided into true and false.   Under the former, is com-
prehended the loss of motion in a joint, depending on the union of the Joint-surfaces;
under  the latter, that condition, in which the movements of the joint are only  more
or less interfered with, as  is observed in long-continued  inflammation of joints, in
swellings of the ligaments, in tumours near the joints, in continued contraction of
the muscles, and the like.   This division is, to a certain extent, incorrect and objec-
tionable, because, in the so-called false anchylosis, the hindrance of motion  is only
to be considered as  a symptom of the disease, towards the removal of which the
plan of treatment must be directed, and the union of the joint-ends of the bones is
alone to be considered as the actual disease.

  1568. The growing  together of the joint-surfaces may be produced in
various  ways.   It is usually  consequent on  inflammation  of the parts
composing the joint, especially when of some standing,  and when the
joint  has been long at  rest.  If the inflammation go  on to suppuration
and the  cartilaginous surfaces be destroyed, if there be carious destruc-
tion  of  the bones, granulations may form, which, by shooting into  each
other, may become the means of union.   Long-continued immobility of
a joint may also  cause  an union of the  surfaces.   Although this is  very
rare,  and may be readily distinguished, from the restrained motion which
is consequent on habitual contraction of the muscles,  on swelling of the
ligaments and the like, observed after dislocation, and after the treatment

  (a) Walther, Ph. F., Ueber  die  ange-    (c) All the additions which seemed  to m
bornen Fetthautgeschwiilste, p. 32.  Land-   necessary, have been already made at d 2fi7G
schut, 1814, fol.                        vol.  i., in treating of Anchylosis as a termi'
  (b) Graefe und Walther's Journal, vol.   nation of joint disease.—j. f. s.
xiii. p. 602. 
OF THE  ENDS OF BONES.
19
of fractures, and may be got rid of by motion, softening rubbings, and so
on, it is,  however indisputable ; although the ordinary explanation given
of it, from want of  synovia, or comparison of it with the obliteration of
blood vessels,  when the circulation is suppressed, is insufficient (a).
  1569.  According to the sort of union of the joint-surfaces produced,
and its duration, is the nature  of the connecting substance.  It is either
soft and  yielding, frequently lengthening into ligament-like bands, or it is
converted  into an actual bony mass  by the deposition of phosphate of
lime.
  1570.  The treatment of anchylosis must be determined by the follow-
ing circumstances.   In most cases where anchylosis takes place, it is a
desirable result, for example, in caries of joints, the so-called white
swelling, and the like; and it should by no means be sought  to prevent
it, for all the attempts made with that object will only increase the in-
flammation, and the danger of  the anchylosis.  In such cases there-
fore, the joint must  be kept in the most perfect rest, and in such position,
that the  anchylosis  ensuing will be most convenient and  advantageous.
Subsequently,  when  the   inflammatory  symptoms  have  disappeared,
three conditions are possible; the substance connecting the joint-surfaces
is either yielding, and by continued and gradually increased movements
of the joint, may be lengthened into ligament-like bands,  or  these  mo-
tions may  reproduce the inflammatory symptoms, or they may be very
difficult  and become every day more and more confined.  In the first
case the movements are always accompanied  with  pain, which  must
be got rid of by emollient and  soothing applications, rubbing in, bathing,
and the  like, and motion not carried to such extent as would produce
fresh inflammation  of the joint.   In the second case,  all motion  must
be  avoided; and in  the third, no effort can be in the least  useful, because
the mass has been already more or less converted into bone.
  J. Rhea Barton (6) sawed through the thigh-bone at the trochanter, in a case of
anchylosis at the hip-joint, brought the limb into proper position, and by motion pre-
vented union.  He also employs this practice on other joints.   It is only practicable
when the patient is in  good health, and when the stiffness depends on the soldering
together of the bones, the soft parts at the same time being unaffected with disease,
and all the muscles and tendons which contribute to the  motions of the joint healthy;
when the cause of the  disease is entirely removed ; when the operation can be per-
formed so close to the  original  point of motion, or  so near to it that the functions of
the greater number of  muscles  and tendons can be preserved; and when the defor-
mity and  inconvenience is so great, that the patient is induced to subject himself to
the pain and danger of such an operation,   von Wattmann has obtained a favoura-
ble result by sawing through the upper-arm bone in anchylosis of the elbow joint.
Dief enbach (c) believes that the separation of the united joint by means of the
chisel and saw, would  not be more hurtful than the above-mentioned sawing through
of the bone, to form an artificial joint, inasmuch as the anchylosed joint is no longer
a joint, and therefore wounding it is not to be so much  dreaded.
   1571. The slighter degrees of the so-called false anchylosis depending
on  contraction of the  muscles or ligaments, or  on  contracting scars,
may be  completely  moved by rubbing in suppling ointments,  by relax-
ing baths,  steam and the like, with the simultaneous use of apparatus

  (a) Delpech ; above cited, p. 611.        American  Med. and Surg. Journal, vol. iii.
  (6) On the Treatment of Anchylosis by  p. 279. 1827.
the  Formation of Artificial Joints; in North    (c) Ueber die Durchschneidung der Schnen
                                    und Muskeln, p. 249. 
20               GROWING TOGETHER OF BONES,
 (1), which gradually straightens the joint.   In  the  more  severe forms
 of contraction little or nothing is effected  in this way; in such cases
 violent and sudden extension; gradual extension  with an apparatus,
 the tendons having been previously divided;  or, sudden and violent ex-
 tension soon after  cutting through the tendons, have  been proposed and
 practised.   The first mode of treatment (Louvrier's)  is  objectionable
 (2); the extension, by apparatus, after division of the tendons is gene-
 rally tedious,  must be very long continued, often produces considerable
 pain, and frequently meets with invincible  obstacles; with it, however,
 no dangerous symptoms are to be feared.  The violent extension after
 division of the tendons will  considerably shorten the cure (Dieffenbach.)
 This mode of treatment especially applies  to the false anchylosis of the
 knee; it may, however, be employed in other joints.
   (1) Of the various apparatus for extending the knee-joint (Stromeyer, Duval,
 Bouvier, and others) I think Stretter's the  most preferable.
   (2) According to Beraro, (a) of twenty-two cases of false anchylosis, treated by
 Louvrier's method, three were fatal, on account of the severity of the violence; in
 neither was a well-formed joint produced;  in the greater number there was disloca-
 tion of the knee  backwards, and always renewed though slight contraction.
   1572. In contractions of the knee-joint  the  patient is laid  on his
 belly, that the crooked knee may project beyond the edge of the table.
 The tendons,  having been  rendered  very tort by violently pulling  the
 leg,  are cut through beneath  the skin and  the limb bent so strongly
 that the heel shall  touch the buttock.  It is then again forcibly extend-
 ed, and again flexed, and  this backward and forward motion  is con-
 tinued till the limb is straightened.  Sometimes there is a loud crack,
 from the false connections  being thus torn  through.   In grown persons
 it  often requires the united  strength of three  or four men,  to break the
 knee-joint perfectly straight.  Even  in  a case of true anchylosis, con-
 sequent on a penetrating wound of the joint, and its resulting suppura-
 tion,  the breaking through of the united knee-joint, and  the straight-
 ening of the limb,  is required (Dieffenbach.)  Immediately after the
 extension of the limb is effected, the knee-joint should be covered with
 pads, enveloped in  a flannel roller,  laid upon a  padded hollow  splint,
 and  the splint  and  limb fastened together with a second flannel bandage.
 On reapplying the apparatus,  the limb must be carefully cleansed, and
 in  replacing it, much local  pressure must be  avoided, or slough  of the
 skin will quickly ensue.   After completion of the cure, the straight stiff
joint  must be carefully bathed and rubbed  with suet.   In  manv in-
 stances, if  the joint again  become flexible, the  patient may be able to
 walk without  halting (Dieffenbach.)
   1573. Very severe symptoms may result from this violent extension
 of the limb, great  inflammation, with its consequences may ensue, so
 as to render amputation necessary, and may  even cause death.   These
 emergencies, as well as the more or less favourable result of the opera-
 tion rests, independent of  the constitution  of the patient, especiallv on
 the changes which have  occured in  the ioint itself  and in the   neigh-
 bouring parts.   In contractions already  long existing, and accompanied
 with  great alteration of the joint, there is  always "a dislocation  of the
 leg upon the thigh, from  within outwards,  or from  without inwards  •
(a) Gazette Medicale de Paris, vol. ix. p. 324.  Paris, 1841. 
AND OF THE NOSTRILS.
21
the shin-bone often gets under the thigh bone, so that the foot  is short-
ened, the knee-cap  very prominent,  and the ham Jess  hollow; the
condyle of the thigh bone is often curved  backwards,  the  whole limb
wasted and atrophic.   In such cases little violence is needed to dislo-
cate the leg backwards.   Even  when by such alteration  of the joint,
the straight posture is effected, it has a most  imperfect result, as the
joint always  remains more or less  bent)  the leg more or less placed
behind the thigh, and the patient is only able to go on a  crutch.  In
long-continued contraction of the knee-joint, the popliteal artery may
be so considerably  shortened, that  extension of the  limb cannot be
effected without tearing it. (Chassaignac.) The splint-bone may be also
so fast connected with one or other condyle of the thigh, or may be so
thrust in between the shin-and thigh-bone, as to  render the straighten-
ing of the limb impossible.  If the contraction of the joint be only con-
sequent on a  change of the surrounding parts, the result of the operation
will be more  favourable, as the joint  will resume its natural form,
power, and motion.   In  this case the joint  is always more moveable
in the  flexing direction.  Great crookedness of the  knee-joint  often
cannot be rendered straight after cutting4he tendons; it  will always
crook again.   The cause is, in this case, in  the shortness of the lateral
ligaments, usually in the external one, which is stretched under the skin,
and must be  cut through beneath it {a).
 III.—OF THE GROWING TOGETHER AND NARROWING OF THE
                            NOSTRILS.

   1574.  A complete  closing up of the nostrils is more rare than their
narrowing,  and is  commonly the result of ulceration and burns; it is
rarely congenital.  In slight narrowing, the malformation is inconsider-
able, and usually requires no assistance.  In more considerable narrow-
ing, or growing together, the breathing is affected, especially at night,
and the speech also.   The connexion may be  either  at the edges of
the nostrils, or the wings of the nose may adhere to its septum, and the
growing together may extend more or  less into its cavities.   By  the
projection of the air in blowing through the nose, with the nostrils still
open, the extent of the connexion may perhaps be ascertained.
   1575. When the nostrils are merely narrowed, after an assistant  has
fixed  the patient's  head, a director is to be introduced into the nostril,
and upon it  a narrow straight bistoury, with which the narrowed part
is to be cut  through according to the form and direction of the nostrih
which is thus widened.   If the nostril be  closed by a  mere skin, this
must  be pierced with  a  bistoury,  and its edges, having been taken hold
of with forceps, raised and cut off.   If the nostril be completely grown
together, the bistoury must be thrust in the direction where the cavity
should be, till it reach it, and being then withdrawn, and a director in-
troduced, the bistoury is to be carried in upon it,  and the  connexion
divided, as above described.  This operation is always more doubtful,
and its consequences less certain, the higher the connexion extends.
   1576.  After the  division, the natural calibre of  the nostril must  be
    (a) Phillips, Ch., De  la Tenotomie souscutance, c, p. 114.  Paris, 1841.   8vo.
  Vol. hi.—3 
22        OF UNNATURAL ADHERENCE OF THE TONGUE.
preserved by dressing, which is managed by introducing plugs of lint,
6r a quill wrapped with lint, by gum-elastic tubes,  or Benjamin Bell's
little tubes  {a) smeared with lead ointment,  and kept in position by a
bandage round the head.   The dressing must be renewed daily, all fo-
reign matters removed, the nose cleaned,  and after injection of lead
wash, reapplied.  If the introduced hard substances produce much ir-
ritation, plugs of lint must be used instead.   This treatment  must  be
continued till the opening of the nostril be completely  skinned  over,
and even still longer, if we  desire to avoid all disposition to a recurrence
of the growing together  or  narrowing.   When  such  disposition  is
noticed, it must be opposed by the use of  expanders, sponge-tent and
the like.
  On account of the great disposition to repeated closure, the operation must never
be undertaken whilst the plasticity is still very active.  When the narrowing of the
nostril depends on unnatural formation of the bones, no expansion can be effected.
      IV.—OF UNNATURAL  ADHERENCE OF THE TONGUE.

  Petit; in Memoires de l'Academie des Sciences.  1742.
  Louis, Sur les Tumeurs  Sublinguals; in Mem. de l'Acad. de  Chir., vol. v. p.
410.
  Oehme, De Morbis recens-natorum chirurgicis.  Lipsiae, 1773.
  Lang, De Frenulo linguae, ej usque incisione.  Jenae, 1785.
  1577. An  unnatural  adherence of the tongue, by which sucking, the
movements of the tongue, and proper articulation of the voice, are more
or less prevented, may  depend, first, on  a  tough, fleshy  swelling  of a
brownish  colour, and often nearly of the same size with the tongue, be-
neath which it  lies; second,  on  the tongue-string {frcmulum,)  which
either extends to the tip of the tongue, or is too  short, {tongue-tied  of
common language, j. f. s.); third, on membranous  connexions of the
tongue on one or both sides; fourth, on union of the under surface of the
tongue with the  corresponding surface of the mouth.
  The diagnosis of these conditions rests on  examination.  In children
by holding the  nose, the  mouth  is made  to open, and then  with two
fingers the tongue is raised and pressed  towards the palate and sides.
The examination is more necessary, as in  many  cases, the inability  of
children to suck from their mother and wet-nurse is ascribed to the tying
of the tongue, whilst it really depends on other causes.
  1578. When  by this  unnatural  attachment of the tono-ue suckino-  is
prevented, or at a later  period the speech is  interfered with' the tongue
must be set loose that it may enjoy free motion.
  1579. In cases where the above-mentioned tumour is observed under
the tongue, speedy assistance is always needed, which consists in cutting
into the swelling.   An  assistant holds the child's  nose, forcibly lifts up
the tongue with  the thumb and forefinger of the left hand, with its palm
upwards, by  which the fleshy mass is made more tense, and then it is cut
into with a pair of blunt-pointed scissors.   The wound generally heals
in a few days, the spittle and milk render any topical application useless
and it is necessary to move the finger under the tongue frequently during
                  (a) System of Surgery, vol. iv. p. 88. 1786. 
           OF UNNATURAL ADHERENCE OF THE TONGUE.        23

the day, in order to prevent the reunion.  In some cases it  is advisable
to scarify the tumour with a lancet,  to  diminish  its size  and give the
tongue free motion.  If the ranine artery or vein be wounded, it must be
treated as  already mentioned.
   1580. The division of the tongue-string either when too short, or when
reaching the tip of the organ, must be effected after properly raising the
tongue, as in the former case, with the two fingers of the left  hand, or
with a spatula  having a cleft in it for receiving the  tongue-string, and
rendering it tense, by JSchmitt's tongue-scissors, which, with their con-
vexity upwards, are carried to the fracenulum  and cut through it, at  a
stroke, to the necessary  extent.  In doing this the scissors  are directed
as low as possible, towards  the bottom of-»the mouth, to avoid injuring
the ranine artery.
  The  instruments referred  to are Petit's  spatula, with a snap-knife {a).  Benj.
Bell's scissors (i).  Schmitt's scissors (c).
   1581. When the  tongue unites with the corresponding surface of the
mouth, the child's mouth must be kept open by means of a piece of cork
thrust  between the jaws, and the tip of the tongue being raised with the
fore and middle fingers of the left hand, the tongue must be set  free with
a curved bistoury to its proper extent.
   [Occasionally, though not, I  believe, very often, after severe sloughing of the
membrane of the mouth, mostly after the use of mercury, the tongue contracts ad-
hesions with the cheek.  I have recently had one such case under my care, the
only one I have seen, in which the side of the tongue was attached to the extent of
half an  inch.  I applied a ligature around the band, which separated in three or four
days, and set the tongue free.  I preferred the ligature  to snipping it through, lest
there might be trouble  from after-bleeding.—j. f. s.]
   1582. The accidents which may occur after separating the tongue in
the above  cases are bleeding, and when the tongue has been divided to
a great extent there is danger of suffocation.  Attempts to stop bleeding
of the wounded ranine artery  must be made with little bundles of lint,
moistened  in styptics, Theden's arquebusade,  or a  solution  of alum,
which  should be pressed against it with  the finger;  or  the actual cau-
tery may be applied to the  bleeding part, which in all cases is preferable
to the compressors of Petit, Jourdain, and Lampe.  Bleeding  may also
be produced by the  child  sucking his tongue; in which case the blood
will be swallowed.  Care must, therefore, be  taken for the  first few
days, that when he awake he be laid on his breast.
   If there be danger of suffocation by the tongue turning backwards, it
must be brought forward with the finger in the  mouth, put in its place,
and there kept  by means of a  thick pad  put upon the tongue, and fas-
tened by a bandage  carried round the  lower jaw; this must be removed
as often as the child needs to drink {d).
   1583. The membranous connexion  of the tongue with the correspond-
ing part of the  gums, fixes the tongue either equally on both sides, or it
is drawn to one  or  other  side,  according as it is unequally attached,
or upon one side.   The division of this  connexion is  always easily ef-
fected  with the scissors.

  (a) Above cited, fig. 1, 5, 6, 7.              (c)  Loder's Journal, vol. iv. part ii. pi. v.
  (b) Above  cited, vol. iii. pi. xiii. f. 166.     f. 1, 2.
           ,                          (d) Petit. 
24       OF NARROWING AND CLOSURE OF THE MOUTH.
   V.—OF GROWING TOGETHER  OF THE GUMS AND CHEEKS.

   1584.  The growing  together of the  gums with the cheeks is mostly
consequent on inflammation and excoriation, the violent use of mercury,
and the severe salivation  following it, if the lips and cheeks be quiet.
It may be of greater or less extent, by which  chewing  and speech are
more or less hindered.   It may be prevented  in the above instances by
frequently cleansing and injecting the  mouth, by pencilling it with mu-
cilaginous fluids, by the introduction of pieces of soft linen, by frequent
movements of the parts, and introduction of the fingers ; and, by the same
means, an already formed  aaglutination  may be got rid of.   If the con-
nexion be firmer it must be divided  with a  bistoury, and prevented re-
uniting.


     VI.—OF NARROWING AND CLOSURE  OF THE  MOUTH.

  Dieffenbach, Erfahrungen iiber die Wiederherstellung zerst6rterTheile,u. s. vr.,
sect. iii. p. 65.
  Rost, G., Diss, de chilo- et stomatoplastice.  Berol., 1836.
  Baumgarten, Diss, de chiloplastice et stomatopoesi. Lips., 1837.
  Zeis, Handbuch der plastichen Chirurgie, p. 435.

   1585.  Complete closure of the mouth as  a vice of the first formation,
is very rare, and mostly accompanied with other vicious  formations.  A
small opening must be  first made in one or other corner of the mouth,
whilst lifted up with the  forceps; a director  is then introduced, and
upon it the closed membrane must be divided.
   1586. Narrowing of the mouth frequently happens in  consequence of
large scars after the operation for cancer of the lip, or  after any other
wound with great loss  of substance  ; usually, however, the mouth ex-
pands  and the lips and  cheeks  retaining their extensibility, gradually
allow its return to the ordinary form.   But  when there is a hard callous
state of scar with simultaneous great  loss  of substance, and growing
together of the membrane of the lips and cheeks with the gums, as after"
burns, destroying ulcers in herpes rodens, but especially after excessive
a*nd ill-employed use of mercury and the like, then such enlargement of
the mouth will not follow, and three degrees of deformity may  be dis-
tinguished ; first,  narrowing of the mouth from  growing together of
the internal surface of the cheeks and  lips  with the jaws,°in which the
external lips are unconcerned;  second, the  growing too-ether  of the
mouth, and the conversion of the cleft  of the mouth into a small round
hole; third, destruction of the external  lips  with great loss of substance
to a wide extent, so that the teeth are exposed, and the jaws cannot be
separated from each other (Dieffenbach.)  The inconvenience is various
according to the degree  of narrowing; the  introduction of food and
chewing, is more or less difficult; the patient often can take only liquids
with  trouble;  the nourishment  fails,  tartar collects on  the teeth • the
smell of the breath is very offensive, and the like.
   1587. Widening of the  mouth by cutting at both corners, as formerly
advised  is useless, as the  cut always again unites, and the deformity is
worse.  The treatment must vary  according to the several degrees of
narrowing  and destruction of the lips. 
          OF NARROWING AND CLOSURE OF THE  MOUTH.       25

   1588. If the lips, otherwise unhurt, be connected by thread-like adhe-
sions to the jaw, that part of the lip where the union is greatest, must
be strongly drawn down, the  tough scar divided,  and the adhesions
throughout  their whole extent properly removed with the knife or scis-
sors, as far as possible, to allow the lower jaw to be depressed.  The
mouth is then to be well washed with cold water, and frequently widely
opened, and  the cure usually soon follows.  But if the entire surfaces
be grown together, a corresponding portion of the sound membrane of
the mouth must  be separated to the thickness of common paste-board,
applied over that part of the cheek opposite  the meeting  of the teeth,
and  fastened with the interrupted suture, so as to prevent the reunion of
the wounded surface by the museous membrane spread over it.  When
in these cases the breadth of the lips is narrowed by previous ulceration
and  proportionally  shrivelled, no  advantage will be derived by  this
operation, as they will always remain attached to the jaws.   The en-
largement, of the aperture of the  mouth must also  be effected  in the
way above  mentioned.
   1589.  In considerable narrowing of the mouth from its  growing to-
gether and firm  scarring, which mostly affects one or other corner of
the mouth, or even both,  Dieffenbach's {a) and Werneck's (6) modes
of treatment are the best.   A thick strip  of the entire soft parts, down
to the mucous membrane, which must be left uninjured, is  to be cut
from the  mouth at one or both sides;  for which purpose, the pointed
blade of a pair of sharp scissors thrust  into the corner of  the mouth is
carried to some  extent between the soft parts  of the  cheek and the  mu-
cous membrane, and the cheek cut through to the part where the angle
of the mouth is to be formed.   From the lower corner of the mouth, a
cut parallel to the- former is connected by a  short circular cut.  The
piece of skin thus circumscribed,  is now to be  completely separated
from the  mucous membrane, and  afterwards the other side similarly
treated.   When the bleeding is stanched, the  lower jaw must be much
depressed, by which the exposed mucous membrane  will  be considera-
bly stretched, and must then be separated  for a few lines from the mem-
brane of the  cheek, and  divided in the middle, but  not  so far as the
corner of the mouth.   After stanching the blood and closing the wound,
the mucous membrane must be drawn out over its edges, and the edges
of the membrane  connected  around with fine needles  and the twisted
suture.   The mucous membrane folds opposite the middle of the lip
which has not been disturbed.   The part of"the mucous membrane not
cut through should be well drawn out at the corners.
  The bloodless expansion of the mouth with sponge-tent, and the like, is useless.
Horizontal  cuts on either side, as formerly recommended for widening the mouth,
are unavailing, inasmuch as  they always re-unite, and  the person's condition  is
worse. The practice of Kruger-Hansen (c), wh'o, after Rudtorffer's statement in
reference to united  fingers, (par. 1555,) made an opening with a trocar into a mouth
half closed  by a callous scar, at the  point where its boundary was  to be  fixed, in
which he allowed a  leaden thread to remain  till the part had skinned over^ after

  (a) Rust's Magazin, vol. xxv.  p. 383, and   tfier's Journal, vol.  iv. p. 202.   His mode
work above cited, p.  44.                 of treatment is  similar to Dieffenbach's,
  (6) Uber die ktlnsiliche Mundwinkel- und   but published subsequently.
Lippenbildung durch blutige Umschlagung    (.c)  von Graeje und Walther.'s< Journal,
der Mundhaut; in von Graefe. und Wal   vol. iv. p. 543.
                                 3* 
26
STRICTURE OF THE
which the remaining cut was made, is tedious, uncertain, and produces a callous
aperture for the mouth.
  1590.  If with narrowing of the mouth there be such loss of substance
in the lips, that the teeth are exposed, and the jaws cannot be separated
from each other, and in which  often the small opening of the mouth is
dragged upon the cheek, the deformity can be only somewhat improved,
and  the patient's condition  alleviated,  after  careful examination of the
peculiarity of the  case, by cutting out  the hard scar, loosening the at-
tachment to the jaws, drawing over the skin, and the like.
  Compare also an interesting case of a similar operation of Dieffenbach's (a).
           VII—OF NARROWING OF  THE CESOPHAGUS.

  Bletjlano, Observationes anatomico-medicae de sana et morbosa Oesophagi struc-
tura.  Lugd. Batav., 1769.
  Von Geuns, M., in  Verhandelingen uytgegeeven door  Holl. Maatschappy der
Wetenschappen, vol. xi.  Haarlem, 1769.
  Kunze, A. G., Commentatio pathologica de Dysphagia.   Lips., 1820.
  Home, Everard, Practical Observations on the Treatment of Strictures in the
Urethra and Oesophagus, vol. i. p. 536.  London, 1805; Third Edition, vol. i. p.
395; Second Edition, London, 1821.
  Fletcher, Robert, Medico-Chirurgical Notes and Illustrations on some danger-
ous affections of the Throat; on Strictures of the GSsophagus, &c. Lond., 1831.  4to.
  Mondiere ; in Archives generates de Medecine, vol. xxv. p. 58.  -1831.
  Appia, Dissert, de Stricturis Oesophagi.  Heidelbergae, 1842.
  Chelius, Ueber die  Behandlung der Stricturen des 03sophagus; in Heidelberg.
JVIedic. Annal.,  vol. i. pt. ii.
   [Watson, John,  On Organic Obstructions of the Oesophagus; in the
Amer. Journ. of the Med. Sciences, vol. 8., N.  S.   1844.—g. w. n.]
   1591. Narrowing of the oesophagus may be produced by various causes;
by scars after  wounds  or burns {par. 474;) by the swelling up of its walls
consequent on chronic inflammation of its internal coat; by scirrhous or
callous hardening;  by fungous, polypous, or warty  growths; by a vari-
cose condition of the vessels; by tumours, especially swellings of the
glands which compress the oesophagus;  and by spasm.
  Hoederer (b) observed an cesopkagus with a blind end in a monster.  The same
was also seen in a full-grown and otherwise well-formed child (c).
   1592.  The consequence of narrowing of the oesophagus is more or less
interference with swallowing; the symptoms, however, vary according to
the kind  and  seat of the narrowing.
   1593.  In simple {membranous) stricture, which, resembling a fold of
the internal membrane of the oesophagus, occupies  only a small extent
and is usually situated at the upper part of the tube, opposite the cricoid
cartilage, the patient first feels, at one particular spot,  a slight difficulty
in swallowing solid food, and, when the food passes over the part often
a shivering in the back.   This difficulty continues a longer  or a shorter
time, diminishes or ceases, and reappears without  any particular cause
or after a chilliness,  mental emotion, and  the  like.  The  disease  may
thus long continue getting better and worse.   Earlier or later the diffi-

   (a) Erfahrungen, sect. iii. p. 110.          (c) Hari.ess, Rheinisch. Jahrbuchern der
   (6) Commentar. Societ. Goettirag, vol. iv.   Med. und Chir.., vol. i, pt. 2. 
CESOPHAGUS.
27
culty in swallowing becomes greater, large pieces of food will be retained
at that particular part of the oesophagus, in consequence of which, symp-
toms of choking, with  the sensation of a violent, spasmodic contraction
of the neck, cough, and great straining are produced, by which the food,
frequently with an audible grating noise, passes over the obstacle, or by
the contraction of the walls of the  oesophagus, and the straining of the
patient, is returned to the mouth, and thrown  out.  The difficulty in
swallowing is now constant, and increases more slowly or quickly, so
that the patient can swallow less and less food, with the above-mentioned
symptoms; at last can swallow it no longer, and is reduced to the use
of thin broths and fluids, in the swallowing of which even, the same symp-
toms come on.   Even when the difficulty in swallowing is constant, there
is often, from time to time, a little improvement, for which, however, as
well as for the subsequent aggravation, no reason can be assigned, if ac-
companying spasmodic  affection  be  not assumed.  With the increased
difficulty of swallowing, the patient's nourishment is affected;  he wastes
to the most extreme degree, and is  starved  to death. In this form of
stricture of the oesophagus, there is, however, no farther appearance of any
specific morbid reaction.
   1594. The change by  which the internal membrane of the oesophagus
causes this narrowing, in which it forms a fold-like projection, capable of
contracting itself to the smallest aperture, generally depends  on an in-
flammatory condition of the mucous membrane of the oesophagus; fre-
quently, however, no decided cause can  be found ;  oftentimes it occurs
after  a cold.   At the  beginning, the disease, on account of its getting
alternately better and worse, is thought to be a spasmodic  affection; it is,
however,  probable that a spasmodic affection may pass into permanent
stricture.   This form  of  narrowing of the oesophagus occurs  more fre-
quently in mid-life, and, according to my experience, more frequently in
women than in  men; I have, however, noticed  it in  persons  of fifty or
sixty years of age.
  Home (a) has given a beautiful engraving of a membranous stricture.
   1595. The callous narrowing  of the oesophagus mostly consists  of a
circular thickening of the walls of the tube, at a  particular spot; it may,
however, be variously spread, often only one or other wall of the  oeso-
phagus is affected to a different  extent.  It is  generally, from the first,
accompanied with great inconvenience; the food, at the moment of swal-
lowing, causes violent pain, mostly between the shoulder-blades;  it is
thrown up, and commonly also with it a morbidly large quantity of tough
 mucus, secreted from the  almost entirely closed breathing passages.   The
 patient assists himself by throwing himself back, stretching out his neck,
 and similar movements, in order to carry the food  over the seat of nar-
 rowing ; oftentimes the food passes on with a noise and cessation of pain ;
 afterwards every portion  of food  is returned, with  a gurgling noise and
violent cough.   This disease also for a time yields, and usually makes
 slow progress;  I have, however, seen in one case the patient starved to
 death in three months, and on examination a circular, regularly callous
thickening of the walls of the oesophagus was found at its  upper part, and
gradually lost itself both  above and below.
(a) Above cited, p. 422. 
28                      STRICTURE OF  THE
   1596. In  scirrhous hardening of the walls of the  oesophagus,  which
otherwise in its symptoms has great resemblance to the callous condition,
and is generally situated at the lower part of the asophagus, and even at
the cardia, the difficulty in swallowing usually increases slowly, and the
patient has also a dull, weighty, dragging,  and  often very painful  sensa-
tion at the part,  especially opposite the spine, which diminishes on lying
down.
   1597. The symptoms and accidents in this stricture of the oesophagus,
are especially different in reference to its seat and extent, and particularly
as regards the condition of the oesophagus above the stricture;  as  when,
as is frequently  the case,  it is considerably expanded, the food that is
swallowed, collects in great quantity, and is only afterwards thrown up.
  The expansion of the walls  of the oesophagus is either of the whole of the canal, or
only partial, and depends on the protrusion of the internal coat between the separated
fibres of the muscular coat, so that a sac of various size  is formed (Diverticulum,
Hernia (Esophagi,  (Esophagus succenturialus, &c.)  This partial expansion occurs
also frequently without any narrowing of the oesophagus,■  at least, I have never ob-
served it with, but twice without stricture.  It depends on the excessive expansion
or tearing of some muscular fibres in the swallowing, and sticking of large, hard
pieces of food, and the like.   The food gets into this sac, expands it still more, and
sooner or later, without any straining, is thrown up into the mouth.  Whilst eating,
the patient, when this sac is full and at the upper part of the oesophagus, must, as I
have witnessed, empty it, from time to time, by pressure with the fingers, so  that he
may be able to swallow better.
  1598. In the  scirrhous  and callous, cartilaginous and bony, narrowing
of the oesophagus,  which  occurs, specially  after the abuse  of spirituous
liquors, from the habit of  eating and drinking very hot things, from the
suppression of the ordinary discharges, from the  venereal disease  and
alike, generally  in advanced age, and in men, ulceration comes on  at the
later period,  by which part of the  stricture is destroyed, and symptoms
of hectic consumption ensue.   When these  strictures are  of long con-
tinuance, the ulceration always begins on  the  side next the  stomach,
which must be attributed indeed to the frequent efforts to vomit, by  which
the walls of the  oesophagus below the stricture are  deprived of their na-
tural activity and natural moisture.  The ulceration is usually seated on
the hind wall of the oesophagus next the spine, and not unfrequently at-
tacks the bones; it may, however, destroy  the front wall and the  corre-
sponding part of the  trachea or^bronchi, and a communication may be
produced between  them, in which case most  violent cough,  choking on
every attempt to swallow, and haemorrhage are produced.
  I have seen one case of callous stricture in a man sixty-three years old, in which
there was a communication between the right bronchus and the oesophagus. Meyer (a)
relates an instance  of strictured oesophagus with a communication between  the left
bronchus and the oesophagus.   Gendrin (b) communicates two cases of narrowing of
the oesophagus at the region of the cricoid cartilage, in which there was also  a fistu-
lous orifice into the trachea, and cough in swallowing, vomiting fluids, speaking
through the nose in consequence of the changed direction given to the air.
  1599. In  narrowing of the oesophagus from fungous growths  fluids
usually pass with more difficulty than solids; if the food be again thrown
up, it is usually mixed with bloody mucus, and membranous fibres,  which

  (a) Med. Vereinszeitung for Preussen,  Chirurgicaks, Nov. 1837. See also SrnMm,-c
1838„No. 27.                          Jahrbiicher, vol. xxii. 1839 ; Oe.tr mSw
  (b) Journal des  Connaissances Medico-  Jabxbucher, vol. xxvii. pt. 2.      *'  etucm- 
ESOPHAGUS.                          29
even on examination with the sound, present a yielding obstacle and be-
come attached to it.
   1600.  The  compression of the oesophagus by swellings of any kind in
its neighbourhood, can be ascertained by careful examination of the neck;
the difficulty of swallowing corresponds with the growth of these tumours,
an oesophagus  sound will pass more readily in this disease than in stric-
ture.  If such swellings be seatetrin the chest, the diagnosis is also more
doubtful.
  See also in Kunze (a) the different observations on these swellings.
  Here also belongs the so-called Dysphagia lusoria  depending on the unnatural
course of the subclavian artery by which the oesophagus is compressed.  Bayford (o)
first  described it under this name, and his  observations have been confirmed by
others.  (Richter (c), Valentin (d), Autenrjeth) (e).  By some this  cause of
Dysphagia is denied, (Fleischmann (/), Ruoolphi,) because the unnatural course of
the subclavian artery has been noticed without this disease; and this notion is set-
tled by Schonlein, as the origin of the dysphagy in this unnatural course  of the
subclavian artery depends on whether the artery pass before the trachea, between it
and the oesophagus, or between it and the spinal column, in which latter case the
disease must take place.  The inconvenience first appears at the period of puberty,
or on the  suppression  of menstruation, when the congestion towards  the chest is
greater.  The symptoms are, violent palpitation and danger of suffocation  on every
attempt to swallow, accompanied with tremulous intermitting, and specially weak
pulse in the right hand : the right arm is also shrunk and weaker;  twisting move-
ments of the neck frequently cause  pain; all the inconvenience  is in swallowing
alone, and even  then often only periodical.
   1601.  The  spasmodic stricture of the oesophagus is  usually seated more
at the lower part towards the stomach,  and is  accompanied with the sen-
sation of the tying together a fast-fixed substance ; sometimes the organs
of swallowing and the muscles of the neck are in spasmodic tension;  the
evil is increased by cold drinks, and diminished by hot ones.  It  is ac-
companied with spasmodic  symptoms in  other organs, qualmishness,
vomitings, cough, secretion of a watery mucus,  not  unfrequently symp-
toms of suffocation, loss of speech, and the like.  The spasm frequently
intermits ; this affection may, however, continue  for a long while, which
renders the diagnosis difficult;  and  also that,  probably, during this long
continuance,  membranous stricture {par. 1594) will be produced.   If
spasm be added to  organic stricture, the  symptoms will be quickly in-
creased.
  There is a difficulty in swallowing, which may amount to the  greatest degree of
dysphagy, dependent on a chronic inflammatory and consequent spasmodic  affection
of the upper part of the pharynx, and which,  on account of its usual connexion with
impetiginous diseases, and the peculiar change  of the mucous  membrane  of the
pharynx, I have distinguished as Angina impetiginosa.  This disease develops itself
without any decided cause, and  after a catarrhal  affection of the  throat.  The
difficulty in swallowing increases gradually to a very great degree, so that it is often
quite impossible for the patient to swallow, and the smallest portion of food or drink
is thrown up, with which  there are also  spasmodic  contractions  in the throat, and
difficulty of breathing.   It is a peculiarity in this complaint,  that it is more difficult
to get down fluids, than more consistent mucilaginous substances; there is often
such dread of fluids, that when brought to the mouth there is the most violent spasm
of the glottis, so that every attempt to swallow  is impossible.  If the  throat be

  [a) Above cited.                         (d) Journal de  Medecine, Chirurgie, et
  (b)  Memoirs of the  Medical Society  of  Pharmacie.
London, vol. ii. p. 251.                      (e) Pfleiderer (Praes. Autenrieth) Dissert.
  (c) Chirurgishe Bibliothek, vol. x. p. 365.   de Dysphasia, lusoria.  Tubing., 1806.
          (/) Neue  Schriften der Erlanger phys. med. Gesellsch,, vol. ii. 
30
TREATMENT  OF
examined by proper compression of the tongue, the hind wall of the pharynx is found •
to be especially chano-ed; the mucous membrane has a net-like or latticed appear-
ance,  and  between the paler streaks are perceived a few light red island-shaped
elevations.  The redness is very indistinct, rather pale, and inclining to yellow; at.
several parts there is  a sort of papular and phlyctenous formation.   The patient com-
plains usually, besides the difficulty in swallowing, of a burning or slabbing pain at
some one part of the  throat;  he has often the sensation as if several little knots or
bladders had formed  and, burst, after which #  wound, very sensitive to the touch,
remains for some time.  These sensations, as well as  their places, alternate irregu-
larly.   The patient has frequently the sensation of a circular contraction at the upper
part of the oesophagus.  I have noticed this disease in  young and old  persons, and
always perceived  a  certain disposition to previous, though inconsiderable  chronic
affection of the skin.  The resemblance of the symptoms may mislead to the pre-
sumption of an organic stricture, and many patients in this condition have been sent
to me  by  distinguished practitioners; but an examination, with the oesophageal
sound is, on account of the excessive sensibility of the throat, impossible, and the
alternation Of the symptoms, and  especially the peculiar appearance of the back of
the pharynx, can  alone determine the diagnosis. The treatment is one of the  most
difficult questions. In a young man the disease had withstood, for many years, the
most different and severe remedies, both internal and external, employed by several
practitioners; at last  he submitted to mine; but, up to the present time, the observa-
tions I have made point out no definite rule.  Close consideration of all the previous
circumstances, and constitutional  relations, must lead the practitioner in the treat-
ment, which requires equal  perseverance  on the part of both  him and the patient.
In one  instance, repeatedly touching the  back  of the pharynx with lunar caustic
seemed effective.  To a certain extent this condition may be compared with the
spasmodic  contractions of the sphincter, in fissura ani.

   1602. The prognosis, in stricture of  the oesophagus, depends on the
kind  and seat  of that  affection.   The  simple, membranous  stricture
admits a  favourable  prognosis, and may be  completely got rid of by
proper  treatment.   Callous  and  scirrhous  stricture rarely  allows  any
check to  its  development, and,  when once existing, its alleviation is
scarcely possible, and still less its cure.   Spasmodic stricture may mostly
be got rid of by proper treatment; the disease  however  often recurs, is
frequently very stubborn, and  may run into organic stricture.  In swell-
ings which compress the oesophagus, the prognosis depends  on their nature
and seat.

   [Astley Cooper (a) mentions a case in which, during stricture of the oesophagus,
an aperture was made from it outwards by ulceration; the  patient was kept  alive
some time by administering food through  an elastic catheter.__j. f. s.]

   1603. In those  cases in which the alteration of the mucous  membrane
of the oesophagus depends on chronic inflammation, a strict attention to
the mode of living accompanied  at first with  antiphlogistic  treatment
repeated  leeching, the  continued internal use  of hydrochlorate of am-
monia, of hemlock, of  mercury, of iodide of potash, with simultaneous
derivation by issues, tartar emetic ointment, setons, and the like together
with carefully-regulated living  are required.  The progress of 'the stric-
ture is, however, rarely  checked by  these means;  and its  existence  may
be ascertained,  m  addition to the symptoms described, by the introduc-
tion of a  sound, in the way presently to be described,  which finds a dis-
tinct obstruction, and is  stopped at the seat of stricture.
   1604.  The introduction of an oesophageal sound  is the most simple
remedy to get rid  of an existent narrowing, by gradual extension.   This
(a) MS. Lectures. 
GESOPHAGUS.
31
treatment in membranous stricture ensures a satisfactory result; in callous
and  scirrhous stricture it  is never,  according to my experience, to be
relied on.   The introduction of the sound has frequently only the pallia-
tive  effect of prolonging the patient's life, by the passage of food into the
stomach.  In such cases, however, the irritation of the  sound may, with-
out delay, drive on the stricture into malignant degeneration and ulcera-
tion.
   1605. The introduction  of a sound  into the oesophagus must  be  con-
ducted  with  the greatest care and delicacy,  or otherwise injury to the
walls of the oesophagus, false passages, and hastening the miserable  end
of the disease will be produced.   The following is the  best mode of pro-
ceeding.  The patient sits upon a  chair, his head moderately thrown
back, and held by an  assistant, his mouth wide open, and tongue a little
protruded  (1).   The oesophageal  sound provided with a leaden stilette,
oiled, and a little curved at its tip, is then introduced into the gullet, and
gently pushed onwards.  When it has reached the seat of stricture, care
must be taken, and  an attempt  made, by gentle  pressure,  to overcome
the  obstacle, over which it  usually  slips with a  jerk, and  can then be
passed  still farther.   If it  be impossible to get through the stricture with
the sound, a thinner one must  be chosen and used in the same way.   In
some cases of great  narrowing, I  could only succeed, after several fruit-
less attempts with the thinnest oesophageal  sound, in passing through
the  stricture  with  a moderate-sized  urethral  sound.   The  instru-
ment  thus introduced, and the  stilette withdrawn,  must be allowed
to remain as  long as the patient can, without much inconvenience, bear
it, which  at  first will not exceed five minutes.   In genera],  the swal-
lowing after  this first introduction of the  sound, very small  though it be,
will be remarkably improved.   The  sound should be  passed daily in
this manner,  and allowed to remain a little longer,  so that the parts
may become accustomed to the  irritation, and then by degrees a thicker
sound may be used.
   The introduction of the sound through the nostril is improper, much more painful
to the patient,  and, if  it be thick, impossible; by this mode  also the  instrument
more frequently slips into the  windpipe, than in passing it by the mouth.  This is
proved by the violent disposition to cough, by the expulsion of the air with the sound,
and the  impossibility of speaking;  it is ri<iht, however, to observe that frequently the
disposition to cough, although the sound be thrust into the windpipe, is not so great;
and that by the choking,  when the sound  is in the oesophagus, the air may be forced
up from the stomach with a hissing noise.
   The introduction of the sound, provided with a leaden stilette, if the  instrument
require passing to a great depth, has the advantage of giving to it every desirable and
suitable curve.  The sound can be introduced with the greatest safety, without in-
terfering with  the  curve of the leaden stilette and is rendered more steady  than
without it.   In very narrow strictures, in  which the thinnest sound  will not pene-
trate, it is better to employ the thinner urethral sounds than that the obstacle should
be overcome with violence, as Boyer (a) did in one case, in which  he employed a
silver catheter, passing it through the mouth, and, having passed the obstacle, then
introduced an elastic sound, the end of which he carried by the assistance of Bellocq's
tube into the nostril.  Any great  force used in introducing an oesophageal sound
endangers tearing the walls of the oesophagus.  I knew one instance abroad, in which
the sound penetrated the  hind  wall of the oesophagus above the stricture, proceeded
some distance  between it and  the spine, and below again entered the oesophagus, as
proved by dissection.  In difficult cases, a sound made of modeller's wax may be
       (a) Richerand, Nosographie Chirurgicale, vol. iii. p. 262.  Third Edition. 
32
STRICTURE OF THE (ESOPHAGUS.
 employed, with which slight pressure may be made against the stricture, and an
 Impression of it obtained as I have sometimes observed (2).
   [(1)  The practice here recommended, of protruding the tongue,  preparatory to
 passing the sound or bougie, and which, I believe, was first recommended by Home,
 is very objectionable, as in proportion must  the epiglottis  be raised, and greater
 facility for the entrance of the instrument into the windpipe afforded.   Moreover, it
 is quite needless, as the passage into the beginning of the oesophagus is  rendered
 easy by placing two fingers of the left hand upon the tongue, and pressing it into
 the bottom of the mouth, which readily exposes the whole cavity of the pharynx.
   (2) Astlev Cooper (a) used to mention a case of this kind; he had been called
 to a person with  stricture of the oesophagus,  and had attempted to introduce an ure-
 thral bougie, but in vain.  Another surgeon was called, who passed an instrument,
 ■with readiness, as he said, and  then injected some milk and wine through it.  A
 swelling immediately arose at the upper end of the breastbone, and the patient cried
 out, "Oh! you burn me."  The same evening the man was dead.  The instrument
 had been thrust through the oesophagus into the  anterior mediastinum, into which the
 fluids had been  poured.  The  preparation  of the parts is in the Museum  at St.
 Thomas's Hospital.—i. f. s.]
   1606.  If in this way much expansion  of the stricture can be effected,
 and swallowing be in a corresponding degree improved, for the purpose
 of sustaining a continual cure, a sound with an olive-shaped  dilator must
 be used, which after some  days must  be changed  for a thicker, and,
 according to circumstances, for the thickest.  In  introducing a sound
 with a dilator, as  in  passing a common sound, care  must be taken that
 the dilator be pushed gently through the seat of stricture, which is dis-
 tinctly  marked by the resistance.  The  instrument is either  moved up
 and down a few times through the  stricture, or, when it is ascertained
 that its thick part is in the stricture, it may be left there  for  some time,
 and then drawn back.  I have  never observed  that in  thus doing the
 patient has  suffered much inconvenience.  The  sound with the dilator
 is generally borne as well  as the common oesophageal sound.  When
 the  swallowing has become perfect, the  sound should not be given up,
 bat passed  once  a week or fortnight, to counteract the disposition  to
 narrowing again,  which  I have also  endeavoured to prevent by intro-
 ducing a seton in  the neck for some time.
   This  treatment has, in all cases of membranous stricture  in which I have em-
 ployed it, effected a permanent cure.  The dilator is either made of ivory, slipped
 on the sound at some distance from its tip, and there fastened, or the sound'itself is
 furnished with a bellying enlargement of caoutchouc  at the  same place.  These
 dilators are of various thickness, up to an inch in diameter.   The mere introduction
•of a common sound, up to  the largest size,  may relieve  and improve the patient's
 condition for some time, and may produce even complete freedom of swallowing-
 hat a permanent result is not thereby commonly produced; earlier or later the disease
 recurs.
   The use of bougies, armed  with lunar caustic, for the destruction of stricture of
 the oesophagus (6) must be considered highly  dangerous in every form of the disease
 Jameson (c), instead of the gradual violent extension of the  stricture, emnlovs an
 oval ivory dilator, which he uses either alone or with a sound, or with a sound armed
 with a bullet, passed three or four times through the stricture.             <«"jeu
   Fletcher (rf)  uses  a metallic  instrument,  which  either serves for tearino-
 merely dilating the strictured oesophagus. It is  curved in front, consists  of three
 close-lying branches, and, when the instrument is introduced into the striot„rl 7w
 are separated by twisting the handle.   The use of this instrument is i        .' .  "
 accompanied with great difficulty, and, in stricture deeply situated 'it '"^  °P1T1101?:

  («r) MS. Lectures.                        (c) Philadelphia Medical Ti„ a   t
  (6) Home, above cited.                  1825.           medical Recorder, Jan.,
                                        (d) Above cited. 
            NARROWING AND CLOSURE OF THE  RECTUM.         33

efficient.  The introduction of a whalebone  stem, commonly known as a probang,
with a sponge (a) for the purpose of expanding the stricture, is not proper.
   1607. In membranous stricture, besides the above-described, no further
treatment  is necessary.  In callous and scirrhous stricture,  the previous
mentioned {par. 1603) treatment, both internal  and  external,  must  be
simultaneously employed.   Spasmodic stricture requires the use of anti-
spasmodic remedies,  especially  ipecacuanha  in  small  doses, and  the
application of emp. belladon. around the neck.   The introduction of the
sound has often, in these cases, better  effect than any other treatment.
  In Dysphagia lusoria, the congestion about the chest must be relieved by strict
attention to  the  mode of living, the blood must be diverted to the lower parts, sup-
pressed menstruation restored, and the like.  Autenrieth recommends also the
frequent introduction of the  oesophageal sound,  for  the  purpose of relaxing the
oesophagus, and to lengthen and strengthen the cellular tissue connecting that tube
to the arteries.
   1608. If the sound be used  for the  purpose  of introducing strong
broths, one should be employed which  has a funnel-shaped  horn mouth-
piece.  The sensation of warmth which the patient feels in the epigastric
region is  a proof that the fluid has entered the stomach.  Previous to
administering  the fluid,  attention  should be paid  t(4 the  symptoms
described  (par. 1605) as  occurring on  accidental  introduction  of the
sound into the windpipe.
  The Dysphagia paralytica atonica, which occurs in old persons after apoplexy and
nervous diseases, in which the patient cannot mention any decided obstacle, any
pain, or tightness does not offer any opposition to the sound, and the breathing is not
interfered with; tough mucus is often spat up; solid food and bits of bread usually
pass better than fluids, sometimes better when swallowed slowly and in the upright
posture ; and frequently there  is a greater or less degree of accompanying palsy of
the tongue.   The introduction of the elastic sound is required when the patient can-
not be sufficiently nourished.   I have found gargles of tinct. rad. pyrethri especially
useful, also  blisters to the neck, and arnica.
     VIII.—OF  NARROWING AND CLOSURE  OF  THE RECTUM.

  Pappenoorf, De ano infantum imperforato.  Lugd. Batav., 1751.
  Petit, Remarques  sur differens Vices de Conformation a. l'Anus, que les enfans
apportent en naissance;  in Mem. de l'Acad. de Chirurg., vol. i. p.  377.
  Stipr. Luiscius, Ueber Verschlossenheit des Afters;  in Hufelano and Harless
Journ. der ausland Med.-Chir. Literat., vol. ii. pt. ii. p. 50.
  Jolliet, in Journ. de  Medecine, Chirurgie et Pharmacie, par Leroux, vol. xxxii.
p. 272.
  Metzler, Ueber die widernaturlichen Verengerungen des Mastdarmes, in Hufe>
lano's and Himly's Journal, vol. vi. pt. i.   1811.
  von Wv, Beobachtungen iiber Verwachsung des Mastdarmes.  Ibid.
  Copeland, Thomas, Observations on the principal Diseases of the Rectum and
Anus, particularly Stricture of the Rectum,  &c.   London, 1814;  Second Edition.
  White, M., Observations on Strictures of the Rectum and other affections.  Bath,
1820; Third Edition.
  Howship, J. A., Practical Observations  on the symptoms, discrimination, and
treatment of some of the most common Diseases of the Lower Intestines and Anus,
&c.  London, 1820.  8vo.
  Wandesleben, F., Dissertatio de  Intestini Recti Strictura.  Hal., 1820.

  (a) Genorin, Du Catheterisme curatif du Retrecissement de  l'QSsophage; in Journal
des Connaissances  Medico Chirurgicales.   Nov., 1827.
  Vol. hi.—4 
34
CONGENITAL CLOSURE
   Calvert, George, Practical Treatise on Haemorrhoids or Piles, Strictures, and
 other important Diseases of the Urethra and Rectum.  London, 1824.
   Salmon, Fred., A Practical  Essay on  Stricture of the' Rectum ; illustrated by
 cases showing the connexion of that disease with affections of the Urinary Organs
 and Uterus with Piles, and various constitutional complaints.  London, 1829;
 Third Edition.
   Hehenus, A. V., Ueber die verschiedenen Formen der Verengerungen des After-
 darmes und deren Behandlung.  Leipzig,  1828*
   Flachs, Dissert, de Atresia Ani congenita.   Lipsiae, 1834.
   Tanchou, S., Traite des Retrecissements du  Canal de l'Uretre et de 1'Intestine
 Rectum, contenant I'appreciation des  divers moyens employes dans le Traitement
 de ces Maladies.   Paris, 1835.  8vo.
   Brodie, Sir B. C,  Clinical Lecture on Stricture of the Rectum, &c.; in London
 Medical Review,  vol. xvi.  1835.
   Bushe,  George, M. D.,  A Treatise on the Malformations, Injuries, and Diseases
 of the Rectum and Anus.  New York, 1837.  8vo.
   Syme, James, On Diseases of the Rectum.  Edinburgh, 1837.  8vo.
   von Ammon, Chirurgische Pathologie in  Abbildungen, part i. pi. x.
   1609.  Closure of  the  Rectum  (Imperforate, Atresia Ani,  Lat.;  Ver-
 schliessung des  Mastdarmes, Germ.;  Imperforation du  Rectum, Fr.) is
 always a vice of the first formation ;  but Stricture (Strictura Ani, Lat.) .
 Verengerung  des Mastdarmes,  Germ.; Retrecissement du  Rectum,  Fr.)
 most usually  arises subsequently, and is rarely congenital.
   1610.  The congenital closure of the rectum depends either on a simple
 membrane, which  more or less resembles the general coverings or  the
 intestinal membrane of the gut, and is situated either immediately at the
 ,anal aperture, or more or less high in  its cavity;  or there is not a trace
 of anus, and  the rectum opens more or less high in a blind sac.   Those
 cases of congenital malformation  must be now also mentioned, in which
 the rectum opens into the urinary bladder, urethra, or some other aper-
 ture, whilst the anus  is  closed.
   Compare von Ammon  (a) upon the unnatural openings of the anus, and the other
 malformations therewith connected.
   1611.  Closure of the rectum always causes violent forcing and strain-
 ing;  with which, nothing being discharged by the anus, painful tension
 of the belly,  vomiting of green or yellowish matter,  arise ;  and to these
 symptoms convulsions  are  afterwards added.   If the  rectum be closed
 by a simple membrane, it is, especially when the  child  ciies, protruded
 like a sac, and  the  meconium is seen through  it.   If the closing mem-
 brane be higher, it is ascertained by  the introduction of the finger or of
 an elastic sound.
   [Although imperforation of the anus or rectum is generally soon discovered by the
 child not passing  motions, yet a case is mentioned by Wolff (b), in which it was
 not found out till  the  evening of the twelfth day after birth, when  the  child was
 attacked with vomiting, hiccough, and convulsions; the belly  was very full and
 tender.  The anus was found imperforate,  but the gut could not be opened  bv a
 lancet thrust into the depth of two inches.   A pharyngotome was then passed up
 and with  it an aperture made, and by the  use of clysters and tents the child ulti-
 mately recovered.]
   1612.  If the external opening of the rectum be closed  by skin it is
-sufficient to thrust into  it a straight bistoury, and to  enlarge the wound
■with  a button-ended bistoury on  a director; and, if it seem  necessary
 tjae flaps thus formed may be removed with  the scissors,   If the closed
£a)Cited at t!ie head of article.           (6) LANGENBECK,sBibliothekrvcl.jii,p,23] 
OF THE RECTUM.
35
part of the rectum  be higher up, a narrow, straight bistoury must  be
introduced, in a proper direction, upon the forefinger of the left hand, or
upon a director, through the closing membrane, and the opening thus
made enlarged with the button-ended bistoury; a trochar or a  pharyngo-
tome will answer the same purpose.   This treatment is, according to the
kind of closure, accompanied with more or less difficulty; the expanded
part of the rectum, instead of the seat of closure, may be lighted on, and
fatal effusion into the pelvis follow.   The  closed part may be hard, cal-
lous, cartilaginous,  and very thick.  To  prevent the  reclosure of the
rectum, it is necessary to insert a plug of  lint, fastened up with strips of
sticking plaster,  and with a thread attached to it, for a long while in the
cavity of the gut, or to introduce the finger, well oiled, from time to time
into the rectum, as the disposition to reclose is often very considerable (a).
   1613. When  there is no trace of an external anal opening, the diffi-
culty of the operation depends on the  higher or lower position of the
blind end of the rectum.  If there be no fluctuating swelling,  no accom-
panying projection or depression, which can direct the  practitioner,  he
then, after  carefully introducing  a catheter into the bladder, and in a
female a sound into the vagina, for the purpose of emptying  the  urine,
and distinguishing,  during the operation, the position of the bladder and
vagina, makes a cut with a  pointed bistoury between the beginning of
the  raphe and the coccyx, in  such way, however, that there be an inch
distance between the latter and the cut, as in  children the rectum does
not lie so close to the coccyx as in adults.   Having penetrated about half
an ineh, the finger of the left hand must be inlroduced into the wound,
the blind end of the gut sought for, and then the cut is to be  cautiously
continued  more  deeply, following, as far  as possible, the course of the
straight  gut,  and taking care  not to wound  the bladder  or  vagina.
When the cavity of the rectum is  penetrated, the aperture made must  be
enlarged with the button-ended bistoury, on the finger or on the director,
and  the dressing to  prevent the reclosure  applied in the usual way.  If
the penetration  have reached a depth of two inches, without coming to
the gut,  it has been advised to proceed with the operation by thrusting
a trochar towards the  blind end of the rectum; the objection, however,
seems to be correct, that the  operation is equally hazardous and useless,
as, although the  gut may be opened, effusion of meconium into the belly
is  the consequence (6).  Here  also may  be mentioned Amussat's (1)
mode of practice, in which he draws forth the blind sac of the intestine
exposed by the cut, opens it, and attaches the cut edges of the gut to the
edges of the external skin.
  (1) Amussat (c) found, on introducing his finger into the vagina, a movable body
on the top of the sacro-vertebral articulation, which he took for the end of the rectum.
He made one transverse cut behind the proper  seat of the anus, and then another
which reached the coccyx.  Through this T cut he introduced his finger, carrying
it along the sacrum to the end of the gut, and therewith broke down the adhesions;
he then drew the intestine with a pair of forceps, to the external opening, cut into
it, and fixed it with two stitehes, so that the mucous membrane overlapped the edge
of the external skin.
  [Sometimes the two portions of the ileo-colic valve are adherent to each other, so

  (a) Henkel, Neue Bemerk., fasc. i. p. 11.    (c) Archives generates de Medecine, 1835.
  (b) Zang, Darstell. blut. heilk. Operat, vol. p. 237.
iii. pt. ii. p. 436. 
36
CONGENITAL CLOSURE
  as to prevent the passage of the meconium, and lead to the presumption of the large
  intestine being imperforate in some part of its course.  A case of this kind occurred
  to me at the General Lying-in Hospital, in  the summer of 1842.  The  child was
  born at 1 a. m., June 6;  and  some hours after, no motion having passed, castor oil
  was given, but did not operate.  On the evening of the same day, an elastic catheter
  was introduced into the rectum, to the extent of two or three inches, and no obstruc-
  tion being met with, the castor oil was repeated, but did not  produce any stools.
  On the following morning an attempt was twice made to throw up an injection, but
  it failed; and Dr. Ferguson, whose case it was, considering it as one of imperforate
  rectum, desired I should  see  the child ; and  on the  evening of this day I saw her.
  On examination, I could pass my finger up about two inches,  but not farther, and
  the gut seemed to terminate in a blind pouch ; no  sensation of fluctuation above
  could be felt; and I therefore did not consider myself justified  in  passing a trocar,
.  without knowing where it might go; but, being desirous to give the child a chance
  of life, I determined on making an artificial anus.  For this purpose I cut upon the
  linea alba about half an inch  above the pubes, and, opening the  peritonaeum, caught
  up a portion of small intestine, and  having cut into it, fixed the cut edges by stitches
 to the wound in the linea alba.  Soon a quantity of meconium passed, and continued
 to do so on the day following; but on  the third day she began to vomit bile and
 frothy mucus, and at 2 p.m. died.  On examination, the gut was found adherent to
 the wound.  The colon was quite empty and contracted to the size of a crow-quill,
 but it  was continuous with the rectum, and both intestines were quite  pervious.
 The finger had been prevented passing up the rectum by a sudden turn, at which
 part it was close bound down to the sacrum.   The jejunum and ileum were much
 distended with faecal matter;  and on slitting open the latter, the two portions of the
 ileo-colic valve were so nearly adherent, that  nothing would pass through, although
 there was a very small aperture.—j. f. s.]
    1614. When  the rectum  opens into  the  vagina, a director  must,  if
 possible, be introduced through the latter into the anus, thrust  down
 vertically, and, when its position has been ascertained by the forefinger,
 a straight bistoury or  a trochar must be thrust through" the closed anal
 aperture, towards the groove of the director, and the puncture after-
 wards enlarged  in the manner described.   This  practice is, however,
 generally fruitless, and it  is preferable to divide, through the vagina, all
 the parts  back  into  the rectum,  and  by the insertion of lint, or, still
 better, by the daily introduction of the  finger, oiled, to pre-ent the re-
 union.

   In one case, in which this treatment was in vain, as the artificial opening of the
 rectum closed again, whilst the  opening of the vagina remained, Barton (a) em-
 ployed the following method with success. He passed a  director through the hole
 of communication in the  vagina, and divided the whole wall of the vagina to the
 place where  the natural opening of the rectum should be.  He did not use any
 dressing, but every  day passed the  finger, smeared with cerate, into the rectum to
 prevent its closing.  The vagina was perfect, and the rectum had a direct  opening,
 except that the stools passed involuntarily. Satchell (6) also,  and I myself have
 by this practice obtained like favourable  results.   Velpeau (c)  had proposed this
operation on the recommendation of \ icq. d'Azyr.  After the division is perfected, a
canula should be introduced into the rectum,  fixed  towards the  hind  angle  of the

Tabled L^^Lw"^ ^ ^^ * "* *™™«> «* *e *&ed parts
   Dieffenbach (d) introduced a director much h^nt inwove *u,    u a
into the aperture of ,he „*», thrust a vcA'XST^A^TSZ


of the ani,, at a siogle sttoke,  te JafcZJm™ ™d Remits the  aperture
division of the eelh.ll, tissue, stre^in/L'S* S"^ ST^SSSrV, the 
OF THE  RECTUM.                        37
bottom of the wound.  He then dissected the edge of the rectum from the wound he
had made, divided to the extent of an inch in the direction of the external skin and
the muscular wound, and fastened the separated edges of the rectum on each side of
the cleft perinaeum.  The aperture of the rectum in the vagina  closed very com-
pletely during the after-treatment by occasionally touching it with lunar caustic.
On the complete cure of all the wounded parts, three weeks after the first operation,
the formation of a new perinaeum was attempted.  The hind  surface of the'open end
of the rectum was farther separated from the vagina.  The portion of intestine thus
set free in the middle, contracted remarkably, and receded about four or five lines.
The scar of muscle and skin was removed from the thus formed interstice, the deeper-
lying parts were brought together with a needle-stitch, but the edges of the wound
with two very short harelip-pins and the twisted suture.  The cure was completely
successful.
   1615. When the rectum opens into  the urethra, a sound must be
passed by the latter into the  bladder, and the unnatural  opening in the
urethra divided  upon it towards the  coccyx, and  with  some cautious
strokes of the  knife the aperture in the urethra and the wall of the in-
testine opposite the place of the anus divided.  If possible, the sound
should be  brought through the unnatural  opening  in  the  urethra, into
the  cavity of the rectum, and  such direction given it, that it may be
distinctly  felt  from  the  perinceum, and the covering of the urethra
divided in the course of the raphe, together with the wall of the straight
gut  opposite the place of the anus, or treated according to Amussat's
plan {par. 1613.)
   When the rectum opens  into the urinary bladder, it  is  possible for  a
girl  to live, on account of the shortness and extensibility of the urethra;
but  in a boy this malformation is fatal, if the wall of the rectum, op-
posite the  place  of the anus be not'open, or an artificial anus made.
  In a case, in which the rectum was imperforate, and opened  into the bladder
Fergusson (a) made a cut into the neck and body of the bladder at the place of the
anus.
   [Cruvelhier (6) gives an instance in which the rectum  opened under the glans
penis, by means of a canal which was formed in the substance of the raphe scroti.
A similar case to this occurred to me, and will be described at the end of par.
1617.—j. f. s.]
   1616. In all  cases, where, by the  above-mentioned modes of treat-
ment, opening the imperforate  end of the rectum is impossible, or when
the rectum terminates by a blind  end in the belly, as also  in the not-to
be-overlooked narrowing of the rectum  by  unreachable strictures and
the  like, some  assistance, though not much, may  be afforded by the
formation  of an artificial anus at the  lower end of the  colon, (laparo-
colotomia,) which may be  performed in two ways.   First, A cut from
an inch and  a half to  two inches long is to  be made  obliquely from
behind forwards, so that  its lower  end should be a little below the
upper front iliac spine, and half an inch from it, and continued, layer
after layer, through the skin and muscles; the peritoneum  is then care-
fully opened, raising it with ihe forceps, and the sigmoid flexure of the
colon sought for, drawn to the wound, two waxed threads carried round
it, and a longitudinal cut having been made in it,  returned into the belly;
and, by means of the  threads, retained between the  edges of the ex-

  (a) Edinb. Med. and Surg.  Journ.,  vol.    (b) Anat. palhol., livr.i. pi. v. 1. fig. 6.
xxxvi.p. 363. 1831.
                                  4# 
38
OPERATION FOR CONGENITAL
ternal wound with which it unites (1).   Second, In order not to wound
the peritonaeum, a cut, three inches in length, must be made, according
to Callisen's (2) method, in the left  lumbar region, between  the iliac
crest and  the short ribs, on the front edge of them, quadratus lumborum,
at which  part of the descending colon lies  enclosed in cellular tissue
externa]  to the peritonaeum,  and is here fo be  opened {a).   Amussat
makes a transverse cut two inches  above the iliac crest, from the outer
edge of the  m. quadratus  lumborum to the middle of the  iliac crest,
through the  skin  and abdominal  muscles,  thus  cutting  across the m.
transversalis and  its aponeurotic layer, then separates the fatty tissue
which covers the  gut, passes  two threads through its wall,  to  prevent
it  falling  together; then stabs  the  colon with a trocar,'enlarges the
aperture with the  bistoury in several directions, and connects it by four
stitches to the front corner of the wound (3).
  (1) This operation was proposed by Littre in 1720; but first practised success-
fully by Dinet in 1793 (b).  See also Freer (c).
  (2) This mode was tried by Roux without success.
  (3) Amussat has performed this operation successfully in a woman of forty-eight,
and in a man of sixty-two years of age (d).                          ,
  Pilore  (e) made an artificial anus  on the  right side, by which he opened the
caecum  as  previously advised by Benjamin Bell, and as  was to be  done in the
immobility  of the S.  Romanum.
  The formation of an artificial anus  has  been also  proposed  in adults, for the not-
to-be-overlooked narrowing  of the rectum  from unreachable strictures, and the like.
Freer (/)  made a longitudinal cut, of three inches in the left iliac region, about an
inch above the  upper front iliac spine, and an inch and a half in front of it, laid bare
the colon fastened it with two stitches in the wound,  and opened it longitudinally to
the extent of two inches.  The patient died on the tenth day.   Pring (g) made a cut
obliquely downwards, and inwards two inches above, and an inch on the inner side
of, the front iliac spine, to within three-quarters of an inch of Poupart's ligament,
through the skin and muscles; opened the peritonaeum, and enlarged it to three
inches.  The  sigmoid flexure of the colon was laid bare to the wound.  The result
was successful.
   [See A6hmead,  On a  new operation for Artificial Anus, in Transac-
tions of the College of Physicians of Philadelphia, vol. i. p. 97.    1842.
G.  W. N.]
  Compare also Martland, a case  in which  the operation for  artificial anus was
successfully performed; in  Edinb. Med. and SuTg. Jour., vol. xxiv. p. 271.  1825.
  Svitzer, E., Anotationes in Colotomia.  f'afnae, 1827.
  Oettinger, Ueber die angeborene Aftersperre.  Miinchen, 1826.
  Loper, Dissert, de Vitiis fabric® primitivae Intestini  Recti.   Wirceb., 18-27.
  Klewitz; in Med. Zeit.  des Verein. fur Heilk; in Preuss., No. 17, 1835,—No.
22, 1838.
  Although in imperforate anus, if  no assistance  be rendered, fatal consequences
ensue, in consequence of the stools not being passed ; there are, however, instances
in  which, with  imperforate anus, and even with accompanying deficient  urethral
opening, life has been sustained months (A), and even years (*);  in which cases the
stools have  been vomitted by the mouth.

   1617. When  the anus, though not  imperforate, is yet  congenially
  ^Sys,lema ChirurgiBB Medicinae, vtl. ii.     (e) Actes de la Soci^te de Lyon"   1797 n
p. 842.  Hafn., 1817.                    189.                     '         P
  (6) Sabatier, Med. Oper., vol. ii. p. 336.     (/) Above cited, p. 31.
  (c) Pring : in London Medical and f hysi-    (?) Above cited p 4
cal/ Journal, vol. xlv p. 9.   1>21.             (Jl) Delamarre'; in Journ. de Medecine
  (d) Memoirs sur la possibility d'^tablir un  vol. xxxiii. p. 510.   1770.               '
Anus Artificiel dans la region Iomb.,i e sans     (i)  Baux ;  in same vol  viii n  <U)   p1B
penetrer dans le peritoinc.  Paris, 1832.     tholin,  Historice  Anatomic*, Cent.'i. Obs
                                      65, p. 113. 
CLOSURE OF THE RECTUM.                     39
narrowed, the existing aperture must be enlarged by means of a button-
ended bistoury and director, and then its reunion prevented by  the in-
troduction of lint.  This congenital narrowing of the rectum may be to
such extent, that so long as, during infancy, the stools have little hard-
ness  and thickness, it  is of no consequence, but as the child grows, and
the motions become larger, inconvenience arises {a), and the treatment
must be such as already mentioned.
  [I  had  under my care, very many years ago, a case of imperforate anus (b)
similar to that mentioned by Cruvelhier.  At the time of birth there was  not any
opening, but a  slight puckering marked the place of the anus, and this was pro-
truded each time the child cried.  In front of the scrotum, and  in the track of the
raphe, as it passed on to the prepuce, was a small aperture, just large enough to ad-
mit the entrance of a probe, and from it,  when the  child cried, a small quantity of
meconium passed.  I cut  upon the puckered skin, but  it was full an  inch before the
rectum could be reached, and I then opened it sufficiently to  admit a large urethral
bougie, and the meconium readily escaped.   A  probe,  introduced  at the  opening
before the scrotum, passed along a canal, beneath the urethra, through the perinaeum,
becoming larger and  larger as it approached  the rectum, in which it terminated.
No bougie, or  any thing else, was left in, as I  thought keeping  the  bowels  loose
would have been sufficient to prevent union; however, in the course of a fortnight
the wound had  closed, and no motion was passed, except by the aperture in front of
the scrotum.  I therefore  had to cut into the rectum again, and a piece of bougie was
then introduced, to be worn constantly, but removed  three or four times a-day,  for
emptying the bowels.  This went on very well for a time,  but,  probably,  from
negligence, the scar contracted, and at the  end of three months  the anal  opening
would not admit even the point of a probe.  The scar was, therefore, again  divided,
and a larger bougie introduced, and worn for a fortnight, after which, a short pewter
pipe, about the  thickness of the little finger, with a circular shoulder to prevent it
slipping entirely into the gut,  was introduced, so that the motion might pass con-
tinually by it, and the opening be established.   Two  months after, the pipe having
slipped out, and been neglected, the opening had again closed, and again  required
enlarging with  the knife to readmit the tube.  The parents' negligence again  com-
pelled the dilatation of the aperture with the knife, and a large bougie was directed
to be passed frequently.   I  did not again see him until he was seven years old,
when he was a  well-grown boy, but with an enormously distended belly.  The anus
continued open, though not very sufficiently, and the  orifice before the scrotum was
still open, and, occasionally motion passed by it.  I was desirous  of removing this
unnatural canal, but the mother was averse to it, and  the child's unhealthy appear-
ance did not  lead me to  expect that he  would  live very long.  I had entirely for-
gotten him, when, eleven years after, (he being then eighteen years old,) I was
surprised on seeing a fine healthy young man, who said he was the person on whom
I had previously operated.  The appearance of the anus could be  compared to
nothing else than a bullet-hole in a board; he said he had no difficulty in passing
or retaining his motions;  but it was quite  evident, from his linen, that there was a
continual oozing.  The opening in front, instead of being near the fraenum praeputii,
was now close  to the scrotum, and a  small  quantity  of stool  occasionally escaped
from  it.  On examining more closely,  I found the anal orifice completely filled with
a protruded portion of the lining of the rectum,-  it, however, offered no obstruction
to the finger, which readily passed up  as far as the knuckle, and was received  into a
 large cavity full  of faeculent matter, and  running forward  along the perinaeum,
beneath the membranous part and the  bulb of the pern's,  to the  back  of the scrotum,
 where the  canal narrowed, and  would only admit the  finger; with this the opening
before the scrotum, communicated.  It was curious, in this case, that although  there
was an entire absence of the sphincter muscle, the stools did not pass involuntarily;
the protruded fold of the  internal membrane seemed to form a valve which prevented
ordinarily the escape of the stool, and compensated the  deficiency of the sphincter.
I proposed to him the removal of the continuation of the bowel into the perinaeum,

  (a) Boyer, Traite des Malad. Ciiirurg.,    (b)  St. Thomas's  Hospital Reports, p.
vol. x. p. 3.                               121.  London, 1836.   8vo. 
40
SPASMODIC CONTRACTION
but he would not submit to any operation.  I have not seen him for the last eleven
years.—j. f. s.]
   1618.  The narrowing of the rectum, which takes place in later years,
arises either from spasmodic contraction of the m. sphincter ani, or from
a thickening, swelling, or degeneration of the mucous or other membrane of
the rectum, or from swellings in the neighbourhood of the rectum, orfrom
large scars, which have formed near the anal aperture.
   1619.  The spasmodic*contraction of the anus is, for the  most part,
accompanied with a fissure, or with a cleft, in the folds of the sphincter
muscle;  though it is, however, seen without either.  Adults appear  to
be almost exclusively subject to this  complaint, and women more fre-
quentlyTthan  men.  Its  causes are very obscure; it is frequently pre-
ceded  by haemorrhoidal congestion, or it occurs after the removal  of
piles.  It is more probable, according to  some, that the fissure  is pro-
duced by the spasmodic contraction, than that the latter is  caused  by
the fissure.  From my own observations, however, I hold the contrary
opinion.
   1620.  The disease develops itself very stealthily;  at first the motions
are accompanied with heat and  burning, which, however, gradually
subside, and often cease entirely, if the patient lake heating drinks, use
clysters, and wash frequently with cold water.   The sensation of heat
and  burning  soon, however, returns, and  continues for a longer time,
after going to stool.   The relief of the bowels is mixed  with blood, the
pain increases; aperients,  clysters, and cooling  diet,  indeed, produce
alleviation, though only for a  short time,  and the complaint proceeds
in spite of their employment.  Going to stool becomes so difficult, that
the  bowels can  often only be forced every forty-eight hours, by a
purge, by repeated  clysters, or injections thrown  up  every hour.   If
the costiveness continues several days, the relief is followed by pain  as
severe as if a hot iron were  thrust into the rectum ; even convulsions
and  fainting  may ensue, and after  the relief of the bowels, there  re-
main pain, shooting, and beating, as in an inflamed part.   Every violent
effort, the use of too heating food, or food taken in too  great quantity,
always aggravates  the  complaint,  and the patient, therefore, usually
takes but little nourishment.   In  females, the  pain often increases at,
the coming  on  of the menstrual  periods, and  also  arises from every
exertion, cough, jumping, making water, and  the  like.   Some patients,
in this disease cannot sit, whilst others cannot stand.  In consequence
of this  contraction,  very large quantities  of stool  are  retained,  the
pressure of which, against the anus, causes long-continued and fruitless
straining, and its discharge can only be produced by injections, or  by
the mucus which the intestines  secretes; even the escape of air is often
accompanied with pain.   When the disease has loner continued, wast-
ing takes place from the severity  of the pain,  and disturbance  of  the
rest, very great sensibility, often hypochondriasis, and affections of the
neighbouring organs, as retention of urine.
   1621. On  examining the external orifice of the rectum, hasmorrhoidal
tumours or little  knots are often found; also, in some cases, a slight dis-
charge, which symptoms, according to  Boyer, not in immediate relation
with the complaint, on the  contrary, are so, according to  my experience
as, after the removal of such knots, I have noticed  a speedy cure.   In 
OF  THE ANUS.
41
those cases in which contraction of the anus is accompanied with fissure,
the lower end of the latter is found at the part where  the patient feels
pain, usually in the right or left side of the circumference of the  anus:
in most cases it, however,  can  only be seen, when  the buttock of the
affected side is forcibly drawn back, and the anal orifice drawn a little
asunder, in many cases, indeed,  the fissure cannot, even in that way, be
discovered.  The introduction of the finger into the rectum, which always
causes severe and almost unbearable pain, if it press on the fissure, dis-
covers a violent, permanent contraction, but  neither swelling nor hard-
ening of the mucous membrane:  but at one  spot, a  lengthy indentation
running the length of the  intestine  may be found ;  or the fissure is dis-
tinguished by the peculiar pain which the patient feels when pressure is
made upon it.
  [Brodie observes, that, "in connexion with the spasmodic  contraction  of the
sphincter muscle, you will  frequently find a small ulcer of the mucous membrane of
the rectum.  This ulcer is  always in a particular spot, at the posterior part, opposite
to the point of the os coccygis.   I imagine that it arises from  the  mucous membrane
there being torn by the pressure of the hard faeces, at the time that the evacuation is
labouring, as it were, to get through the contracted orifice of the anus.  Such an
ulcer as I have just described  adds  very much to  the patient's sufferings.  It is
always excessively sensitive; the least pressure of the finger upon it occasions the
patient the greatest pain, and the pressure of solid faeces produces the same effect.
(p. 26.)
  Bushe (a) speaks of another form of spasmodic contraction of the sphincter ani, in
which no primary affection of the gut  is discoverable, and in which the introduction
of the finger into the gut does not give pain. (p. 126.)]
  1622. Spasmodic contraction  of the anus may be distinguished from
its narrowing, by the swelling, and  by the disorganization of its mucous
membrane, by the pain which accompanies going to stool, and continues
some time after, by the  absence of discharge of matters,  by the long-con-
tinuance of the complaint,  and  by the introduction of the finger beyond
the contraction of the  sphincter, discovering neither tubercle nor hard
ring formed by the internal  membrane of the rectum.   The characteristic
sign is the fixed pain at one spot of the circumference of the anus.  It
must not, however, be overlooked, that continued spasmodic contraction
of the rectum gradually causes a  greater development and activity  of the
sphincter, as  well as plastic exudation, organic changes, and  thickening
of the gut itself from the constant irritation.
  1623. The remedies employed for spasmodic contraction are, cooling
treatment, the  avoidance of all heating food  and drink, frequent  use of
gentle purgatives, and  clysters  several times a-day, steam-baths of hot
water, decoction  of chervil, infusion  of elder flowers, cold hip-bath,
whole or half bathing, application  of leeches, narcotic injections, sup-
positories  of opium, hyoscyamus  and belladonna, a drachm of acetate of
lead, a drachm of extract of belladonna with six drachms of fat, according
to Dupuytren's prescription, opiate ointment; also, a salve,  composed
of equal  parts of lard, expressed juice of houseleek,  nightshade, and
sweet  almonds.  These remedies, indeed, relieve the  patient,  but are
nearly always inefficient for the cure, and even commonly  for assuaging
the complaint (1).  Any attempts to  enlarge the anal orifice with bougies,
according to Boyer and others, increases the  pain and contraction.  Be-
(o) Above cited, 
42
TREATMENT OF SPASMODIC
clard {a) has, however, employed masses of lint, of gradually increased
thickness, to cure the spasmodic contraction of the rectum without  fis-
sure.  According to Delaporte {b) the bougie should be smeared with
belladonna ointment.   He prefers this to cutting, and does not object to
touching the fissure at the same time with caustic,  by which the pain is
suddenly got  rid  of: he mentions instances in which cutting was of no
service.   According to Bushe (c) all purgatives should  be avoided, as
they always irritate ; a linseed clyster daily, together with careful cleans-
ing of the parts, is preferable.   If the disease be slight, the application
of lead ointment may be sufficient, and in violent spasm, extract of bel-
ladonna at the same time.   In  superficial tissues, lunar caustic should be
used, and with it  a dressing of lint  spread with one  part of  extract of
belladonna,  and seven parts oiung. rosat. (2).   According to Pagen  (d)
the parts should be smeared with a mixture of opium cerate and extract
otmonacia; and Bretonneau (e) recommends fomentations of rhatany.
I have, in some instances, effected a  cure at the  beginning of the disease
with bougies  smeared with zinc ointment, or  by its introduction.   We
should always examine the anus very closely,  touch every part with  the
finger, especially every knot, and remove it, if painful.   I have  ascer-
tained by experience, that  spasmodic  contraction  of the  anus is more
frequently the  consequence of  seemingly trifling things, than  is usually
supposed.   Similar symptoms  are often observed, from the trifling ulce-
rations, and little  excrescences about the female urethra,  after the cure
or removal  of which, the most severe symptoms of difficulty  in making
water quickly subside.  I have ascertained that, in such cases, the dis-
ease may be got rid of, at first,  by the removal of such excrescences, or
the cure of the fissure, but which is often "useless, if too long delayed  till
the above-mentioned changes of the rectum have occurred (3).
  (1) Only in one instance, where the fissure was accompanied with moderate con-
traction, was the cure effected by Boyer's treatment.  I noticed this once in a fissure,
with violent contraction and very severe pain, in a woman.
  [(2) Brodie objects to the use of the belladonna, as  "even  in the form of a sup-
pository, it sometimes produces very serious symptoms by its influence on the brain."
(p. 26.)]
  (3) In one case, in which the spasmodic  contraction of the anus was accompanied
with most severe pain, I found, on examination, a fissure, and with it a very small
red knot; I first cured the fissure by frequently touching it with a solution of cor-
rosive sublimate, which gave relief, and then by the removal of the little knots, an
immediate cessation of all spasmodic contraction, and a complete cure ensued.
  1624.  The  surest mode of getting rid of the contraction, either with
or without fissure, if it withstand the previous  treatment,  is, to cut into
the edge of the anus, either at the seat of the fissure or at any other part.
The patient should take a mild purgative three days  before, and on  the
morning of the operation a clyster  to empty the bowel, and to  avoid  the
necessity of going to stool for  some days.  He  should be laid upon  his
side, as m the operation for fistula in  ano, the forefinger of the left hand
oiled passed into the rectum, and a narrow, button-ended bistoury intro-
duced flat upon it,  the edge of which being turned  to the side on which

  (a) Bulletin  des Sciences Med., 1825, p.   (d) Gazette Medicale, vol. viii. p. 59 1840
                                   No. 4.
  (b) Revue Medieale  vol. ii. p. 110.  1830.   (e) Trousseau ;  in same. No. 36
  (c) Above cited, p. 137.                                           °D" 
CONTRACTION OF THE ANUS.                 43
the fissure is, cuts through  with  a stroke the intestinal membranes, the
sphincter muscle, the cellular  tissue, and common teguments, forming a
triangular wound, the apex of which corresponds  to the cavity of the
bowel, and its base to the external skin ; sometimes a lengthening of the
latter is requisite, which must be  done with  a second stroke of the bis-
toury.  If, by the escape of the bowel from the edge of the knife, the
wound in the cellular tissue be higher than in the intestinal membranes,
the latter  must be farther divided with the  knife or with blunt-pointed
scissors.   In very violent contraction of the  anus, two cuts may  be thus
made, one on each side, and if the fissure  be before or behind, it is not
to be included  in the cut.   The  success of  this  operation is often very
surprising.
   1625.  The dressing consists of a pretty thick plug of lint between the
edges of  the wound,  upon which some wadding  and  an oblong pad
should be applied, and the whole fastened with a T bandage.   Bleeding
but rarely occurs, and is easily stopped by a slight pressure.  After three
or four days, the first dressing is  to be removed, and replaced daily till
the  cure  is  completed, which happens in  about  four  or  six  weeks.
Walther rejects the  introduction of lint  and the like  as useless and
painful.
   Upon this subject, see further,
   Delpech, Precis Elementaire, vol. i. p. 598.
   Bover;  in Journal complementaire du* Diet des Sciences Med.   Nov., 1818.
   Baillie, Matth., M.D.; in Med Trans, of College of  Physicians of  London,
vol. v. p. 136.
   Gaitskell; in London Med. Repository, vol.  iv. p. 51.
   Blackett; in same, vol. vii. p. 377.
   Boyer, Traite des Malad. Chir., vol. x. p. 125.
   Baseoow, Ueber die Strictura Ani spastica; in von Graefe und von Walther's
Journ., vol. vii. p. 125.
  Nevermann,  Ueber die Fissur des Afters  oder die Strictura  Ani spastica; in
Holcher's hannoverischen Annalen, vol. i.  p.  729.
   1626. The narrowing of the rectum, depending on chronic inflammation
and incipient degeneration of its mucous membrane, is always of slow pro-
duction.  At first there is  a  troublesome  itching  in the bowel, and a
secretion  of muco-purulent fluid.  By degrees the patient  is attacked
with frequent inclination to go to stool, when he strains much and passes
only hard  motions, of thinner size than usual: there  is a sensation of ful-
ness in the course of the colon, but especially in the  region of the sigmoid
flexure ;  going to stool becomes more  painful  and difficult,  digestion
fails, frequent belchings occur, with occasional severe colic ; the collec-
tion of stool is often  so great that the belly becomes swollen, and inflam- ,
mation ensues.  Frequently, if  the narrow part be high  up,  and the
bowel below have lost its expulsive power, the  stools  squeeze through
the stricture in little pieces, collect beneath  it, and are discharged in the
ordinary sized  masses.   If diarrhoea occur, the patient usually feels more
easy,  in rare  cases there  is diarrhoea  throughout the whole pourse of
the disease;  these  are  of the  worst  kind, as  ulceration  is going  on
simultaneously in the upper part of the intestinal canal.
   1627.  The disease proceeds more  or less quickly according  to the
difference of constitution ; the general health is sometimes affected early,
sometimes remains for a long while undisturbed.  As the narrowing in- 
44
CHRONIC STRICTURE
 creases, the  costiveness  becomes greater,  the belly harder and fuller;
 the digestion becomes more affected, the colic more frequent and severe,
 and the feet swell.   From the continuing costiveness, faeculent vomiting,
 as well as quickly fatal inflammation of the belly, or perforation of the
 intestine  above the stiicture,  may ensue,  especially if kernels or other
 foreign bodies  remain sticking in the stricture, and completely close it.
 If there be perforation, it usually occurs  close to  the stricture, at one
 part softened by inflammation, at which the stools are rarely poured forth
 into the cavity  of the peritoneum, but rather into the cellular tissues sur-
 rounding the rectum,  and  gangrenous  abscesses form around the  anus
 and on  different parts of the buttocks.   When these burst, or are opened,
 a quantity of foetid  ichor  and  motion burst forth,  a  large part of the
 coverings  becomes  gangrenous, and the patient dies quickly, or fistula
 form, and the person may live some time in  a lamentable condition.
  The  stricture may run on to ulceration ;  severe pain,  ichorous dis-
 charge, and  even  bleeding then occur;  all assume  a carcinomatous
 character;  the  destruction attacks the neighbouring parts,fistula form,
 the skin about the  anus  and on  the buttocks,  the  urinary bladder, the
 vagina, and womb, are attacked with ulceration; and when the destruc-
 tion  has extended far,  the stools cannot be retained, but pass involunta-
 rily, and the patient dies exhausted.
  ["In  some instances,"  Brodie states, "the patient  dies with symptoms of stran-
 gulated hernia ,• that is, a piece of hard fasces is lodged above the stricture and cannot
 pass through it; thus there is a mechanical obstruction to the passage of the faeces ,•
 the belly becomes tympanitic, the tongue dry;  there is sickness, vomiting, and the
 other symptoms indicating strangulation.  He may have one of these attacks, and
 by means of injections and the use of a bougie, may recover; he may have a second
 and recover from that; and then he may have a third, which may prove fatal."
 (p. 28.)
  Astley Cooper (a) used to  relate the  case of a woman who, labouring under
 stricture of the rectum, was obstinately costive.  On examination, a plum-stone was
 found to have lodged just  above the stricture;  it was  removed with stone-forcepa,
 and she  recovered.]
  1628. By the chronic  inflammation,  which  causes  stricture of the
 rectum, the mucous  membrane, the  cellular tissue beneath it, and after-
 wards all  the other  membranes, are thickened, till at last the whole gut
is affected.   The changes which the inflammation  produces, are either
 its conversion into  a hard, fibrous, even cartilaginous  tissue (1) or into
 scirrhous degeneration, or into  ulceration, with  or without fibrous, carti-
 laginous, scirrhous, or oedematous degeneration, or into the formation of
fungous loosenings, sarcomatous excrescences (2), or into shrivelling and
 contraction  of  all  the parts at  once, so that  this part of the (nit is
 diminished  to the size of  a quill, and its cavity often completely disap-
 pears.
  [(1)  Brodie says :—"On dissecting a simple stricture of the rectum, I have found
 the mucous membrane thickened, of a harder structure than natural, and the muscular
 tunic thickened also.  The stricture sometimes occupies the whole length of the
 gut, for some way up, above the anus, perhaps three or four inches; at other times
 it is only of short extent." (p. 28.)
  (2) This, I presume, is the  condition to which Lawrence (b) refers  where  he
 speaks of " another form of disease, (stricture of the rectum,) in which the mucous
 membrane seems to be formed into a large, spongy, soft, excrescence, in which the

   (a) MS. Lectures.                 (i) Lectures; in Lancet, vol. ii. 1829-30. 
OF THE RECTUM.
45
 patient was affected with all the symptoms that would be produced by stricture; for
 this spongy state of the membrane diminished the dimensions of the bowel." (p.
 855.)—j. f. s.]
   1629.  These changes have either a  less or a greater extent; com-
 monly, they are circular, and the  narrowing is so considerable, that an
 aperture, not larger than a straw,  alone  remains; often they occur only
 at one side or on the edge  of the valvules conniventes, in consequence of
 which  cord or bridge-like  contractions, single,  cone-like growths are
 produced.   These growths, of different size, attached with narrow necks
 or by a broad  base, soft, hard, spherical,  oval, single,  and vegetating
 sparingly, or growing luxuriantly,  collected in wide or thick groups, are
 often confined to the edge of the rectum, or  spread over the whole extent
 of the cavity of the rectum, or even extend into the  colon.  Although at
 first insensible, they grow, become painful, and terminate in cancerous
 ulceration, as already described.   The distinction between these excre-
 scences and the hard, hsemorrhoidal knots consists specially in their yel-
 lowish red colour, their smooth-skinned, even, tense  surface exhibiting
 not the  slightest trace of  blood-vessel,  in  their  regular, firm, in  some
 degree elastic consistence, in the absence of all fluctuation, and in their
 complete insensibility on great pressure.   The various form and condi-
 tion of these hardenings depend on the seat, extent,  and character of the
 inflammation and irritation.
   See further on this subject,
   Desault, Squirrhosites du Rectum, in his 03uvresChir., vol. ii. p. 422.
   Schreger, Ueber tuberculide Excrescenze; in his Chirurg. Versuchen, vol. i. p.
 258.
   Tanchou, above cited.
   1630. Stricture of the rectum,  from the above-mentioned  changes
 of its  membranes, may happen  at all parts of the bowel, but most fre-
 quently in the region of the internal sphincter, about two or three inches
 above the anus.  The knowledge of stricture of the rectum, its seat,
 nature, and form, is simply and  alone to be obtained by examination.
 On the introduction of the finger, oiled, a narrow, hard, unyielding part
 is felt, either as one or several little, projecting folds or partitions, into
 the opening  of which the  finger can be introduced only with difficulty or
 pain, or not  at all; or as  a hardening and contraction of the walls of the
 gut to a great extent; or as ulceration, with hard edges; or as tumours
 of various form.   The examination should be always made in the recum-
 bent posture, because the valve-like narrowings at the upper part of the
 gut, which mostly are seated on its front, form a sort of pouch  in front,
 and above the  narrowed  part, which, when the patient stands  upright,
 prevents the examining finger discovering the stricture.  If the narrow-
 ing be so high that the finger cannot reach it, the  examination  must be
 made with a wax bougie or a sound covered with modeller's wax, which,
 softened and oiled, should be carefully introduced into the rectum,  and
 gently pressed on the seat of  stricture, in  order to take an impression of
 it.  In doing this, the anatomical relations  of the rectum, and the rules
 subsequently laid down for the introduction of the  bougie,  must be
remembered  to  prevent  mistake, as the  examination by this  mode is
much less certain than with the finger.  Particular instruments, used for
examining  stricture of the rectum, a  stem with a ball, as recommended by
   Vol. hi.—5 
46
STRICTURE
 Howship and Calvert, are to be set aside, if the finger can  reach  the
 stricture.  When the symptoms lead to the supposition of stricture of the
 rectum the examination  should always be made  as soon as possible, in
 order to  discover the disease in its earliest stage of development.

   [Lawrence (a) observes :—" We cannot, however be certain that stricture of the
 rectum is the cause of any of the  symptoms under which a patient laboors, unless
 we have  the power of feeling the contracted part of the gut with  the finger, or of
 ascertaining its existence by an instrument, a rectum bougie, introduced there:  and
 indeed we can hardly  get clear evidence of the fact, when stricture  is higher up in
 the bowel than we can reach with the finger; for you will recollect that the course
 of the rectum is by no means straight, and the surface of the intestine is not smooth
 and uniform; in its natural  state  there are folds and  irregularities which present
 obstacles to the passage of an instrument along it. * * *  In all instances, therefore,
 when the disease of the bowel is  situated  higher up than you can  reach with  the
 finger, the evidence is more or less uncertain, unless the difficulties  in the evacua-
 tion of the faeces, or the peculiar configuration and diminished size of them should
 be well marked." (p.  856.)
  Bushe (b) remarks, that "organic stricture (of the rectum) is supposed by many
 to be  of very common occurrence,  but I have not found it to be so; for the cases I
 have seen bore no proportion to the number I ought to have met with, were the state-
 ments made in books correct."  (p. 264.)
  There has been much said and written as to the usual seat of stricture of the rectum,;
 it has been said to be  most common about the termination of the  colon (White)
 (c), or five or six inches from the anus, and next in frequency at the junction of the
 sigmoid flexure of the colon with the rectum.   (Salmon) (d).  These, however,
 must be very rare cases, for all the best authorities declare the stricture to be almost
 universally low down.  Charles Bell (e) says:—"not unfrequently, the inner
 edge of the deep sphincter ani being the seat of this stricture; and then the finger only
 enters to the depth of the second joint, when it is obstructed by a sort of membrane
 standing  across the passage.   Sometimes  the stricture is more than two inches
 within the anus, and feels like a perforated septum." (p. 330.)   Colles (/) says  :—
 " In a few instances the stricture has been seated so high up in the gut, that it could
be but barely touched with the point of the finger, until  the patient was desired "to
force down," and then a satisfactory examination of it could be  made." (p.  139.)
 According to Allan (g), " stricture of the rectum most commonly occurs near  the
 termination of the gut, a little within the sphincter, but it may take place in any part
 of the rectum, sometimes the whole gut is lessened in diameter, and on other occa-
sions the stricture is situated in the sigmoid flexure of the colon." (p. 488.)  Lis-
ton (h)  speaks of it as "readily ascertained by  examination with the finger."  (p.
73.)   And Syme (i) that "it is generally found at about two and a half or three
inches distant from the orifice, but may he situated much hio-her up." (p. 445.)
Brodie (k), in speaking of these strictures, says they  "are commonly situated in
the lower part of the gut, within  the reach  of the finger.  Are they ever situated
higher up ?  I saw one case where stricture of the rectum was about six inches above
the anus, and I saw another where  there was stricture in the sigmoid flexure of the
colon,  and  manifestly the consequence of a contracted cicatrix of an ulcer which had
formerly existed at this part.  Every now and then, also, I have heard from medical
practitioners of my acquaintance of a stricture of the upper portion of the rectum, or
 of the sigmoid flexure of the colon,  having been discovered after death. Such cases,
however, you may be assured, are of very rare occurrence.   Inquire of anatomists who
whnP«pJ?r ma,ny yeKrS te/chers.ln 'he dissecting-room, or of surgeons who have
witnessed a great number of examinations in the dead-house of an hospital, and they




 Ti) SSi^d M^          8 « ElLL9 °f ^^y.^don8^.

 Ur^srKutts^smhr^0^  i8g.pt::ples  of Sur^-  **»*»*
 l822'                                    (k) Above cited. 
OF THE RECTUM.
47
will bear  testimony to the  correctness of what I have now stated.  Nevertheless,
an opinion has of late years prevailed among some members of our profession, that
a stricture high up in the  rectum  is a very frequent  cause of constipation of  the
bowels; and I have known an almost incredible number of persons who have been
treated on the supposition of their labouring under such a disease, by the introduc-
tion of long  bougies  into the bowel.  The only evidence of the existence of  a
stricture in these cases has been, first, that there was obstinate costiveness; secondly,
that a bougie introduced into the rectum could not be made to pass beyond a certain
number of inches beyond the anus.  But what  is the  value of this evidence com*
pared with that which anatomy affords of the rarity of this kind of stricture?  Are
there not many causes of a costive state of the bowels, besides mechanical obstruc-
tion'?  Will  it be always easy, even in the most healthy rectum, to introduce  a
bougie more than a few inches into it?  Although we  call the lower bowel  the
rectum, you know very well that it is any thing but a straight gut.  Three  or four
inches above the anus, the rectum begins to make flexures, which increase as you
trace it upwards, until they terminate  in the sigmoid flexure of the colon.  These
flexures of the rectum differ in different individuals, and even in the same individual,
at different periods.  When a bougie is introduced, be  it small or large, it is  certain
that it  will be stopped somewhere  or another by one of these flexures; and nothing
can be more unphilosophical than to conclude, because a bougie  meets with  an im-
pediment at the distance of five or six, or eight or nine inches, that this is the result
of an organic disease  of the  rectum, when  the natural formation of the parts will
sufficiently account for it.  But let  us  suppose that you actually meet with one of
those rare cases  in which there is a stricture in the upper part of the rectum ,•  by
what means are you to recognise the disease in the living person?  Or  if you can
recognise  it, how can you know its exact  situation ?   If the  bougie can only be
introduced to a certain distance, how are you to be certain that it is stopped by the
stricture, and not by a fold  of the  bowel, or even by  coming in contact with the
sacrum?   Further  than this, if you employ the force which you would  suppose to
be necessary to make the bougie penetrate through the stricture, is there no  danger
of penetrating the tunics of the intestine instead?  This last is no theoretical objec-
tion to the use of these long bougies in diseases of those parts.   I will not say that
I have seen the  patients; but I have been informed on  good authority,  of not less
than seven or eight cases in which  this frightful accident occurred, and the patients
died in consequence." (p.  30.)   Lastly, Bushe states:—"Independently  of the
malignant forms of disease hereafter to be described, I  have very seldom  seen a con-
traction of the rectum  which was not within the  reach of the finger." (p. 265.)   I
am  afraid that the conclusion of one of his notes is not  without its parallel  in this
country, and ought to be held up to the reproof it richly deserves.  " I am  mortified
to add," says he, " that I have good reason for supposing  there are a few who make
a profitable trade of treating dyspeptic patients for stricture of the rectum, asserting
that the obstruction is high up, when in truth, this intestine is perfectly free from
structural disease.  Such practitioners, by passing bougies, apparently cure, what in
reality never  existed, and thus obtain a character for skill in the treatment of this
disease, which in truth they do not possess."—(p. 266.)

   1631.  The immediate cause of stricture of the rectum is always a more
or less extensive inflammation or continual irritation  of the rectum, in
consequence of which there is  secretion of plastic  matter, thickening and
degeneration of the tissue.  The causes are, hseniorrhoidal affections and
abdominal plethora, anomalous gout, syphilis, metastasis of skin diseases,
suppression of the  usual discharges, frequent indigestion, badly treated
irritation  of the intestinal canal,  diarrhoea,  improper use of irritating
purgatives, constant costiveness, injury of the rectum by foreign bodies,
extirpation  of hasmorrhoidal  knots,  operation for fistula in  ano, and
paadarasty, as I have witnessed in two instances.
  1632.  The prognosis differs  according to  the degree, condition, seat,
and cause of the stricture.  Membranous, circular, and strictures unat-
tended with ulceration, if not  seated high up, lead to a favourable prog- 
48                         TREATMENT OF

nosis.   If the disease be more advanced, the stricture accompanied with
much hardening, seated high up, and its causes cannot be removed, the
prognosis is unfavourable;  perhaps  by cautious treatment  temporary re-
lief may be obtained, but never a perfect cure.  If the stricture have run
on to ulceration, the patient, generally, can scarcely obtain relief, and any
treatment  not especially cautious,  renders  him worse, and hastens the
evil results.   The same happens in carcinomatous degeneration.
  [Brodie observes, that " success in the management of this disease will vaTy very
much in different cases.  It will depend chiefly on the period of the disease on which
you are  consulted.  If it be quite in the early stage, you may render the patient
great service; and although you cannot  cure the stricture of the rectum, any more
than you can cure  the  stricture of the  urethra, yet you can dilate it, and keep it
dilated, so that the patient will suffer little from it, and that it will not shorten his
life.  But if you are  consulted in the advanced stage, when the stricture is much
contracted, when the mucous  membrane is ulcerated, when abscesses have formed
in the  neighbourhood, you can only palliate the symptoms  in some degree.  The
patient  under the circumstances, in  spite of all your efforts, will lead a miserable
life, and in all probability will  utimately fall a victim to the disease." (p. 30.)]
  1633. The treatment of  stricture of the rectum  consists in subduing its
cause  and the constitutional disease in  causal relation to  it, and in the
removal of the stricture.  The first indication requires the use of  suitable
antiphlogistic remedies, or such as operate on the skin,  purging, proper
treatment of hemorrhoidal affections and abdominal plethora, and so on;
but especially strict attention to the  mode of living, carefulness as to free
relief from  the  bowels, repeated application of leeches, soothing injec-
tions into the rectum, hip-bath, rubbing in mild ointments  with,  accord-
ing to circumstances, extract of belladonna or cicuta.   By such treatment,
with proper  care, and corresponding  to  the circumstances of the indi-
vidual  case, a stop may be put  to  an  incipient  stricture,  as I have in
some instances  observed.   I have also used at the same  time, internally,
iodide of potash with good effect.  But such  result is only possible in
the very beginning  of a stricture; if it have already proceeded farther, no
effect can be produced on  the stricture itself, but  it  is necessary, if the
stricture and the rectum be in  a state of  irritation, to undertake in addi-
tion the direct employment of mechanical remedies upon  the stricture,
which  consist of stretching, cutting into  or cutting out, and cauterization
of the  stricture.
  ["In some cases,"  says Brodie, "the faeces accumulate above the stricture, the
bowel,  in this situation, becoming distended into a large ba<r, formina an  immense
reservoir of feculent matter, always pressing against the  stricture, and aggravating
the disease.  It is very important to empty the bowel which is thus loaded ; and you
can only do it in the following manner:—Introduce an elastic gum catheter through
the  stricture into  the  feculent mass above; inject tepid water,  or tepid  soap and
water, or a weak solution of caustic alkali; and by repeating this operation, and wash-
 n"! Snip6 f 11 Wf   T"? W3ter ^Ve-ry *?*> or every other daV< W ™J at last get
£?,  t*\     feculent accumulation d.ssolved, and empty "the  reservoir.  When
reneated  tZ T™™* 'f^'  the  lnjfCtion °f Warm water should be constantly
repeated, so as to  prevent the accumulation taking place again."  (pp. 29, 30.)]
   1634. Stretching, by which the narrowed part may be enlarged and
the  consolidation of the  cellular tissue accompanying  it  overcome  is
effected, with plugs, wax, and elastic bougies, spoJgeW with metal-
lic, linen, or goldbeater's skin dilators, and  the like.
   163o. The plugs of lint  which Desault used with the especial object 
STRICTURE OF THE RECTUM.
49
 of introducing medicated substances,, are carefully passed into the stric-
 ture with a plug-holder, after having been smeared with mild ointment,
 to which extract of belladonna, or cicuta have been added; or an injec-
 tion of decoction of cicuta is made.   The plugs should be made thicker,
 and allowed to remain up for a longer time, according as the patient can
 bear them.   As their introduction with the holder is often difficult, and
 the plug completely closes the rectum, so as even to prevent  the escape
 of air, Tanchou has proposed fixing the plug on an elastic metal canula,
 and to  introduce it on a silver button-ended probe, first passed into the
 stricture.
   1636. Elastic and wax bougies, of corresponding size, are  introduced
 into the stricture.   Properly prepared wax bougies, of from one to three
 and half inches in circumference (Salmon) are the  best.   In introducing
 these bougies the  following rules are to be observed, according to the
 different heights at which the stricture is situated.   The bougie, curved
 according to the  curvature  of the rectum, and well oiled, with the con-
 vexity corresponding with the first curve of the gut, and directed towards
 the sacrum, is thrust in upwards and backwards, in this direction, to the
 extent of two inches.  After a little waiting, the bougie  is  introduced
 still higher, from three to three and a half inches above the second curve
 of the rectum;  the  inner extremity of the bougie still remains  in the hol-
 low of the sacrum,  and the outer end is inclined to the left side.   If the
 bougie  be introduced still further, its direction must be changed, the
 outer end being raised from left  to right in  a semi-circle, and  pushed
 forwards at the same time, and in this manner it may be introduced yet
 four inches further.   If the instrument have to be passed  into the sigmoid
 flexure its outer end  must be pressed gently down, and pushed upwards,
 till it be completely carried in.   The deeper the instrument is  introduced
 the  more care must be taken, lest dangerous irritation, or even perfora-
 tion, of the  sigmoid flexure should occur.   There is, commonly, pain
 over the whole  belly, and violent  forcing.   The contraction  of the
 sphincter  causes the most difficulty;  the bougie,  therefore, of different   •
 length,  according  to the  seat of stricture, is to be well passed into the
 rectum, and there retained by means of a bandage attached to it.  The
 patient should keep quiet in bed, and the bougie allowed to  remain in,
 not longer than from six to ten minutes, nor so long, if the patient corn-
 plain of severe  pain.  Its  introduction is to  be repeated every two or
 three days, its size  increased, as also the time it should remain, accord-
 ing  to  the patient's  irritability, but every violent irritation  should  be
 carefully avoided.   I have used elastic bougies, with a dilator, as  in nar-
 rowings of the oesophagus, (par. 1606,) which I once  introduced into a
 stricture, and repeated every two days, as dilatation, continued, for some
 time, easily sets up  considerable irritation, and even becomes unmanage-
 able.  In strictures, situated high up in the rectum, the elastic or wax
 bougies are the only  remedies which can be employed.

  [Brodie observes :—" In a great  number of  cases, where the the disease is far
 advanced, you cannot resort to the use of the bougie  in the first instance, or, if you
 do, it must be employed in combination with other remedies.  It will be necessary
 to lessen the irritability of  the bowel by the introduction of aa opiate  suppository
 every night, and a gentle aperient taken in the morning.   The patient  may take a
combination of caustic potash with, copaiba; half a drachm of balsam  of copaiba,. 
50
TREATMENT OF
fifteen  minims of liq. potass, three drachms of mucilage of  gum arable, and about
nine drachms of carraway water.  A draught of this composition may be taken three
times a-day with very great advantage.  Bryant, of Edgeware-road, recommended
to me a decoction of Achillea millefolium, which I have employed in some of these
cases with manifest advantage.  About two ounces  of the Achillea may be put into
a pint and a half of water and boiled down to a pint, of which the patient may take a
wine-glass full three times a-day." (p. 29.)
  With regard to the use of bougies in stricture of  the rectum, Lawrence says:—
" It is a question how far the stricture can be relieved by the introduction of bougies.
"When the stricture is situated so near to the anus that you can examine it with your
finger, and when you can, therefore, ascertain with considerable certainty something
of the state of the bowel, when you can ascertain, by such means, how far the me-
chanical irritation of dilatation will be borne, you may cautiously use bougies, as in
the case of stricture of the urethra, but you must employ them under the same kind
of restrictions and cautions as  in that case.  Indeed, you may find  it necessary to
be even more cautious in the case of the rectum than in that of the urethra, inasmuch
as you  are so much uncertaiu, when you meet with a difficulty, whether you  are
pressing against strictured  or sound  parts  of the gut.   You must  employ  instru-
ments which  will not be likely to injure  the  bowel.  Very  commonly you find
instruments of elastic gum recommended for this purpose, which have the advantage
of being sufficiently smooth, but they do not readily accommodate themselves to the
course of the canal: I do not consider them eligible instruments.   Therefore you
had better use rectum bougies, made  of a  soft composition; and, I consider, indeed,
that the common plaster bougies, used for the urethra, are not of a sufficiently soft
substance for a rectum bougie.   There are rectum bougies, made for  the purpose, of
a composition so soft, that if you dip them into tepid water, they will be immedi-
ately softened, and very well adapted for the purpose.   These are  what I would
recommend; and you should never employ any force." (p. 856.)
  "In  some cases of stricture of th& rectum," Brodie says, "I have thought that
the patient  has derived benefit from the application of mercurial ointment to  the
inside of the  gut, which  is easily managed in the following manner.  Let  the
bougie  be covered  with lint smeared with mercurial ointment;  the bougie, thus
anointed, must be allowed to remain  in the stricture for a few  minutes dailv."  fo.
30.)]                                                             J   ^
   1637. For the purpose of increasing the extension at pleasure, and to
operate  specially upon the  narrowed part, peculiar  dilators have  been
proposed by Arnott, Bermond, and Costallat.   Arnott, Ss well as
Charles Bell, introduces a piece of prepared gut, by means of a sound,
into the stricture; the distension of  the  former is effected by blowing in
air, and of the latter by injecting water.  Bermond's {a)  and Costal-
lat's  (b) apparatus consists of a little  bag of linen or gold-beater's skin,
introduced into.the stricture, and by filling it with lint, extension can be
made  specially at the seat of the stricture.  The constant distension pur-
posed by these apparatus easily  excites violent irritation and pain  which
is unbearable.
   1638.   In the  dilatation by  metallic  means,  as   the dilators recom-
mended by Weiss and Charriere, for  which also Astley Cooper em-
ployed a pair of narrow forceps, the distention is effected gradually and
repeated m a few days.  Astler Cooper (c) in this  way established the
calibre of the bowel in course of a few weeks, in two instances.   Dilata-
tion with  metallic instruments  can only be  employed in valvular and
recent strictures which are not  complicated with hardening or inflam-
mation.                                                     &

  (a) These, 1827—Velpeau, Elemens de  tion r^rtfcuueremenfcappliq^auxretrpcisse
Kuepf.pr330V.°L 1I'P-988-F—'• ^ir.  mens.du  Rectum.  PaTis? [sT.Zt^Z
  (b) Essai sur un nouveau mode de Dilata-    (c) Tanchou,. above cited. 
STRICTURE  OF THE RECTUM.                  51
  1639. Cutting into the narrowed part, generally objected to by many
surgeons, can be employed only in valvular or circular strictures which
can be  reached with the finger, and are unconnected with inflammation,
hardening, or hypertrophy.  In hardening, and in carcinomatous degene-
ration it always produces bad  symptoms.  A button-ended bistoury is
to be carried in upon  the introduced finger of the left hand, or upon a
director, and the bridges divided with it, or several notches made in the
stricture, at proper distances apart  from each other or at the most pro-
jecting part.  If possible these cuts should be  made towards the sacrum,
and always with care not to extend beyond the bounds of the disease,
nor to cut open the walls of the bowel itself.
  Wiseman (a) first made use of such cuts in stricture of the rectum.
  Copelano (6) says :—"In the indurated annular stricture, which has for a long
time resisted the  introduction or the enlargement of the bougie, I have more than
once introduced a probe-pointed curved bistoury, and divided the thickened parts, on
that side of the rectum which is contiguous to the sacrum;  and I have frequently
seen the late Mr. Foitn perform the same operation.   Wiseman divided a contracted
gut three or four times in the same person; his case,  however, was not one of idio-
pathic stricture, but was produced by the rude operation for fistula in ano, which was
practised at that time." (p. 32.)
   [Brooie recommends the division of the stricture, in the following manner:—
" Introduce a bistouri cache, and let the  screw be so adjusted  that the blade may be
opened about the sixth of an inch, but certainly not more than a quarter of an inch.
The bistouri must be introduced with the blade shut;  then press on the handle, open
the blade, and drawing it out, you nick the stricture first in one part of its diameter,
then in  another, and then in a third..  This being done, a larger bougie may be intro-
duced than could be done before, and the cure is very much expedited." (p. 29.)]
   1640. Extirpation can only be employed in narrowings of the rectum
dependent on tuberculous excrescences, when situated at  the edge or
in the lower part of the rectum, from whence they may be drawn  forth,
or protruded by straining at the anal aperture,and being held with forceps
 or by a thread passed  through  them, may be removed from  their  base
 with knife  or  scissors  without  danger.   Schreger, from  experience,
prefers extirpation in  such  cases, although it had been objected to by
 Desault.   If the excrescences be seated higher, extirpation can only be
 performed under certain conditions as to their form, that is, when they
 are provided with a neck.  No important symptoms follow this opera-
 tion, as the absence of vessels  in  these excrescences and their insensi-
 bility prevent bleeding, and sympathetic affection of the rectum, and the
 internal coat readily shoots over.   If the excrescences be situated higher
 than we can venture without danger to extirpate them, the  removal of
 those nearest the  anal orifice will, however, relieve the patient's condi-
 tion; the application of pressure sufficient to efface those above facilitates,
 and considerably shortens the cure.
   Compare Rognetta (c) in reference to those warts of the  rectum, which in their
 tissue precisely resemble warts on the  skin, and must be removed though they fre-
 quently return.
    1641. Cauterization with a bougie armed with lunar caustic has been
 employed by Home {d) in ring-shaped stricture of the rectum, and cau-

   (a) Several Chirurgical Treatises, p. 239.   (d) Practical Observations on the Treat-
 London, 1676.  fol.                      ment of Strictures  of the Urethra, &c, vol.
   (b) Above cited.                       ii. p. 418.
   (c) Gazette Medicale, vol. iv. p. 387. 1836. 
52        TREATMENT OF STRICTURE OF THE RECTUM.
terization with dilatation by Sanson, in  three cases, though without
particular effect.  (Tanchou.)  Sanson has  recommended a  caustic-
holder similar to that of Ducamp;  Tanchou employs an elastic catheter,
opened at the side, into which he introduces a second fitted with caustic.
Cauterization must always be considered a very uncertain mode of treat-
ment :  it can only  be of use  when properly performed, and the dilatation
is sustained (a).
  1642. If, in the course of this disease, fistulse form about the rectum,
the  treatment must first be directed towards the stricture, and when that
is got rid of, the fistula may  be treated in the usual manner.
  If the disease be  cancerous, alleviation only can, in most cases, be
obtained by thin plugs, smeared with softening and soothing ointments,
by injections of decoction of cicuta, suppositories of hyoscyamus, bella-
donna, and the like.   But, if the disease be  seated at the lower part of
the  rectum, if its upper boundary can be reached with  the finger, if the
cellular tissue  surrounding  the lower part of the gut be healthy,  the
bowel moveable and permitting its  drawing down, the extirpation of the
cancerous part, according to Lisfranc's (6)  proposal, may be  under-
taken.
  1643. The patient being placed as in the operation for the stone, two
semi-circular cuts  should be made  about  an inch in front of the anus,
which, dividing the parts to the cellular tissue,  should meet behind.   The
intestine is then to be dissected from its connexions till it is completely
set free all round.   The forefinger, half bent, is now to  be introduced
into the gut, and sufficiently drawn down to make the mucous membrane
protrude, so that a portion of it can be easily removed with eurved scis-
sors, or with the knife.  If the cancer affect the whole  thickness of the
intestinal wall, and do not extend more than an inch upwards, the whole
gut must be everted, and the entire disease laid bare.  The everted part
is then to be cut into, parallel to the axis of the trunk,  and cut off with
the  curved scissors.   Should the cancer have  affected all the membranes
of the  intestine and the neighbouring cellular tissue, then after  the first
two cuts have been  made, and the lower part dissected, a cut  must be
made with a pair  of straight  scissors upon   the  introduced forefinger,
through  the whole wall of the intestine  backwards, where few vessels
and the peritoneum can be wounded, and which has also the preference
of rolling out the gut and laying bare the disease at the same time, after
which it is to be removed with scissors in the  sound part.  In operating
on men, a catheter must be kept in the bladder, to prevent injury to it.
The bleeding vessels must, as far as  possible,  be tied, or sponge dipped
in cold water, or a sufficiently thick bundle of lint introduced.   If the
bowel have been plugged, the plug must, after some hours, be renewed.
For the purpose of preventing the narrowing of the gut whilst the scar is
forming, a pretty large bundle of lint must be introduced, and there kept,
during suppuration, for a month.
  This operation is more difficult in the female than  in the male, and an assistant
must keep his finger  in the vagina to prevent its  injury, whilst the operaSTro-
ceeds   In the female, after an oval eut  is made, distant about three qua™  Jan
inch from the opening of the rectum, and continued to the gut, the rectum must be
(a) Tanchou, above cited, p. 182.         (fe) R6vue Medicale, vol. iii. 1830,. p. 
PHIMOSIS.
53
gently pulled, and two inches of its side and-hind part removed, without  injuring
the vagina.  The projection which the rectum forms in  front is about sixteen
lines, on account of the  connexions it has with the vagina, which, formed of an
aponeurotic tissue, and very thick cellular  tissue, stretches through the muscular
fibres from the fatty tissue beneath the skin, at a depth of three lines.  When, in
the female, the rectum  is dissected  up to  the attachment of the peritonaeum, and
drawn by means of  a pair of forceps, there is a space of six inches forwards, and
aside between the lower end of the bowel and the peritonaeum, but behind we may
proceed still higher, on account of the meso-reclum.  In the male, the distance from
the anus to the peritonaeum is about four inches.
   1644. When  the narrowing depends  on a large scar, nothing more
can  be  done than to cut deeply into  it at several places, and to widen
the  anal aperture by the introduction of  plugs, lint, or sponge. ^ In the
narrowing of the rectum by tumours in its  neighbourhood, which impress
it, the prognosis and treatment are guided by their situation and con-
dition.
  A "narrowing  of the anus by growing together of the buttocks, as the conse-
quence of badly treated ulceration, so that the motions are only as thick as a feather
stem, and for the most part involuntary, Rust (a) cures completely by division of
the united buttocks.
   1645. If narrowing of the rectum run on to closure, and ileus  be pro-
duced,  the formation of an artificial anus is required, although always a
very doubtful remedy  {par. 1616.)
 IX.—OF GROWING TOGETHER AND UNNATURAL CLOSURE OF
                           THE PREPUCE.

  Petit, J. L., Traite des Maladies Chirurgicales et des Operations qui leur con-
viennent, vol. ii. p. 421.
  Zier, Dissertatio de Phimosi et Paraphimosi.  Jena, 1785.
  Muller, De Phimosi et Paraphimosi earumque curatione.  Erf., 1797.
  Loder, Medicinisch-chirurgische Beobachtungen, part i. p. 84.  Weimar, 1794.
  Travers,  Benj., On  Phimosis and Paraphimosis;  in Cooper  and Travers'
Surgical Essays, part i.  London, 1818.  8vo.
  Kirnberger, Theoo., Historisch-kritische und pathologisch-therapeutische Ab-
handlung iiber die Phimosis und Paraphimosis.  Mainz, 1834.   4to.
  Collin, Die Beschneidung der Israeeliten.  Dresden, 1812.
  Terquem, Guide de Posthxtomiste, avec un expose d'un nouveau procede.  Metz,
1843.
  Bergson, J., Die Beschneidung vom historichen,  kritischen  und  medicinischen
Stanpiinkte.  Berlin, 1844. With a plate.
   1646. The  unnatural narrowing of  the prepuce, so  that it cannot be
readily retracted over the glans penis, is  called Phimosis; and  if the
very narrow prepuce which  has been  retracted cannot  be again  brought
forward, it is named Paraphimosis.
   1647. Phimosis is either a vice of the first formation, and congenital,
or it may be accidental, from inflammation of the glans and prepuce; in
which latter case it is named by some  complicated phimosis, in opposition
to the first form.
   1648. The prepuce, in children, has generally so narrow an aperture,
that it cannot be retracted over the glans ;  and peculiar symptoms may
occur if this aperture  be very narrow  or entirely closed.   When, for
(a) Magazin, vol. i. p. 237. 
54                       TREATMENT
example, the orifice of the prepuce is smaller than that of the urethra, the
urine cannot flow in its usual stream, part of it collects under the pre-
puce, distends it, and can only be completely voided by pressure.  By
the urine thus retained, and becoming putrid, the prepuce is inflamed,
often lengthens and becomes hard;  and  even stony concretions may be
formed between the glans and the prepuce.  If the prepuce have not an
opening, it becomes distended by the collecting urine to  an oval trans-
parent swelling, and the retention of urine may be fatal, if assistance be
not afforded in proper time.
  1649. If the congenital narrowing of the prepuce be not so great as to
produce the just mentioned symptoms, it is rarely noticed before puberty.
If the erections of the penis then occurring be not sufficient, by degrees,
to enlarge the aperture of the prepuce, so that  it can be easily  retracted
over the glans, which depends on the great length of the prepuce or the
shortness of the frtenum connecting the prepuce and glans, or it may be
on the imperfect development of the penis itself, erection and connexion
will be painful; inflammation, excoriation, and so on, will be produced
by the obstructed  flow of the urine,  and  by the collection and putrifying
of the cheese-like matter beneath the prepuce; and also the proper ejec-
tion of the semen will be prevented by a very small orifice of  the pre-
puce.
  1650. Accidental phimosis arises from  inflammation, in which, as con-
sequence  of swelling of the prepuce,  its aperture contracts,  and, as
consequence of increased determination of blood, the glans itself  en-
larges.  Usually,  those  persons are attacked with accidental  phimosis
who have, from birth, a  very long  and  narrow prepuce.  The special
causes may be, venereal ulcers, when seated on the edge of the prepuce,
upon the corona glandis, or on the frcenum, internal or external gonorrhoea,
warty excrescences, and  excoriation of the prepuce from putrescence of
the cheese-like matter retained beneath it, or from any other irritant.
The inflammation  is either acute or of an erysipelatous kind;  often is
the prepuce swollen with oedema.  Phimosis may also be produced by
any chronic swelling and thickening of the prepuce, as in hardening, in
scirrhous or any other degeneration.
  1651. The symptoms  caused by such phimosis vary  according to its
degree and its cause.  In venereal ulcers upon  the corona glandis, if the
pus be retained, the prepuce may be  gradually eaten through, and the
whole glans often protrudes through the  whole.   The inflammation may
run on to gangrene, which is particularly  to be feared in adults,  and if
mercury have been previously  and frequently used;  the urine collected
beneath the  prepuce may cause  excoriation, may be effused into the  cel-
lular  tissue of the whole penis, and producing gangrene,  cause its de-
struction.   The swelling may even be so great that the glans  and urethra
may  be partially  compressed.  If the inflammatory stage  pass  by,  a
chronic phimosis  may remain,  in which there  is a hard, cartilaginous
swelling of  the prepuce,  or growing together of the prepuce and glans.
bnould the obstruction to the voidance of the urine by the narrowness of
the prepuce, affect  the bladder and urethra, distension, weakness  and
even palsy of those parts may be produced.                      '
   1652. The treatment of phimosis consists in removing the narrowin 
OF PHIMOSIS.                          55
by operation;  or in phimosis, accompanied with inflammation, by reme-
dies capable of diminishing the swelling of the prepuce and glans.   In
children this operation is only called for when there is complete closure
of the prepuce, or the congenital phimosis is to such degree that it pre-
vents the discharge of the urine, and in adults, when, besides the voidance
of the  urine, the discharge of the semen is also  stopped, connexion pain-
ful, or if the orifice of the prepuce have a cartilaginous ring.
  If the narrowing of the prepuce be only slight, softening rubbings-in, bathing, and
repeated daily attempts to retract the prepuce, are sufficient to widen its orifice (a).
Particular instruments have been also used for this purpose (b).  This practice is,
however,  always tedious, painful, and can only in a few cases be effective.
   1653.   The two  usual  modes of operating for phimosis are circumcision
and slitting up the prepuce, with or  without removal of the flaps.   If a
congenital phimosis be distended by collection of the urine, it is sufficient
to thrust in a lancet at the under and  fore part of  the prepuce, without
injuring  the glans, and then, after every discharge of  urine, to  insert a
little plug into the aperture for a time.
   1654.  Circumcision {Circumcisio, Lat.;  Beschneidung, Germ.;  Cir-
concision, Fr.) consists in the operator taking hold of the prepuce, above
and below, with the thumb and forefinger of the left hand, so that their
tips are  about a line distant from the glans; an assistant draws  back the
outer fold of the prepuce,  as far as possible, to the  root of the penis, or
compresses the glans with his thumb and finger; the operator then  cuts
off'that part of the prepuce which he holds with a stroke of the bistoury,
but cautiously, that he do not injure  the glans.   The size of the piece to
be  removed must depend on the length of the prepuce, and on the extent   *
of its narrowing and thickening; too little, however,  must not be removed,
as, if so, the inflammation following the operation  easily produces fresh
narrowing.  It is superfluous to hold the part to be cut off with a clamp,
as recommended by some  practitioners.  If, as almost always happens,
the outer fold of the prepuce be retracted further than the inner, the lat-
ter must also be cut  off to correspond.   The  bleeding, which  is often
considerable, must be stanched with cold water, with sponge, with con-
tinued pressure, or if any single vessel spirt forth, it must be tied.
  Samuel Cooper and Wattmann recommend the connexion of the two folds with
stitches.
  The  Jewish circumcision differs  in that  after  the child  is wrapped  from  the
shoulders to the pubes and from the middle of the thighs to  the ankles in a cloth
properly fastened and  laid across the thighs of a sitting man, by whom he is  pro-
perly held, the circumcisor grasps the prepuce with the thumb and forefinger of his
left hand, draws it forwards, and inserts it in the cleft of an instrument similar to a
silver spatula.  Thus holding the prepuce, and raising the penis upright, he cuts off
the former close to the plate with a single stroke of a button-ended knife.  The cir-
cumcisor  now,  as quickly as possible, seizes  the inner fold of  the prepuce with his
thumb-nails, which have been specially cut for the purpose, and tears it immediately up
to the corona glandis.  He then spirts some water from his mouth upon the wound,
takes the  penis in his mouth, and sucks the blood out of it  a few times.   A strip of
fine linen is then wound round the corona and  the cut surfaces, as a dressing, and
the penis  laid upon the pubes,  in a ring to prevent it being  touched  (1).
  Terquem (c) speaks in favour of removing the inner layer of the prepuce, and has
proposed  an instrument like  a pair of scissors (posihetome mobile) for the purpose.
(a) Loder, above cited, p. 90.
(c) Above cited.
(6) Heister j Instit. Chirurg., pi. xxvi. f. 5. 
56
TREATMENT
   fl) Many years ago I was present at a Jewish circumcision, and was so much
 struck with its facility and appropriateness to the purpose, that I have  ever since
 performed the operation in the same manner, except that instead of inserting the pre-
 puce in the cleft spatula, I merely grasp it with a pair of dressing forceps, as close
 as possible to the glans, and then cut it off before them.   The tearing up the inner
 part of the prepuce to the corona  is a very important part of the operation, and far
 preferable to its division to that extent with the knife, as, whilst the inflammation ia
 subsiding, the cut edges, especially near the angle of the wound, are prone to adhere
 together, by quick union; and even if this  do not extend far, it causes a girthing  of
 the glans, which is inconvenient and often requires a second division to complete
 the  cure.  By  tearing the  inner skin, which should always be torn completely
 behind the corona, or the operation will be useless, the edges of the wound become
 sloughy, and disposition to quick  union is prevented.  From repeatedly having per-
 formed circumcision in this way, I am  sure it is the  best  mode.  And I may add,
 that,  as regards circumcision  or slitting up of the prepuce, the former is in every
 case much to be preferred.  I never, however, put in any  stitches, as  they are not
 merely superfluous, but add to the necessary inflammation without sufficient reason.
 --J. F. S.]
   Upon the bleedings after circumcision, see, Goldmann (a).
   1655.  Slitting up the prepuce is performed  in various ways, in doing
 which,  however, it must always  be remembered that the  outer fold
 should first be well drawn  back, so that, as far  as possible,  an  equal
 division of both folds should be  made.   Through the orifice  of the pre-
 puce is  to be  introduced Savksny's fistula-knife, or a knife specially for
 this operation {b),  with its point guarded, and held flat, till it reach the
 middle  of  the corona glandis; it must  then be turned on edge, and, by
 sinking  the handle and raising the point, it is thrust through the skin,
 and then being drawn towards the operator, it divides the prepuce at  a
 stroke.   The flaps are  to be grasped, one  after  the  other, with the
 thumb and forefinger of the left  hand, and cut  off obliquely downwards
 and forwards with the curved scissors, along and close to the  frcenum,
 or, if they be  not too large, they may be left, and gradually  shrink and
 retract.   According to Cloquet's  mode (c), a  director  should be intro-
 duced at the under part of the prepuce, parallel to the frcenum, and upon
 it the division made with the knife.   If the frcenum be very  short, it
 must also be  divided with the  scissors.   The longitudinal wound be-
 comes transverse  by the retraction of the prepuce, and heals without
 deformity.
  Covering the point of a narrow bistoury with wax, for the purpose of introducing
 it into the aperture of the prepuce, is unnecessary.  Many persons in this  operation
 use button-ended scissors; others introduce a director up to the corona glandis, and
 upon it a narrow-pointed bistoury, which they thrust through, after withdrawing the
 director, and divide the prepuce as just mentioned.
  If in consequence of the  retraction  not having been properly made, the external
 fold of the prepuce be insufficiently divided, it  must be done with the scissors.  If
 the narrowing of the prepuce be of that kind that slitting it up half way  is  sufficient,
 this must be done, and the flaps cut off obliquely from above downwards, or left to
retract.
  In order to prevent the swelling  of the flaps of the prepuce, which, by sewino- to-
 gether, causes that of the obtuse angled wound, Fricke (d) makes, after the divfsion
 ot both folds of the prepuce as already directed, a cut of the length of half an inch
 through the skin to the underlying cellular tissue, towards the  root of the penis.
  (a) von  Graefe  und  von Walther's    (c) Bulletin des  Science Medicales 182fi
 Journal, vol. iv. p. 284, vol. xiii. p. 201.      June p. 206.                    '     '
  (6) Guillemeau, Benj.  Bell, Petit, and    (d) Annal. der chirurg. Abth d?q Ham
 Latta, have  proposed  particular kinds of burger Krankenhauses, vol. ii. 256
knives for  this operation. 
OF PHIMOSIS.
57
 The division of the prepuce at the upper, middle, or under part, is always preferable
 to that on either side.
   Sometimes the narrowing of the prepuce depends on a hard ring, situated at its
 inner fold ;  it is then sufficient to pass a narrow button-ended knife behind this ring,
 and to cut through it in withdrawing the knife.
   1656. After  the bleeding  is stanched, the edges of the wound should
 be covered with lint, confined with sticking plaster,  a small compress,
 and a narrow bandage, and the penis placed upright  towards the  belly.
 If inflammation ensue,  cold applications  are  to  be made; and in
 cedematous swelling and gangrene, warm ones.  The dressings should
 be removed as  often as necessary.
   1657. Although circumcision of the prepuce is by many practitioners
 considered to have great advantages,  especially when its aperture is
 narrowed  merely by a hard ring, if the fore part of the prepuce be not
 only unnaturally narrow, but also thickened, relaxed, or to some extent
 contracted into a tube  (a), yet by this treatment  less of the inner than
 of the outer fold is cut off, and frequently so much less that the object
 of the operation is not  attained, if the inner coat be not also either cut
 into or cut off; for which  reasons the slitting  up of the prepuce is,
 indeed, in  general properly employed (b), and circumcision only  in the
 simultaneous great degeneration of the  prepuce, and then  the inner fold
 must be also specially divided.   It is also always most advisable to
 remove the flaps after slitting, as already mentioned, as they swell con-
 siderably after  the operation,  remain thick and misshapen, and render
 connexion painful, or prevent it, and only in children after  the lapse of
 some years resume their proper size.   This  renders  Cloquet's pro-
 posed operation superfluous.
   1658. The operations in which not the whole thickness of the pre-
 puce, but specially only its inner fold, seem preferable to those already
 mentioned.  The origin of  congenital  phimosis is not, as usually sup-
 posed, a narrowing of  the two folds of  the prepuce, but merely a  want
 of extensibility in the inner one.   The operation may therefore be most
 simply performed in the following way.   The external skin of the  penis
 should be retracted sufficiently far to discover  the aperture of  the pre-
 puce, into  which a narrow-pointed bistoury, with its edge upwards, is
 to be introduced, or a pair  of scissors, and  some lines distant of both
 folds divided.   With the fingers of the left hand the skin is much drawn
 back over  the glans, which,  thus somewhat uncovered, the  slightly ex-
 tensible inner fold  appears  tightly  stretched  over the glans, and
 preventing the retraction of the prepuce.  This inner fold is now  to be
 divided either with the  knife  or scissors, as often as is necessary, till the
 prepuce is  quite free upon the glans, and capable of being brought back-
 wards and forwards.   The bleeding is  of no  consequence; the whole
 after treatment  consists in repeatedly drawing back  the skin over the
glans and bathing the  penis  in cold water.   In a  few days  the patient
 is cured  without  any  mutilation.   I have frequently  performed this
 operation,  with  the best result (c).
  (a) Loder,  above cited, p. 86.—Richter,  ancient  and  modem mode of curing Dis-
 Anfang-sgrunde, vol. vi. p. 191.            eases in the Urethra and Bladder, &c.  Lon-
  (6) Zang ;  Operationen, vol. iii.'pp. 34 and  don, 1826.  8vo.  Eighth  Edition.—Fer-
 40.                                A'ERi Note sur  l'Operaiion  du Phimosis
  (c) Foot,  A critical Enquiry into  the  naturel; in Revue Medic, vol. viii. p. 305.
   Vol. iii.—6 
58
TREATMENT
1DLa"0«bi« f*) ?SS3.^a  riSilar Jay. though manifestly less simple and
satisfactory!  After an assistant has forcibly drawn back the general coverings, he
™Sp^ the edge of the prepuce with a pair of forceps, introduced within it and With
fpah: of scissors makes some little snips at different parts, and so many of them, till
the whole prepuce  can be completely drawn back.   After each snip the prepuce
must be still drawn back, till it be everted and the  inner fold come into view,  in
which he then makes the snips which may be still necessary.   In old and hard pre-
puce, with little extensibility of its inner fold, Begin (c) employs a practice whicB
indeed is to be considered as  a modified  slitting of the prepuce already described.
After previously slitting up the  prepuce, he cuts off the corners of the flaps with
scissors, so that ihe wound  becomes round ; he then Tetracts the skm of the  penis,
and cuts off the inner fold of the prepuce, as far back as  its base, with the sissors.
The skin will soon draw together, and  healing follows, a  V-shaped  scar being
formed on the inner fold, by which its breadth is increased.   According to  Vidal
de Cassis (d), the operator, whilst an assistant fixes the prepuce with a strong pair of
forceps, from above downwards, passes through the prepuce, below the forceps, three
transverse threads, and a fourth vertically from before backwards ; then with  strong
scissors he cuts off  the prepuce in  front of the forceps, avoiding the threads.  The
forceps being then removed, the glans is partially exposed with the threads over it.
The middle of each thread is  now taken hold of with forceps, and  being  drawn a
little forwards, four loops, are made, each of which being cut through,  eight sutures
are formed, which after just sufficiently cutting through the inner fold of the prepuce
strongly retracted are tied, and thus the edges of the outer and inner fold of ihe pre-
puce brought into contact.
   1659. If the prepuce be united  to the glans, after that it has been cut
into where not united, the connexion must be separated with  the spatula,
the scissors, or the knife; but if their junction be so  complete  that no
instrument can be introduced  between the glans and the prepuce a  cut is
to be made carefully lengthways  through the  prepuce without injuring
 the glans, and then it  must be ^attempted by lengthening the  cut  upon
the director or by careful dissection, in which the knife is to be always
more  towards  the prepuce than the  glans, to separate the connexion and
remove the divided flaps.  In all cases where the union is close and firm,
where no instrument can be introduced between  the glans and prepuce,
the operation is  excessively painful  and  difficult, and the result rarely
corresponds to the expectation (e).  In  such  cases  therefore the prac-
 titioner should be content, if the patient do not urge the more extended
 operation, to cut into the aperture of the prepuce so far. and so to enlarge
 it by the introduction of bougies  that a free escape of the urine may be
 effected.
    1660. When the connexion of the glans with the prepuce by  bands
 is such that many functions  of the  penis  are  interfered with,  the opera-
 tor holding the glans with  the thumb  and forefinger of the left hand,
 whilst  an assistant draws  down and  stretches the  prepuce near the
 bands,  introduces a narrow curved knife through the bottom of the tri-
 angular fold   of  skin forming the freenum,  and draws it out.   Lint

 1822.—Chelius, Ueber Phimosis und Para-    (c) Nouveauv Elemens de Chirurgie, vol.
 phimosis; in Heidelb. kin. Annal, vol.  iv. ii. p. 550.   Second Edition.
 PM^" p„,m„  u    •. ,                   <rf) Trait6 de Pathol°g''e  cxterne et  de
    (a)  *rickb, above cited.                Mcdecine  Operatoire.  Pari8  1838—41
    (6) Ncue  Bibhothek fur die Chirurgie und Large 8vo.
 Ophthalmologic,  vol. iv.                    (e) Richerand, Nosographie Chirurgicak,
                                      vol. iv. 
OF PHIMOSIS.
59
moistened  with lead wash is put between the edges of the wound, and
the prepuce kept retracted as much as possible till the cure.
   1661.  In the treatment of phimosis arising from  inflammation,  its
three stages may be observed; first, swelling and inflammation of the
glans which can begot rid of by the proper application of antiphlogistic
remedies;  second, such considerable swelling that the urethra is  com-
pressed,  partial stricture  thereby  produced, and  if unrelieved, abscess,
ulcerations of the urethra, extravasation  of urine, and gangrene of the
coverings ensue; third, when the  chronic phimosis cannot be altered or
got  rid of, the glans  and the prepuce become  firmly connected.  In
such case the prepuce has often entirely lost its  cellular structure, and
is thickened; the surface of the glans is covered with warts, shrivelled,
the proper opening of the urethra scarcely to be found, and the glans
often nearly  entirely separated from the spongy body by a deep pit (a).
   1662.  The treatment of phimosis caused  by  simple  excoriation or
putrefaction of the cheese-like matter, requires  frequent injections of
warm  water with a little liq. plumbi acet., frequently bathing the  penis
in luke-warm milk and water, and placing it against the belly, and also
leeches at a distance from the  inflamed parts.   When the inflammation
 subsides, slightly astringent injections may be used.  If  any hard swell-
ing remain  about  the aperture  of  the prepuce, it  is  best  to rub in
mercurial ointment with  camphor, and in oedematous swelling, bags of
aromatic herbs, strewed with camphor.
   1663.  Syphilitic phimosis, depending on chancre or clap, first requires
corresponding antiphlogistic treatment, blood-letting, leeching, softening
poultices, and luke-warm injections, in order to wash out the matter col-
lected between the  prepuce and  glans.   As soon as the inflammation
and swelling subside,  mercury is  to be used externally and internally;
but if used  earlier, there might be transition to  gangrene.  If with
venereal clap and chancre phimosis be feared, it can often be prevented
by frequent purifying injections, quietude, and laying the penis straight
 upon the belly.  If after the inflammation, swelling, and narrowing of
the prepuce have ceased, its growing together  must be prevented by
 frequently drawing backwards and forwards.
   Under the supposition that contact of the ulcerated surfaces is favourable to keep-
ing up this kind of phimosis, and that it always subsides with the cure of the ulcers,
 many practitioners, putting  off the  use of mercury  and  blood-letting,  merely
 introduce beneath the prepuce little rolls of lint smeared with cerate, and after a few
 days dry  lint.   This is repeated every  twenty-four hours  if the secretions of pus be
 considerable, but only every forty-eight hours if it be trifling.  After the fourth day
 usually, the glans can be uncovered, when it may be slightly cauterized with nitrate
 of silver, and the application of dry lint assists in effecting a cure in from eight to
 ten days. (Pigne).
    1661.  Inflammatory and venereal phimosis but rarely require opera-
 tion, and mostly cause bad symptoms, violent pain,  considerable bleed-
 ing, increased inflammation  and  gangrene;  the danger of  general
 infection is  increased, and sometimes growths difficult to get rid of
 arise about the cut.   The operation.is only called for when the pus is so
 retained beneath the  prepuce, that it cannot be washed out by injection
and bathing, and can only get an outlet by ulceration.  In such case,
(a) Travers, above cited. 
60
PARAPHIMOSIS.
 however, it  is not necessary to divide the whole  prepuce, but it is
 generally sufficient only to enlarge the aperture of the prepuce so much
 that the pus can  escape  and injections be admitted.   II the retained
 matter form  a large swelling at one or other part of the prepuce which
 runs on to bursting through, it must  be opened  with a lancet for the
 escape of the pus, and injected.  If the prepuce  be eaten through, and
 the glans protruded through this hole, it  is best to cut off the prepuce
 on  the side next  the  constricted  part, as  its opening cannot be again
 brought to its natural place.
  1665.  In those cases in which from the pressure of the inflamed and
 swollen prepuce upon the  orifice of the urethra, the voidance of the urine
 is slopped, the  ulceration  must be  prevented by the  early introduction
 of an elastic catheter into the bladder, and if it already exist, at least the
 bursting  of the urethra, and extravasation of urine which  often causes
 gangrene of the whole penis, be prevented.
  1666.  The above-mentioned statement  {par. 1658) that  congenital
phimosis does not depend on narrowing of both folds of the prepuce, but
 merely on deficient extensibility of the inner one, is important in explain-
 ing the origin of Paraphimosis.  If, for instance, the very narrow piepuce
 be retracted  in connexion or in any other manner, its narrow aperture
 where the two folds meet, is situated like  a cord behind the glans, the
 inner coat is turned outwards, and the prepuce everted.  The inner coat
 forms one  or more swellings, behind which, and mostly covered by it,
 the constricted part is exposed.  The symptoms caused by paraphimosis
 are various according as  the prepuce and glans had  been  previously
 healthy, or both  inflamed, ulcerated, or in  any other way diseased.  In
 the first instance they are usually not of importance ; the swollen, everted
 fold of the prepuce inflames and becomes more swollen, and especially
 on the sides and beneath,  the swellings are greatest, become like blad-
 ders and transparent.  The swelling spreads to the glans, but usually in
 a moderate degree.  I have only once noticed  priapism accompanying
paraphimosis.  In  the second case, the  inflammation and swelling are
 more  quick and  violent, as  both the inner coat and the glans may be
 considerably swelled: retention of urine may occur from the contraction,
 and even gangrene of the glans.  In both cases the prepuce may mortify,
 but usually only the constricted ring behind  the glans is destroyed by
 ulceration in consequence of neglect.  When  the constriction is not very
 great, and the prepuce is not brought over the glans, its folds behind the
glans may grow together by the accompanying inflammation, and in this
 way an irremediable deformity be  produced.
  1667.  The treatment of paraphimosis always requires the replacement
 of the everted prepuce as quickly as possible", which must be attempted
 in various ways.   The glans should be squeezed with three fingers of
 one hand for several minutes, or plunged for some time in ice-cold water,
 to reduce its size, and then with the finger and thumb of the other hand,
 it must be attempted to draw the  prepuce  forwards whilst the glans is
 pressed back. This handling, however, is rarely successful  if there be
 much swelling and some time have elapsed (1).   If the paraphimosis be
 accompanied  with  inflammation, blood-letting, leeching, and  other anti-
 phlogistic remedies proportionate to  it, must be employed:  the handling 
TREATMENT OF
61
 just proposed will only increase the inflammation.  Scarifications of the
 swollen prepuce,  recommended by many, can only be  useful by the
 bleeding.   According to  Walther (a) the swelling of the  inner fold
 should be  moderately pressed, so  that  it may  slip in,  and the  prepuce
 return to its  place.  By this  easy and almost  painless handling, Wal-
 ther  almost  always  effects his  purpose; compression of the glans in
 doing this is unnecessary,  but if this treatment be ineffectual,  the opera-
 tion is required.
   [(1) The reduction of paraphimosis in this, which is the best way,  is  often ex-
 ceedingly difficult, and  always excessively painful, so that frequently  a strong-
 minded person will scream like a  child from  the pain.  I have, however, scarcely
 ever known it fail, and hardly remember it needful to perform any operation with the
 knife.  It requires, however, great patience and perseverance,  often for the space of
 half an hour, at the very  least, and I have often succeeded when the prepuce had
 been everted six or eight days, and it might have been supposed that the adhesive
 inflammation  would have prevented the  replacement of the  skin.  Although the
 diminution of the bulk of the glans, by pressing the blood as completely as possible
 out  of it, is a very important part of the proceeding, yet squeezing out  the fluid
 effused in the prepuce is no less  so;  and  unless both be done, there is  great
 hindrance to the replacement of the skin.   I, therefore, always first squeeze gently,
 but  steadily, for a few minutes, the  prepuce, till it become somewhat  flaccid, and
 then firmly press the  whole glans with the thumbs of  both hands, whilst the two
 forefingers of each  hand  grasp the penis behind the everted prepuce, like a collar,
 and draw it forwards, whilst the thumbs empty and thrust back  the glans.   Or if I
 do not so succeed,! grasp the whole penis with  the left hand, making the thumb and
 forefinger a collar behind the everted prepuce, which thus rests against it, whilst,
 with the thumb and fingers of the other hand, the glans is emptied, and thrust within
 the constricted ring, by pushing first one part and then another of the corona glandis
 till it get beneath the  constricting band; and this done,  the rest  soon follows.  Im-
 mediately that the least bit of the corona has been thus got in, that next it must be
 poked in (no better  expression than this can be used) with the finger end, and so on
 the next, till the greater part has been thus returned, and the  reduction  is speedily
 completed.  It must, however, be remembered, that directly the return has com-
 menced, the  poking must be  continued without intermission,  as, otherwise,  the
 whole proceeding will have to be repeated, as, on the least cessation, the glans again
 fills  and protrudes.  If the everted prepuce do not relax by pressure, the constriction
 being so great that the effused  serum cannot be dispersed easily upon the body of
 the penis, it will be found very convenient to make a  few punctures through the
 skin, by which the squeezing presses out the fluid, and then the prepuce  is  rendered
 flaccid.   It is always  advisable to try this mode of proceeding even if  part of the
 prepuce should have become gangrenous, as this is often merely superficial and the
 replacement puts a  stop to its progress.  After the reduction, it is well for some
 hours to wrap the penis up in linen, and keep it constantly wet with cold water, for
 the purpose of preventing the disposition to erection, and re-protrusion of the glans,
 but after that time, a warm poultice will be most agreeable to the patient's feelings,
 and most favourable to the dispersion of the inflammation.  The soreness, however,
 will commonly continue for many days, proportionate to the severity of the constric-
 tion, and its duration.   No attempt at retraction of the prepuce, to see what is going
 on inside, should be made for several days, or the mischief will probably recur.—
 j. f. s.]
   1668.  The operation for paraphimosis  is best conducted in the follow-
 ing  manner.    A little  fold of the outer skin of the penis, just behind the
 constriction,  is to be raised and cut through ; into this  opening  a small
 director, curved  at  its  tip, is to be introduced, and thrust into the cellular
 tissue beneath the constriction, forwards, till it can be felt  on  the other
 side, and then upon it  the constricting skin is to  be cut  through.    After
  (a) Ueber die Reduction der Paraphimosis und  fiber die Behandlung der Phimosis ; in
his Journal fur Chirurgic und Augenbeilkunde, vol. vii. p. 347.
                                     6* 
62
PARAPHIMOSIS.
 this operation  the  prepuce cannot  generally be  drawn  over the glansy
 because it is too much swollen, and attempts to bring it forward are use-
 less and dangerous;  but it returns gradually when the inflammation and
 hard swelling of the prepuce diminish.   If the return of the prepuce be
 impossible, on account of (Edematous swelling, a few little  cuts may be
 made, and its contents squeezed out. The longitudinal cut soon becomes
 transverse.
  In the mode above mentioned, the operation for paraphimosis differs, in no respect,
 from that already described (par. 1658)  for phimosis, namely, the division of the
 aperture and inner skin of the prepuce. The object  of the operation is not the
 division of the swelling and of the circular protuberance, but of  the retracted aper-
 ture, and of the inner fold of the prepuce. On this presumption, I cannot agree to
 the unsatisfactory opinion which Walther has given of the operation for paraphi-
 mosis (a).   Langenbeck is also of the same opinion.
   1669. If suppuration have already occurred at the circular  constriction,
 the operation is superfluous, for the two folds of the prepuce are already
 divided, and there is merely  the  cedematous swelling, which drawing
 forward the prepuce  prevents.  In  this case, the prepuce must either be
 brought forward in the way already described, by squeezing and dimi-
 nishing the size of the swollen inner fold of the prepuce, or  several little
 cuts must be made into it,  so as to  squeeze out the fluid.
   1670. After the  operation, merely cold water is to be  applied, and the
penis laid straight upon  the belly.   If, during the operation, the spongy
 body be  wounded,  and there be  consequent bleeding, this  must be
 stanched  with  cold water,  or with  pressure when  it  can  be employed.
 An cedematous swelling of the prepuce frequently remains a long while
 after the operation, to disperse which bags of aromatic herbs, rubbing; in
 mercurial ointment and camphor, and if these be inefficient, cutting into
 it, or moderate pressure by rolling the penis, should be employed.
   1671. Constriction of the penis may also be caused by threads  or thin
 tapes, and the like,  which have been  voluntarily put  round it. The
 symptoms in general, become  quickly very severe; the place  of con-
 striction is speedily  and completely covered by  the  swelling, and  the
 band will quickly cut into the urethra.  A thin director must be attempted
 to be passed beneath the band, which is then to be cut through with a
 narrow curved bistoury.  If the constriction be caused  by a metal ring,
 it must be cut  through with a file,  or with nippers, and removed in  the
 most careful manner.
  X.—OF THE  NARROWING AND CLOSURE OF THE  URETHRA.

  Daran, J., Observations  Chirurgicales sur les  Maladies de 1'Uretre,  traitees
suivant la nouvelle methode.  Paris, 1748.
  Guerin, Dissert, sur la Maladies de 1'Uretre, avec des reflexions sur la methode
qu ont employee jusqu'a present les praticiens.  Paris, 1T80.
  Hunter, John,  A Treatise on the Venereal Disease.  London, 1810   Third
ftidition.   8vo.
  Whately, Thomas, Observations on Mr. Home's Treatment of Strictures in the
Urethra,  with an improved method, &c.   London, 1801.  8vo.  Ibid., An improved
method of Treating Strictures in the Urethra.  London, 1804.  8vo.     "uP"™e
(a) See my Observations on Phimosis, and Paraphimosis, above eited. 
STRICTURE OF THE  URETHRA.
63
  Chopart, Traite des Maladies des Voies Urinaires.   Nouv. Edit., par Felix
Pascal.  Paris, 1821.
  Sabatier, Sur la Nature et le Traitement de Retrecissemens de 1'Uretre; in Four-
croy, Medecine Eclairee, vol. i.
  Desault, Maladies des Voies Urinaires; in his CEuvres Chirurgicales, vol. iii.
Paris, 1813.   Edited by Bichat.
  Labraud, Sur le Retrecissement Chronique de 1'Uretre.   Paris, 1805.
  Kleeman, Dissert, de curandis Urethrae Stricturis chronicis.  Erlangen, 1811.
  Home, Everard, Practical Observations on the Treatment of Strictures in the
Urethra and in the Oesophagus. London, 1805, 21.  Third Edition.
  Howship, John, Practical  Observations on the Diseases of the Urinary Organs,
&c.   London, 1816.
  Arnott,  James, M.D., A Treatise on Strictures of the Urethra, containing an
account of an improved method of treatment. London, 1819.  8vo.
  Bell, Charles, A Treatise on the Diseases of the Urethra, Vesica  Urinaria,
Prostate, and  Rectum.  Third Edition; with Notes, by J. Shaw,   London, 1822.
8vo.
  Ducamp, Theodore, Traites des Retentions d'Urine causees par le Retrecisse-
ment d'Uretre et des Moyens k l'aide desquelles on peut detruire completement les
Obstructions de ce Canal.  Paris, 1822.
  Lisfranc, J., Des Retrecissemens de 1'Uretre.  Trad. Lat. par J.  B. Vesignie et
J. Richard.  Paris,  1824.   8vo.
  Lallemand, F., Observations sur les Maladies des Organes Genito-Urinaires. 2
Parties.  8vo. Paris, 1825,27.
  Winzheimer, M., Ueber  die organische Harnrohrenverengerung und die ver
schiedenen  Untersuchungs-  und Heilungsmethoden derselben.  Erlangen,  1832.
4to.
  Amussat, Lecons sur les  Retentions  d'Urine causees par le Retrecissement du
Canal de 1'Uretre, et sur les  Maladies de la Prostate.  Publiees sous ses yeux, par
A. Petit.  Paris, 1832.  8vo.
  Tanchou, Traite des Retrecissements du Canal de  1'Uretre, &c.  Paris, 1835.
8vo.
  Brodie, Sir B. C, Lectures on the Diseases of the Urinary Organs.  London,
1842.   8vo.  Third  Edition.
  Kugler, J., Praktische Abhandlung iiber die Verengerung der Harnrobre, und
ihre Heilung ohne Aetzmittel.  Wren.,  1843.
  [Post, A. C, On Stricture of the Urethra, in N. Y. Journ. of Med. and
Surg.,  vol. 1.  1840.
  Parrish, I., Practical  Observations on some of the  Diseases of the
Urinary Organs.   Philadelphia, 1836.  8vo.—g. w. n.]
   1672. Stricture of the  Urethra (Strictura Urethree, Lat.;  Verengerung
der Harnrohre, Germ.; Retrecissement de PUretre, Fr.) results more fre-
quently from a change of the mucous membrane with which it is lined,
than in any other outlet.   In women only it  is very rare, on account of
the shortness of the passage.
  The narrowing of the urethra from other causes, will be  treated of subsequently,.
in considering retention of the urine.
   1673. The development of this disease is always exceedingly tedious,
and at  first is usually not  noticed by the patient.   He first feels a slight
pain  in passing his urine, and there is frequently some mucous discharge
from the urethra, which spots the linen. Gradually more frequent urgency
to empty the bladder comes on, and the voidance  of the urine is accom-
panied with much straining.  The  stream  of the flowing water begins to-
diminish in  thickness, is  frequently divided  and spiral, or if the urine
have been  already discharged  in  a stream, a small quantity still falls
vertically in drops.   Frequently all the urine is not \roided at once,  and
a large quantity is- still passed on additional effort.  When  the  proper. 
64
STRICTURE
 discharge of  the urine  is completed, there still remains  a small portion
 behind  the  strictured  part, which, as the penis hangs down, gradually
 escapes by its own gravity.  If there be several strictures existing at the
 same time, the  stream of urine is powerless, and the  urine drips away.
 In this  state  the  pa'ient long  continues  getting alternately better and
 worse;  and after violent exertions, after taking heating food and drink,
 after connexion, and after catching cold, a momentary stoppage of urine
 may occur.
   [Brodie justly remarks, that "in some cases the urine dribbles away constantly
 and involuntarily, and the patient's  clothes by day, and his bed by night, are abso-
 lutely sopped with urine, making him  disgusting to himself and to all around him.
 This involuntary  discharge of urine  does not indicate  an  empty and contracted
 bladder.   The bladder, in fact, is loaded with urine, and it is when it does not
 admit of  further distension  that  the  urine overflows,  and all  beyond a  certain
 quantity escapes, without the patient being able to prevent it, the bladder being a!
 the same time to be felt like an enormous tumour in the lower part  of the abdomen."
 (p. 11.)]
   1674.  At last the disease reaches its highest pitch; the urine can only
 be voided with the greatest effort  and in extremely small quantity, and its
 discharge is often  completely  stopped.   By the  pressure  of the urine
 against the stricture, the urethra behind it is expanded, and it may be so
 much that the urethra tears or is destroyed by sloughing, upon which the
 urine infiltrates  into the  neighbouring parts.   If only a small quantity of
 urine  be extravasated into the cellular tissue, it forms a hard, definite
 swelling, which runs on to abscess.   In greater extravasation there is a
 spreading tumour, which may extend from the perineum over the scrotum,
penis, groins, and so on.   The skin has at these parts a dusty red, shining
 appearance; gangrene soon comes  on, and,  after its separation, fistulous
 apertures are formed, by which the dTine escapes.   In this state the con-
 stitutional powers often  soon sink, and the patient dies.
   ["Conceive," says Brodie, "a distended bladder,  and the spasmodic action of
 the abdominal muscles and diaphragm of a powerful man acting like a syringe, and
 forcing the urine through the lacerated  urethra into the cellular membrane.  In fact,
 the scrotum, the  penis, the perinaeum, sometimes even the groins are enormously dis-
 tended with urine.  The first effect of this mischief is  to relieve the patient's suffer-
 ings.  There is  no more straining, and the spasm of the stricture, no longer excited
 by the pressure  behind, becomes  relaxed, so as to allow some  of  the urine to flow
 by the natural channel.  After this deceptive interval of ease, another order of symp-
 toms shows itself.  The urine, under any circumstances, would  irritate the parts
 unaccustomed to its contact; but, in a case of retention of the urine, it has been long
 in the bladder, much of its watery parts have been absorbed, and it is in consequence
 unusually impregnated with saline matter, so that its stimulating properties are much
 increased.  Wherever this acrid fluid penetrates, it  first excites inflammation, and
 then kills the parts with which it is in contact."  (p. 13.)
  "In cases of stricture, where the disease has existed for many years, and nothing
effectual has been done for its relief," Brodie  observes, "abscesses form in the
eellular membrane external to the bladder, but communicating with it, similar to
 those connected with the urethra.  A considerable time  elapses before such abscesses
 present themselves externally, and they point at last in the groin, or above the pubes,
 discharging a putrid, offensive pus in the first instance, and giving- exit to urine
 afterwards. In  Dr. Hunter's Museum  (now at Glasgow) there  is a preparation
 exhibiting an  abscess of tbis kind communicating with the bladder at the fundus,
 extending upwards in the course of the urachus, and opening externally at the navel.
 1 believe that the formation of these abscesses is always preceded by chronic inflam-
mation of the  mucous  membrane of the bladder, and their existence is marked bv
 severe typhoid symptoms.   For the most  part they may be  remarried as a sitrn of
 approaching dissolution." (p. 26.)}                                      s 
OF THE URETHRA.
65
   1675. If this do not  happen, however, severe symptoms arise from
the changes which the  mucous membrane  of the  hinder  part  of the
urethra undergoes in severe and long-continued strictures.  By the con-
stant irritation of the urine collected behind the stricture, it swells up and
becomes spongy; this change spreads upon the mucous membrane of the
prostatic part of the urethra, the  prostate itself enlarges and its mucous
follicles swell considerably (1).  Hence arises the sensation of weight in
the rectum, the frequent, often  useless  straining at stool, the  mucous,
sometimes purulent  discharge which precedes  the  flow  of urine;  the
fibrous, tenacious urine, with  the deposit of long mucous threads upon
the bottom of the chamber-pot, which may be drawn out to the extent of
two or three feet.  The  hind part  of the urethra, and the neck  of  the
bladder at last  become so expanded, that  the urine is only retained by
the stricture, and drips involuntarily (2).   By the extension of this dis-
eased  change in the mucous membrane to the excretory canals  of the
semen, and the  seminal vesicles, there  is frequent swelling of the testi-
cles, very quick discharge of the semen in connexion, (in which it also
escapes without  elasticity,  and often  before the venereal orgasm is
finished,) and. frequent nightly pollutions.  In very severe state  of the
disease voidance  of the  semen at a half  erection, without the patient
having any sensation of it, with the efforts to discharge the last drops of
urine, and in going  to stool, occurs.  These changes at  last  reach the
mucous membrane of the bladder, the walls of which then often become
considerably thickened ;  they extend even along the ureters to  the pelves
of the kidneys, which, in like  manner, are  expanded (3).  The  great
disturbance  of the general  health  which  accompanies long-continued
structure now appears ; the  more or less  disturbed digestion, wasting,
feverish symptoms at uncertain periods, often accompanied with violent
headach and great  heat, sometimes with shivering  and without  par-
ticular heat, at other times with cold  shivers, great heat, and copious
sweating (4).
  £(1)  The following observations of Brodie, in reference to the combination of
stricture, with enlargement  of the prostate, are most truthful  and well  put, and, if
borne in mind, will save the  patient pain, and the surgeon credit.  "Although the
combination of stricture with enlarged prostate is common enough; yet it is not,"
says he, " so common as it is by some surgeons supposed to be.   An old man, who
has a frequent desire to void  his urine, and voids it  slowly and with difficulty, ap-
plies to a surgeon, whose  hand is light and  accustomed to the use of the catheter.
The instrument is then introduced readily, or, at any rate, meets with no obstruction
until it reaches the neck of the bladder, and the case is set down as one  of enlarged
prostate, which it really is.   Another old man, under  precisely similar circumstances,
applies  to a surgeon, who  uses the catheter rudely and incautiously.  The urethra
resents  this rough usage;  spasm is induced, and the point of the catheter cannot be
passed  farther than the membranous part of the urethra.  The case is then supposed
to be one of stricture, and is treated as such; I need not tell you to how little  pur-
pose."  (p. 23.)
  (S) Brodie mentions a remarkable instance of enlargement of the urethra follow-
ing "stricture at  the distance of three inches behind the external meatus.  The
posterior part of the urethra  was so much dilated, thgt, whenever he made water, a
tumour, as large as a small  orange, and  offering a distinct fluctuation, presented
itself in the perinaeum .• it  might be compared to a second bladder.  Once, when he
sent to  me labouring under a complete retention of urine, I punctured the tumour in
the perinaeum with a lancet.   Immediately the urine gushed out in a full stream."
f P. «.) 
66
STRICTURE
  (3) "In some instances," Brodie observes, "the mucous membrane is protruded
through some of the interstices of the muscular fibres, forming numerous small cysts,
communicating with the cavity of the bladder.  These cysts appear to be formed in
the following manner; when the patient strains in making water, the mucous mem-
brane, while it is pressed on by the muscular fibres externally, has to sustain an
equivalent degree of pressure on its inner  surface from the  reaction of the urine.
Wherever there happens to exist a small interstice between the muscular fibres, the
latter force alone operates, and the bulging outwards of the mucous membrane is the
necessary consequence.   These cysts, however, are not peculiar to cases of stricture
of the urethra, and they  occur equally where the obstruction to  the  flow of urine
arises from an enlargement of the prostate gland, or from any other cause." (p. 25.)
He mentions "a case of long-neglected stricture of the urethra, in  which, on exa-
mining the body after death, I found one of the cysts interposed between  the bladder
and rectum; at least, equal in capacity to the bladder itself. * * *  For the most  part
the contents of the cysts  are similar to those of the bladder itself; but I shall have
occasion to mention a case  in which  a large cyst of this description contained pure
pus,  while in the bladder there was nothing but urine." (pp. 25, 6.)  He also ob-
serves that he has "met with several cases  of stricture of the urethra, in which the
mucous membrane of the bladder was found, after death, not  only inflamed, but en-
crusted, even over a large portion of its surface, with coagulated  lymph.  Such an
effusion of lymph is the result of acute inflammation, differing in its character from
the chronic inflammation which produces merely a secretion of the vesical mucus;
and it is observed chiefly (if not exclusively) when the patient has died after having
been harassed by repeated attacks of retention of urine." (p. 24.)
  (4) "Rigours also occur," says Brodie, "in many cases of stricture, independent
of abscess.  We  meet with them most frequently in patients from  hot climates.
They usually recur at irregular periods, being in many instances brought on by the
introduction of a bougie,  or the application of caustic to a stricture.   The paroxysm
very nearly resembles that of an intermittent fever, and it is more severe when it
follows the use of a bougie than when it occurs independently of it.   In general, the
cold fit having been followed by a hot fit, and that by  a profuse perspiration, the
patient is relieved.  At other times, however, the constitution is disturbed for a great
length of time afterwards; and sometimes  the rigour is followed by an attack of
continued fever, which lasts for some days, or even for some weeks.  I met  witn a
case in which a rigour followed the application of eaustic to a stricture, and this  was
followed  by an attack of mania, which (if my recollection be correct) did  not subside
for nearly a month.  Another patient had laboured under a stricture of  the urethra
for many years, during which no instrument had  ever been made to  enter the blad-
der.   I succeeded in introducing a small gum catheter.   Having emptied the blad-
der,  I removed the catheter.  In a few hours after there was a severe rigour.  An
attack of fever ensued, attended with rheumatic inflammation of the muscles of the
neck, from the effect of which the  patient never entirely recovered, though he lived
for many years afterwards."  (pp. 27, 8.)}
   1676. The origin of stricture  always depends on, and  is accompanied
with, a chronic inflammatory state of the mucous membrane of the urethra,
by which it is swollen  up, thickened,  and loses its natural  extensibility.
In many instances the immediate cause of  stricture is unknown.   It is
frequently observed after gonorrhoea,  especially if  that  have been long
continued, and improperly treated.  The causal* relations, however,  which
the  stricture has to a previous clap, are often  unknown, as  it is observed
after both severe and  slight clap, whether  treated with or without injec-
tions.  Strictures,  also, commonly appear long after gonorrhea, often as
long as  thirty or forty years.   Neither  their  seat nor" their  extent at all
corresponds with that of the previous gonorrhoea! inflammation.  Scrofu-
lous or  gouty inflammation,  long-continued onanism, accidents  which
befal the urethra, and long suffering with stone in the  bladder  especially
in old persons, may be causes of stricture.   Warm climates seem to be
more favourable to their development  than cold.   Varicose swellings of
• 
OF THE URETHRA.
67
 the vessels, as well as tumours in the neighbourhood  of the urethra, may
 also produce them.
   [Brodie mentions that "in some cases  of long standing, we find a gristly in-
 durated mass at the lower portion of the penis, where it is covered by the scrotum.
 This is, probably, in some instances, the contracted portion of the urethra, thickened
 and converted into a substance approaching in its character to  cartilage.  But, in
 other cases, it depends on a different cause.  A gentleman laboured under a stricture,
 and voided his urine with great difficulty.   A hard oblong tumour could be felt in
 the neighbourhood of the stricture, though somewhat anterior to it, at the upper part
 of the scrotum.  I dilated the stricture  so as to  enable the patient to  introduce  a
 bougie for himself; but still the stricture  remained unaltered.  He died about a
 year afterwards of an accidental attack of disease in the brain; and I found, on dis-
 section, that the tumour had arisen from a deposition of lymph into the cells of the
 corpus spongiosum.  Immediately behind the stricture there was  an orifice leading
 into a long and narrow sinus, extending from the urethra into the gristly substance
 of the tumour.   The direction of the sinus was from behind forwards, so that it was
 evident that it could not have been produced by the improper use of the bougie.  I
 conclude that it was the result of the forcible and the repeated pressure of the urine
 against the urethra behind the stricture." (pp. 8,  9.)]
    1677.  The  most common seat of stricture is at four and a half, or five
 and a half inches from the orifice  of the urethra, rarely at other parts (1).
 The strictured part is, according to the duration of the complaint, more
 or less hard, white, almost fibrous, generally of slight extent, not exceed-
 ing a  line's breadth, as if the urethra were tied round with a thread ;  but
 sometimes it is  wider, and then not equally thick, and the canal of  the
 urethra is variously curved.   These changes seem to result from repeated
 severe attacks of inflammation, which  even affect the spongy body of the
 urethra, and render it thick and hard.   Sometimes several distinct stric-
 tures exist at the same time.   Stricture does not always attack the whole
 circumference of the urethra, it is often valvular, or tape-like, divided and
 branching, and  sometimes runs lengthways.   Not unfrequently strictures
 are noticed, the  middle of which is ulcerated.   Complete closure of  the
 urethra from stricture is very rare; but most commonly in long-continued
 stricture, the urethra in front of it is contracted.   The so-called caruncle,
 or growth from the inner membrane of the urethra, which was formerly
 considered the  most common cause  of stricture, and probably nearly
 always  confused with what we call  stricture,  is rare.  They are  fre-
 quently found as little masses of soft warts behind the stricture ; at other
 times they are not found behind, but before the stricture ; they are com-
 monly similar to those growths observed  on the prepuce and glans.  I
 have  seen  in  one person, who had frequent claps, the urethra filled with
 round excrescences  for an inch  behind the fossa navicularis.
    Hunter (a) has described three forms of stricture of the urethra,- first, a perma-
r nent stricture depending on a change in the structure of the urethra; second, a mixed
 condition of permanent and spasmodic stricture; and, third, a  simple spasmodic
 stricture.  The adoption of this third kind rests on the notion that the  inner mem-
 brane of the urethra is endowed with actual capability of expansion and  contraction,
 depending on  its muscular nature.  This  opinion is contradicted by examination,
 which shows that the membranous part of the urethrals surrounded with an injectable
[ tissue similar to the spongy body, but in which no muscularity can be discovered (b).
  Charles Bell (c), who considered the urethra to be simply elastic, supposed that
' many symptoms of stricture depended  on the influence of the perineal muscles sur-

    (a) Above cited,  p. 120.                 Membranous Parts of the Urethra; in Med.
    (b) Shaw, John,  On the Structure of the  Chir. Trans., vol. x. p. 339.  1819.
i                               (c) Above cited. 
68
STRICTURE OF THE  URETHRA.
 roundino- the neck of the  bladder and the urethra.  Although there may he some
 ffrounds°for this opinion, a certain capability of contraction  and  expansion cannot,
 however, be denied to the urethra, as so many excretory passages which  equally
 exhibit no  muscular character, and where only very rich  vascular ramifications are
 noticed, are so endowed, without, on that account, distinguishing with the name,
 spasmodic stricture something else  than a  stricture (depending on a change of struc-
 ture in the  inner membrane of the urethra) which is accompanied with great inflam-
 mation,  great  sensibility of surface, or in the neighbourhood of the canal  of the
 urethra, and with increased irritability of the surrounding muscles, by which a great
 degree of stricture may be  produced.  Here, also, must be distinguished from spas-
 modic contraction of the urethra and neck of the bladder those cases which come on
 without inflammation and organic change, and  merely as a symptom of diseasedly
 increased sensibility of the bladder and the urethra, and mostly only transient (a).
 It must also be remembered, that even spasm may accompany every acute and chronic
 inflammation.  The mistake must  not be made of  assuming the existence of spas-
 modic stricture, because on examination of the urethra after death no trace of stricture
 can be found, of which, during life, there were symptoms, and which generally de-
 pends on the mode of examination, as, if  it be not carefully conducted, nearly every
 thing disappears  on cutting into the stricture (b).
   [(1) "In the  majority of instances," observes Brodie, "the disease (stricture)
 began in the anterior portion of the membranous part of the urethra immediately
 behind the  bulb and in the situation of the triangular ligament of the perinaeum; that
 in some instances it had its origin  in the urethra, some where between the part just
 mentioned and the external orifice; and that in a few cases it is confined to the ex-
 ternal orifice, and the canal immediately adjoining to it.  Occasionally where the
 original and principal stricture has been in the membranous portion of  the urethra,
 there is another stricture anterior to it; and in cases of very long standing it is not
 unusual to find the greater  part of the canal  in  a  thickened and contracted state,
 (p. 4.)   A  stricture which  affects the external orifice, and anterior extremity of the
 urethra, is,  in many cases,  connected with an adhesion  oe the inner surface of the
 praepuce  to the glans.  Such adhesion is usually the  consequence of a congenital
 narrowness of  the praepuce, combined with want of due attention on the part of the
 nurse to the child's cleanliness ; and hence it is that patients who  labour under this
 kind of stricture, frequently declare that they do not know when the disease began,
 and that  they cannot remember the time when the  urine flowed in a full stream."
 (pp.  6, 7.)]
   1678. The diseases which may be confused with stricture are, inflam-
 mation of  the urethra, clap, spasm of the muscles surrounding the urethra,
 abscesses  or  swellings in its neighbourhood, stone, and diseased prostate.
 A close inquiry into the course of the disease, a  careful examination, and
 the following circumstances decide the  point. In stricture, the discharge
 after connexion occurs quickly, and  recurs usually after a week; a clap
 rarely appears  before the third day,  increases, and the  pain  on making
 water and inflammation become more severe.   Stoppage of the urethra
 by stones  is  distinguished  by the previous  symptoms  of stone, by the
 sudden stop to the flow of  urine, and the  striking of the  sound against
the  stone.   Swelling of the  prostate is felt by the  finger  through the
rectum,  the catheter can be readily introduced as far as the prostate, but
it then frequently excites severe pain, and most commonly only an elastic
 catheter can be introduced.
   1679. The prognosis in stricture of the urethra varies according to the
seat  and condition of the disease.   The nearer to the orifice of the urethra,
the more recent and  extensible, the shorter and narrower the stricture is,
so much  the more  easily  can  it  be got  rid of.  When, however the
 symptoms  mentioned (par. 1675) have  set  in, the  prognosis is more
  (a) Soemmering,  above  cited,  p. 216.—    (b) Amgssat, above cited
 Lisfranc, above cited. 
TREATMENT.
69
doubtful, except that the patient's condition may be rendered tolerable;
it cannot, however, be decided whether after the removal of the stricture,
these symptoms will diminish or cease.   The treatment is in many cases
tedious, and relapses are very frequent.   If urinary fistula have already
formed, what has been already mentioned {par. 948) must be borne in
mind.
   1680. In the cure of stricture, two circumstances must be distinguished,
namely, whether the  voidance of the urine be  completely stopped, or
whether the patient suffer under the common symptoms of stricture;  the
latter only will here be considered, but the former in treating of retention
of urine.
   1681. The object  in the treatment of stricture, is to get rid of  the
obstacle which opposes the passage of the urine, and which is be effected
either by gradual widening of the canal of the urethra, by the introduc-
tion of foreign bodies, as tapers,  bougies, or catheters ; or destruction of
the stricture with caustic, with  conical catheters  or  special instruments.
If the stricture be in  causal relation with syphilis or any other dyscrasy,
they must be counteracted.   General treatment, however, has not in itself
any effect on stricture.
   1682.  The first  object of  the treatment  by widening or with bougies,
is to determine the seat of the stricture.   For this purpose, an elastic wax
bougie corresponding in thickness with  the orifice of the urethra, and
smeared with oil is to be introduced into the aperture of the urethra, the
penis being held with the finger and thumb  of  the  left  hand behind  the
glans, but without pressing the urethra.  The penis is  then drawn  up,
whilst the bougie, held like a writing pen, and gently rolled from side to
side, is passed in so as not to get entangled in  the mucous membrane.
When  the bougie has reached the seat of stricture, a mark is to be made
on it with the nail close  to the  mouth of the  urethra, and thus  the  dis-
 tance of the stricture  from  it  is shown.
   ["The bougie which is used for the purpose of examining the urethra  should,"
says Brodie, " be of a  full  size, that is, large enough to  fill the urethra without
stretching it. A small  bougie may deceive in two ways: it may pass through a
stricture, and thus lead you to  believe that there is no stricture when there really is
one, or it may have its point entangled in the orifice of  one of the mucous follicles
of the urethra ,• or in some accidental irregularity of the canal, and lead you into the
opposite mistake of supposing that there is a stricture where none exists.  If  you
 use a bougie of the size of the urethra, you are not at all liable to the first error, and
 you are much less liable to the  second than you would be otherwise." (pp. 29, 30.)]
    1683. A thinner elastic or wax bougie, about  the  thickness of  the
 stream in which the  urine  flows is  now taken, and a mark made upon it
 at the same distance  from  its point as on the former one; after which,
 being introduced as  already directed, an  attempt must be made to pass it
 through the stricture, in doing which all violence must be avoided.   The
 entrance of the bougie beyond  the nail-mark shows it has passed  the
 stricture, and this  is  still farther proved when, on  drawing it  back, it is
 somewhat held, and if left quite  alone it does not rise up.    The  last  cir-
 cumstance shows that the  bougie has bent in the canal of the urethra in
 front of the stricture without  penetrating it.  If the point of the bougie
 enter a mucous follicle, it is known by the nearness of the obstacle to the
 orifice of the urethra, by the  pain the patient feels,  by its farther progress
 when the bougie is drawn  a little back, which is effected without the least
    Vol. m.—7 
70
TREATMENT OF
difficulty, and then again introduced in a different direction, and by the
absence of any impression of the stricture which is always observed, when
the bougie  is withdrawn, to  have been made by the stricture.  If the
bouo-ie will not enter, a smaller one should be tried.   If the condition of
the stricture be such as to render  the passage of the bougie impossible,
we must endeavour to obtain an impression of it with Ducamp's model-
bougie, presently to be described, which must be  pressed against it a little
while for that purpose, so as to give to  the point of  the bougie to be in-
troduced  the proper  curve by which perhaps it will pass  through the
stricture.   Or a very thin bougie  is to  be carried down  to the obstacle,
and there left some hours, from eight to twelve; afterwards it will of itself
enter the stricture, and pass into the bladder (Dupuytren.)  When the
bougie have to be pushed beyond the curve of the urethra, beneath the
arch of the pubes, it is most advantageous to give  it a  proportionate curve,
or to introduce a stilette of lead or iron properly curved into the cavity
of an elastic bougie.  Or if a  straight bougie be carried beyond the curve
of the urethra, as soon  as its point gets under the pubic  arch, the penis
must  be depressed to lessen  the curve of the canal, the  bougie gently
rotated as it is pushed forwards, and assisted by  pressure  of the finger in
the perineum.
   The introduction of the bougie is often rendered difficult by the spas-
modic contraction of  the muscles  surrounding the urethra, especially in
irritable persons, or if the stricture be in an  inflammatory state.  In this
case the introduction of the bougie may be often  effected, if a slight rub-
bing be made on the perineum with one hand,  whilst the instrument is
gently pressed forwards with  the other, or if it be  allowed to lie some time
upon the stricture, and then attempts made to pass it farther.  Under these
circumstances, remedies which lessen  the great irritability, as luke-warm
bathing, clysters, leeches, and the like should sometimes precede the use
of the  bougie.  No force should ever be employed in passing a bougie;
if it will enter only a few lines deep into the stricture, there it should be
allowed to remain, and by repeated introductions it will pass farther.
  Common bougies, wax bougies, are prepared in  the following manner:—A piece
of fine linen, which has been already used, nine inches long and to an inch in width,
according to the thickness of the  bougie to  be made, is to  be dipped into melted
plaster, and when a little cooled, spread flat and even with a platula; it is then to
be rolled together between the fingers and afterwards between two plates of marble
till it is quite firm and smooth.   The boujjie must be equally thick throughout its
whole length to about one inch from its point, from whence it should gradually taper
and terminate in a firm round point.  Bougies are also made  by dipping cotton
threads in melted wax till they have acquired sufficient size, after which they are
rolled between  marble plates.  By the addition of  various medicaments to the sub-
stance of which bougies are formed, were made the bougies medicamenteuses formerly
in use.  The elastic bougies are to be preferred, as  besides their flexibility they are
also tolerably firm, and not so  easily dissolved by the urine.  If hollow, an iron
stilette may be  introduced into them, and their strength thereby be  much increased.
  Wax bougies seem preferable to elastic ones in  all cases where  there is difficulty
in penetrating the stricture, as, on account of their great flexibility, the urethra  is not
easily injured.   In very narrow strictures the  introduction of silk-worm gut bouoies
has been recommended, which enlarge about  half their size, and  by their softness
yield to the directions of the canal.  The objection made to them,  that by their irre-
gular and hard  point, they injure the canal of the urethra, and even pierce through
it, may be diminished by their proper preparation,  and careful introduction (a).
  (a} Kothe, die Harurohrcn-Strietur undihre Heilung j in Rust's Magazin, vol. xv. p. 1. 
STRICTURE OF THE URETHRA.
71
  If the wax  bougie, when it  has penetrated the stricture, be a little while with-
drawn, an impression upon it from the stricture is observed, by which the condition
and  extent can be  determined.   The  same also happens with the silk-worm  gut
bougie.
   [In passing wax bougies, Astley  Cooper (a) directed  " always  to warm them
by the fire, for the purpose of rendering them soft; when, if they are introduced into
the urethra and pass through the stricture, you will ascertain the distance at which
it is situated from the orifice, and the form and size of the stricture will be modelled
on the bougie.  You then pass another bougie a little longer than the  first, and
directly that is withdrawn, another still larger.   On the following day you again
introduce two  bougies, that is, if there should be  no existing inflammation to prevent
it; the first bougie you then use is to be of the same size as the one with which you
concluded on the previous day; after this has been withdrawn, you again pass ano-
ther, a size larger than the first, thus  using on every occasion two bougies, always
beginning with one of the same size as that with which you had concluded on each
preceding time.   By adopting this plan, strictures may be cured in a quarter of the
time that they usually are, and  the strictured  part of the  urethra speedily made to
regain its natural  size. * * * Never attempt to pass a bougie in its straight state, for
if  you  do, it will be  obstructed in its passage, whether  there be stricture or not.
You invariably give it, before its introduction,  the curve of the catheter." (p. 223.)
  Abernethy (b) says:—"You should pass a bougie very gently, and withdraw it
immediately after the first application, and if  no reaction ensue, you will find that
the part will bear twice as much next time;  but if you pass it roughly, the contrary
will happen, and you will  increase  the disorder.   You  should never repeat the
passing a bougie till the effect  of the first stimulation  is completely gone off.  In
many cases  there is no necessity for introducing  them more than once a week."
   Brodie justly remarks:—" Success  in the cure of this  disease will depend on
your attending to  this important rule.   Whether  you  use a bougie, or a sound, or a
catheter, let the instrument be held lightly, and, as it were, loosely  in your hand ;
it will then in some measure find its own way in that direction in which there is the
least resistance; whereas, if you grasp it with force, the point can pass only where
you direct it, and it is just as likely to take a wrong course as a right  one.  A stric-
ture will invariably resent rough usage.; it will yield to patience and gentle treat-
ment." (p. 68.)
   In the treatment of stricture of the urethra, there is difference of opinion as to the
material  of which the bougie or sound should be made, whether wax, elastic gum,
cat-gut, or metal is  to be preferred; and whether such instrument should be conical
or cylindrical.
   Astley Cooper says:—" The bougie I use is  made of silver; it is of the form of
the catheter, but at the point, and running back  for some distance towards the handle,
it is conical.  The way I  use it is this, I first  pass down in the manner above de-
scribed, a wax bougie, for the purpose  of ascertaining the form, size, and distance of
the stricture.  Having obtained a knowledge of these, I then  introduce my conical
silver bougie,  the point of which having entered the stricture, the farther it passes
the greater is the dilatation produced,  in consequence of the form of the instrument.
This bougie I have found extremely serviceable, and  it is the best with which I am
acquainted.   When it is not at  hand I use a common silver catheter instead." (pp.
223, 21.)
   Abernethy observes:—"Metallic instruments are good in  some cases;  if there
be a spasmodic stricture at five inches, and  another at six, and one beyond it, when
a common bougie is passed it may get by the first stricture, but when it reaches the
second it will  be  so griped by the  one through which it first passed,  that it will go
no farther:  here,  then, the metallic is useful;  it cannot  be indented, and being ex-
ceedingly polished, it slides on, but it requires great  knowledge of the direction of
the canal, and great gentleness  in passing it."
  In the following observations it will be seen that Brodie considers difference of
situation of  the stricture  requires corresponding  modification in the treatment with
instruments.
  "Strictures  in the anterior part of  the urethra, but behind the orifice," says he,

  (a) Lectures; in Lancet, 1833-4, vol ii.    (b)  MS. Lectures on Surgery.
Third Edition. 
72                           TREATMENT  OF

"require to be mechanically dilated by the introduction of bougies or metallic in-
struments.  At all events, I know of no better method of treatment;  and sometimes
the patient obtains relief on very easy terms, the  dilatation being  readily accom-
plished, and the use of a bougie once in three or four days being sufficient to prevent
a recurrence of the contraction.  At other times, however, the disposition to contract
is so great, that it becomes necessary to introduce the bougie  once  or twice daily;
and, indeed, I have known cases  in which the patient was seldom able  to expel his
urine until the bougie had been employed.
   "The simple rules which have been just laid down are not sufficient for the treat-
ment of 'strictures at the bulb of the urethra.   The circumstance  of  these being
situated where  the  curvature of the urethra begins, at a  distance of six or seven
inches from the external orifice, and their liability to spasm, distinguish them from
strictures in the anterior part of the canal. The management of them requires greater
skill, attention, and experience on the part of the surgeon; but, at the same time, it
must be acknowledged that it leads, on the whole, to more satisfactory  results  than
that of strictures which  take place elsewhere.  If you were to ask me, how then do
you treat strictures at the bulb of the urethra ? my answer would  be, I have no par-
ticular method :  sometimes I adopt one method, sometimes another, according to the
peculiar circumstances of the case. (p. 49.)   The methods which are chiefly useful
in the case of stricture at the bulb of the urethra, are: First, The dilatation of it, by
means of the common plaster bougie.   Secondly, The dilatation  of  it by means of
the metallic bougie, catheter, or sound.   Thirdly, The retention of the gum catheter
in the urethra, and bladder.   Fourthly, The application of the bougie  armed with
nitrate of silver.
   " The common plaster bougie, if of  small size, should be of a  conical shape, but
if of a middle size or of a full size, it  should be cylindrical.   Ascertain the size of
the stream  of urine, and introduce a bougie of this size, whatever  it may be.  If the
bougie be very  small, it may be used straight, otherwise it should be curved like a
catheter, but in a less degree.   Neither you nor  your patient are  to be disappointed
because the bougie does not enter the stricture at the first trial.   In many cases this
will not happen until you have seen your patient three or four times;  and in very
difficult cases, the delay may be still  greater than this.  When a bougie has once
entered  the stricture and bladder, allow it to remain  for a few  minutes.  In two or
three days  introduce either the same bougie or one of the same size.   Then with-
draw it, and use one of a size larger.   Allow this to remain for a few minutes, and
after two ox three days more, repeat the operation.   Thus, by degrees, you dilate
the stricture, until it is  of the  same diameter with  the rest of the urethra.  This
method of curing strictures is applicable to a great number of cases ;  and, whenever
it  will answer the purpose, I would advise you  to resort to it in preference to other
methods.   The common bougie gives little or no pain ; it excites no irritation, un-
less it be introduced clumsily or  rudely; and it can do no harm  by penetrating or
tearing the membrane of the urethra.
   "The metallic instruments which I  am in the habit of employing are not those
which are sold under the name of flexible metallic bougies.   These are liable to
lose the shape which you have  given  during their introduction, and, in fact, are at
the same time too flexible and too inflexible for  any useful purpose.   Those which
I have, if of a small or middle size, are made of solid silver, the larger ones of silver
or steel, or steel plated, or of a composition similar  to, but firmer than, that of the
flexible metallic  bougie.  These sounds should be very slightly curved  and for
ordinary cases not more than eight inches and a half or nine inches loner, exclusive
of the handle.  You may use them as you would use the common bou>ie, for the
purpose of  gradually dilating the stricture, beginning with one  of a smafl size, and
gradually proceeding to those which are larger.   Sometimes you will find it best to
introduce the sound without turning, that is, with the concavity towards the patient's
abdomen;  at other times, you will pass it more  readily by keeping the handle in
the first instance, towards the patient's  left groin, turning the instrument afterwards
as it approaches the stricture.  In either case, if  you wish to avoid making a false
passage, take care that the point is kept sliding, as it were, against the upper part of
the urethra.  Press the instrument firmly, but gently, against  the stricture  in the
expectation that it will gradually become dilated  and allow the point to enter- then
depress the handle, and  pass it into the  bladder, provided that you  can do so readilv
and without the application of force, but not otherwise.  Two  or three days after 
STRICTURE OF  THE URETHRA.
73
wards, (and the interval ought to be never less than this, and sometimes it ought to
be greater,) introduce the sound which has  been passed before, withdraw it, and
introduce another of a size larger; and thus  go on dilating the  stricture until that
part of the urethra has regained its natural diameter.  - If in the course of these pro-
ceedings you are  in doubt whether the sound has reached the bladder  or not, you
may easily determine the point in question by introducing a catheter.   You might,
indeed, use the catheter from the beginning, but that the openings near the point,
and its comparative lightness, render the introduction of it less easy than that of the
solid instrument.   This method of treatment is applicable to a  large proportion of
the cases which you will meet with in practice: first, to those of old and indurated
strictures, which the common  bougie is incapable of dilating; secondly, to those in
which, in consequence of some improper  management, a false  passage has been
formed, into which the point of a common bougie will  easily penetrate, but which
an inflexible instrument may be made to  avoid; thirdly, to those in which, from
long-continued  disease, and without any previous mismanagement, the urethra has
become distorted and its surface irregular; and,fourthly, to  several recent cases, in
which  the smooth, polished surface gives less pain to the urethra, and is less likely
to induce spasm,  than the softer, but  less smooth surface of a common bougie, (p.
51—4.)
   "In treating  a stricture of the urethra with the gum catheter, you are to introduce
it and allow it to remain day and night in the urethra and bladder.  If the patient
can bear it  to be  retained for  a sufficient length of time, the stricture will become
dilated not only to the size of the instrument employed, but to a size considerably
larger.   Perhaps you will be able to introduce the catheter without the  wire or
stilette.  Do so, if possible.   If not, you should employ one mounted on a strong, un-
yielding iron stilette, having a flattened handle, like  that of a common sound or staff.
Being so mounted, it is more readily directed  into  the bladder than when mounted
in the usual way on a piece  of thin flexible wire.  When the  gum catheter  has
entered the  bladder, withdraw the stilette, and leave  the catheter with a wooden
peg in its orifice, which the patient is to take out whenever  he has occasion to void
his urine, it being at the same time secured by a suitable  bandage.  After  three or
four days, you  may withdraw the catheter for twelve hours ;  or, if much suppuration
be induced in the urethra, you may withdraw it for a longer period.   Then introduce
another catheter, larger than the first; and thus you may, in the course of ten days or a
fort-night, dilate a very contracted urethraKto its full diameter.  This is a very certain
and expeditious method of curing a stricture.   You may by these means sometimes
accomplish  as  much in the course of ten days as  you would accomplish in three
months by the  occasional introduction of the  bougie.   This method is  particularly
applicable,y»-s/, where time is of much value, and it is of great consequence for the
patient to obtain a cure as soon as possible; secondly, where a stricture is gristly and
cartilaginous, and therefore not readily dilated by ordinary methods; thirdly, where,
from the long continuance of the disease, the  urethra has become irregular in shape,
or where a false passage has been made by previous mismanagement.   Under these
circumstances,  if you can succeed in introducing a gum catheter,  and let it remain
for a few days  in the bladder,  you will find your difficulties at an  end ;  the irregu-
larities will  disappear,  and the false passages will heal;  fourthly,  there is still
another class of cases in which this method  of treatment is particularly useful.  I
allude to those in which  a  severe  rigour follows each introduction of  the bougie.
This disposition to rigour is such,  that it  is sometimes impossible to proceed with
the treatment in the ordinary way.   Observe, in these cases, when the rigour takes
place.  It  seldom follows the  use of the bougie immediately.  It almost always
occurs soon after the patient has voided his urine, and seems to arise not as the im-
mediate effect of the operation, but in consequence of the urine flowing through the
part which  the bougie has dilated.   Now, if instead of a bougie  you  use a gum
catheter, and allow it to remain, the urine flowing through the catheter,  the contact
of it with the urethra is prevented, and the rigour is prevented also.   I have  no right
to say that this plan will invariably succeed,  but I do not remember that it failed in
a single case among many in which  I have resorted to it." (p. 57-9.)
   Although the harmlessness of plaster bougies is asserted by the high authority
just quoted, yet I cannot accord with that  statement, for I am quite sure that they
are very frequently exceedingly mischievous, and that, even with the  greatest cau-
tion, much injury may be done  by their frequently slipping  from the  stricture and 
74
TREATMENT OF
perforating the wall of the urethra in front of it, and P^«^» ^S^XNfi
not very uncommonly laying the foundation for urinary ^scess and fistula^   I He
quickness with which they often soften by the mere beat of the ^J "° ^JJ *£
that it is almost impossible to be sure of the precise quantity of p essur> which they
will bear- and when they once begin to yield, they speedily curl and twist in a
very JSorfii J manner near their tip, and, though they may not actually pene-
trate the watl of ythe urethra, yet  they may seriously damage  it by their  increased
bulk at this part, as the curve assumes the shape of a corkscrew to a less  or greater
extent.   I Tiave known bougies pushed through the urethra  again and again, and
false passages formed whilst the surgeon supposed he was making progress in the
cure of the stricture, when, in reality he was making matters worse.   Ihere are, 1
apprehend, more false passages made  with them than with any other instrument,
and few Museums are without examples of such  results.  I therefore have long
since almost entirely given  up using bougies, and  prefer a  catheter or a  sound, as
with either of these the precise  quantity of pressure  made,  as well as the actual
course which the  point of the  instrument takes, is  more readily ascertained, and l
it  be inclined to go wrong  can be more easily and satisfactorily corrected.  And
with them there is little or no excuse for tearing the urethra.   In addition to which,
experience shows,  that the smoother  surface of  the  metallic instrument greatly
favours its movement along the urethra, and that its tip will often, without difficulty,
overcome any little spasm about  the stricture, and pass through it, when it is im-
possible to make  a bougie move on without mischief.  1 do  not think it of much
consequence whether a catheter or a  sound be used;  perhaps the former has the
advantage of showing at once its entrance into the  bladder, by the flow of urine
through  it, whilst  the latter, on the whole, passes  more readily, and  with  less
resistance, as its  own weight  gently urges it  on,  if it be only kept  in the proper
direction.  A  silver sound  is preferable to a  steel one, as most practitioners who
have been in the habit of using it will bear testimony ; but it should be solid silver,
and not,  as is too commonly the case, merely a silver catheter filled with composi-
tion, which is not only less  weighty than the solid one, but is liable to be broken in
two if it be necessary to make any alteration  in its curve, as  is not unfrequently
requisite, to adapt it to the particular case.   I think, also, the conical fonn recom-
mended by Astley Cooper is highly advantageous, and of the best which can be
used.  A couple  of them is amply sufficient for any surgeon's armamentarium, of
which the point of one should be that of No. 3 or 4, and of the other that of No. 5,
increasing in size upwards to  Nos. 10 and 12 respectively.   Some practitioners are
in the habit of using a straight sound like a skewer, with a conical point; but if the
stricture be in the membranous part of the urethra, it is a very dangerous instrument
in the hands of most persons, and not adapted, I think, for general use.
   The excellent  directions  given by Brodie for the introduction of the sound or
catheter leave little to be added.  The importance of avoiding all violence cannot be
too strongly urged.  An instrument to be passed into the bladder should  rather, as
Abernethy used to say, be "coaxed," not forced.  There are, howeveT, other two
points which must  be carefully attended to in this operation;  the urethra may fall
into folds, either in its length, or in its transverse diameter, in consequence of which
the point of the instrument becomes entangled, and will be at once stopped, and may
or may not be thrust  through  the side  of the canal, although  at the part where the
hitch is, no stricture exists.  The urethra  folds lengthways, when the instrument
does not completely fill it, for which reason it is always  advantageous to introduce
such an one as nearly of the size of the urethra, as will have  a chance of its point
entering the stricture; and I am convinced that there are few strictures in which  it
will be necessary to commence operations with one smaller  than No. 6 or No. 4;
provided the cure only of the stricture is considered, and not the immediate relief of
 the bladder from retention of urine, in which case a small instrument is admissible.
 But small catheters or sounds are at all  times very dangerous, except in more dex
 terous hands  than  those by which they are commonly used; and,  as  they  more
 quickly slip through the wall of the urethra than larger ones,  the patient's condition
 is rendered worse than before, because it often becomes necessary to suspend the use
 of instruments, if luckily the accident should be discovered, which is far from  com-
 monly the case, till the tear has healed up,  even if it do not give opportunity for the
 escape  of the urine, and so give rise to abscess.  The transverse  folding of the
 urethra roost commonly occurs in the membranous part, and  may happen whether 
STRICTURE OF THE URETHRA.                   75
the instrument be small or large, and the obstruction thus produced very frequently
leads to the presumption of a stricture  when  none really exists.  This transverse
folding depends on the gent's and urethra not being sufficiently drawn forward upon
the instrument;  so that, when the  handle of the instrument  is depressed to tilt the
point up  behind the suspensory ligament into the bladder, the point lifts with it the
lax urethra in front of it, and, doubling it, from a valve which blocks its further pro-
gress. Attention to keeping the whole length of the urethra stretched will generally
prevent this, or it may be corrected by elevating the handle of the instrument so that
the point disentangles itself, and will then pass on without  hindrance.  The point
of the instrument is also not  unfrequently stopped, by depressing the handle too
early, that is, before it has completely entered  the membranous part of the urethra,
in which case it strikes against the front of the suspensory ligament, and will not
pass  further.  The greatest care must therefore be taken that the instrument  has
passed well beyond the ligament  before the handle  is depressed 'and  the point
tilted up;  and if then it will  not enter the bladder without much difficulty, it is better
to pass the finger into the rectum, and the end of the instrument being felt,  it is in
general easily directed into its proper course, and little risk encountered of thrusting
it through the urethra between the bladder and pubes, or between the bladder and
rectum, which, especially the latter, is of not unfrequent occurence in not very prac-
tised hands.   When the instrument has entered the bladder, its point can usually be
freely moved in any direction;  but when it will not move but forward after its handle
is depressed, it is pretty certain it  is not in the bladder but in a false  passage, and
must be withdrawn, and fresh attempts made to carry it in the proper direction,
instead of thrusting about and doing serious  mischief.  The  frequency of intro-
ducing the instrument must vary according to  the irritability of the urethra; in some
cases it cannot be used more than once a week at first,  as it will frequently produce
severe irritation in the passage, and be followed by shivering, and occasionally a hot
fit afterwards, and it may be necessary to defer the second introduction for even a
still longer period.  But if no  febrile excitement follow, it may be introduced every
third or second day, which is generally often enough.   It is also very advantageous
to bathe the perinaeum night and morning with warm water, and even  immediately
after the  introduction of the instrument,  if it  have caused much irritation; and if
there be continuing pain, it is best  to apply a few leeches.   Going into a warm bath
twice a week, and the use of leeches to the  perinaeum as frequently, if the stricture
be very obstinate, will be often found to assist very materially in hastening the in-
troduction of the instrument, and the widening of the  stricture.  If the patient be
desirous of keeping the passage free, he should  persevere in  passing a  large bougie
once a fortnight, long after the cure appears to have been effected, as there is always
great tendency to its recontraclion.  Some  surgeons consider  the introduction of a
bougie is rendered more easy, by having its tip smeared with extract of belladonna.  I
have tried this plan, but I think not with much advantage.  If any benefit be  gained
from it, it will not be immediate; the bougie thus smeared must be passed down to
the stricture, and left in some hours, after which it must be withdrawn, and  another
introduced.  It may, however, be doubted whether the mere residence of the  bougie
in the urethra has not more to do with  the relief than the operation of the belladonna ;
for occasionally a bougie thus managed, as recommended by some French surgeons,
will facilitate  the introduction of an instrument which previously would not enter
the stricture.   I  do not like cat-gut, nor elastic gum-bougies; they are tough enough
to do mischief, but not sufficiently firm to enable us to judge of the pressure made
with them, nor to guide them  properly.
   I cannot say that  my experience,  as regards  the wearing a gum elastic catheter for
the cure of the stricture, has  been so successful as Brodie has found it.   Frequently
the irritation set up by it in both urethra and bladder has been so great as to compel
its removal; and, although I think wearing a silver catheter is  more easily borne, if
the patient be kept in  bed,  which, under either mode of treatment, I have  always
found necessary  to enjoin, yet even then  I have known in one  instance a slough of
the urethra take  place in front of the scrotum,  without  warning, in the course  of a
few hours; so that, although the case  has seemed to be going on well  at one visit,
on  the following day the first step towards a certain  aperture in the urethra has
been made.—j. f. s.]
   1684.  The time which the bougie should remain  in the urethra must 
76
TREATMENT OF
especially depend on the sensibility of the patient in general, and of the
urethra in particular.  It must be so managed that the  patient shall suffer
as little pain as possible.  The bougie should, therefore, remain only til]
the patient complains of pain, which on the first  day does  not exceed a
quarter or half an hour, but in an irritable urethra not longer than  a few
minutes.   The introduction must be repeated about every other or every
day.   If the bougie be left in longer, severe pain, swelling of the testicles,
febrile symptoms, and abscesses near the urethra, often occur.  The use
of the bougie must then be  suspended for a long time, and the inflam-
matory condition got rid of by blood-letting, quietude, warm-bathing, and
antiphlogistic diet.  Many writers have, however, advised that the bougie
should remain  for several days, in  consequence  of which  an increased
secretion of  mucus in the urethra is excited, its sensibility blunted, and
it is protected against the  presence of foreign  bodies (a)  For the  most
part, patients soon become accustomed to  the longer resting of the bougie
in the  urethra, and after some  days it  may be left.  It is then advisable
to exchange it for an elastic catheter, which is specially indicated, if there
be  already fistulous openings, because the patient is thereby relieved from
the necessity of its frequent removal, and  re-introduction, for the purpose
of discharging his urine.
   The bougie, or catheter, when left in, should be properly fastened; a
tape must be bound tightly round it at the mouth of the urethra, the  ends
of which, carried over  the glans penis, must be  fastened behind it with
several turns of sticking plaster, and the loose ends tied together.   This
mode  of fastening is  simple, safe, without difficulty,  and preferable to
fastening a thread to a ring placed upon the penis. (Dupuytren.)
  When the bougie has been long left in, it often, especially at first, acquires an
indent from  the  stricture, in consequence of which, if it be carelessly withdrawn,
violent pain may be produced.  This may be prevented, if the bougie be frequently
moved, and  gently drawn up and down.
   1685. Thin bougies,  or catheters,  should be gradually exchanged for
thicker ones, which, in  not very tough  strictures,  may  be soon; and this
should be repeated till the urine is voided in its accustomed stream.  The
bougie must not be left off at once, but  must still be left in for some time
every day, or every other day, and afterwards every week for some hours.
It will be also advantageous in dispersing the hardness of the membranes
of the urethra to apply, externally, mercurial ointment, and to give, in-
ternally, cherry bay water (b) and the like.
   If,  afterwards, the stream of urine should begin to diminish, and the
patient have difficulty in passing it, the use of the bougie must again be
prescribed.
  In order to effect the expansion of the stricture at pleasure, Arnott (c) has pro-
posed an instrument, consisting of an oiled silk tube, which, for the purpose of
rendering it air-tight, is lined with the thin gut of some small animal, and connected
with another tube, through which air can be blown, or water injected by means of a
syringe, and retained by a  cock.  Although  the introduction of this instrument is
generally as easy as that of a bougie, it is,  however, frequently, better,  especially in
an irritable urethra, to introduce it through a cannla.  When it has penetrated the

        (a) Desault, Chopart, Delpech, PrecisElementaire, vol. i. p 55ft
        (6)  Riohter, Anfangsgrilnde, vol. vi. p. 283.
        (c)  Above cited, p. 92. 
STRICTURE OF THE URETHRA.
77
stricture, it is to be filled with air or water, as long as the patient can bear it with-
out pain.
   [Conundrums of this sort are very well pour s'amuser, but every practical person
will be very well aware that  if a stricture will  admit such a contrivance it is suf-
ficiently expanded not to require the assistance of a surgeon, or any one else, but had-
better be left alone.—j. f. s.]
   1686.  The operation of bougies consists in the expansion, compression,
and irritation, produced by their introduction and inlying, in consequence
of which an increased secretion of mucus, and modification of the vitality
and condition of the diseasedly changed mucous membrane is set up.  In
common cases their presence in the urethra excites only a little pain and
mucous discharge ; but in sensitive persons, violent pain and inflamma-
tion, painful  erections, transition of the inflammation to the testicles, and
swelling of the inguinal glands,  will be produced with the inlying of the
bougie;  also inflammation of the cellular tissue upon the outer surface of
the urethra, terminating in suppuration and  extravasation  of the  urine.
All these symptoms require,  besides the removal of the bougie, an anti-
phlogistic treatment corresponding to circumstances, blood-letting, spare
diet, luke-warm bathing, and the like.   If, during the use of the bougie,
an abscess form, with severe pain increased on pressure, Desault {a)
advises the introduction  of an elastic catheter, not to  open the abscess,
but to let it burst of itself, or, if it empty into  the urethra,  to let the pus
escape by the catheter; but  if it  be then necessary,  on  account  of the
great size of the abscess, to  open it, then always to make a  small open-
ing, as a large aperture retards the cure.  Although,  however, I have in
several instances pursued this treatment successfully, yet it appears better,
on account of the danger from extravasation of urine, in these case's, as
soon as inflammation shows itself, to  remove the bougie, and to employ
active antiphlogistic treatment by general and local blood-letting, bathing,
softening poultices, rubbing  in  mercurial ointment, and the  like, and if
fluctuation should show itself, by early opening the abscess {b).
   [Astley Cooper adverts to the not unfrequent circumstances of bleeding from the
urethra  after the introduction of the bougie; or, it may be  added, of a sound or
catheter which has been roughly handled, or after the use of a caustic  bougie.  He
says:—"The passing of a bougie is often attended with very considerable haemor-
rhage from the urethra," and mentions a case in which he " pressed a roller upon the
perinaeum, which instantly checked the flow of blood.  A short time after he was
sent for to the same patient, the  haemorrhage having returned; he had,been loung-
ing before the  fire with  a foot on each side of the  chimney-place;  the  warmth
coming in contact with the perinaeum had brought on a renewal of the  haemorrhage.
He made an incision on the part,  and divided the artery of the bulb ; this operation
completely succeeded, and the bleeding was permanently subdued." (p. 225.)  I
apprehend the necessity for such active treatment is  rare, at least I have never seen
any need  for it, and believe that Abernethy's mode of proceeding  (c) is amply
sufficient in most cases.   "When haemorrhage occurs it is best,"  he says,  "to put
the penis  in a tumbler, so that the quantity of. blood may be evident.  I cover the
feet and upper part of the body with the bed-clothes, leaving the pelvis bare; I then
wash the perinaeum with vinegar and water. The vessels of the urethra speedily
contract, and the bleeding stops.  I would  recommend you to do these things your-
self, and not to trust to the patient or his attendant."
  Astley Cooper also gives  the following  advice, which, if followed, will often
save the patient much suffering:—" Whenever you suspect a  tear  of the urethra in
passing a  bougie, immediately withdraw the instrument, and  desire the patient, if

                           (a) Above cited, p. 252.
  (b) Docamp, above cited, p. 87.            (c) MS. Lectures. 
78
TREATMENT OF
 possible, to retain his urine, that it may not irritate the wound, and also to prevent
 its escapino- through the  opening and becoming  extravasated in the  surrounding
 cellular substance.   In this way you give time for a clot of blood to form over the
 surface of the wound, a slight degree of inflammation is excited,  and it becomes
 healed  by the adhesive process without any further mischief." (p. 225.)  To this I
 would add that, under such circumstances, it is advisable that no attempt should be
 made to introduce the instrument again for several days,  and  that it should then be
 done with a very light hand, and with great care.—jr. f. s.]
   1687. The  destruction of  stricture  by caustic  is effected either with
 nitrate of silver or caustic potash.   'The  application of both these remedies
 varies, according  as the cauterization  is  made upon  the stricture from
 before backwards, or on  its walls in  the narrowed part itself.
   The  destruction of strictures by ulceration, in which very hard bougies are violently
 inserted in the stricture, so  that they are grasped by it, in order to produce com-
 pression and ulceration of their walls, is to be completely rejected as dangerous and
 unsafe.
   [Brodie says:—"I am much mistaken if  a stricture is not sometimes destroyed,
 at least in  part,  by  ulceration.  For example: I attended a. gentleman who had
 laboured under a stricture of the urethra for a  great many years.   He voided his
 urine with the greatest difficulty, the stricture being very rigid and unyielding; but
 I succeeded in introducing a cat-gut bougie,  and this enabled him to make water in
 a small stream.   Under these circumstances he was seized with pain in  the act of
 making water, which lasted for some minutes afterwards, being  referred to the
 situation of the stricture  in the posterior part  of the urethra.  The pain became
 more severe, and the patient described it to be intolerable, saying that he could
 compare it to nothing but the  sensations which he supposed  would  be produced if
 melted lead had  been poured into the canal.  Every half hour he had a desire to
 make water, and  his groans  might be beard,  not only through  the whole house, but
 even in the street.   In the; course of a few days these symptoms began gradually to
 abate, and now it was discovered that the  urine flowed in a much larger stream.
 When  the attack had completely subsided,  the condition of the patient was much
 improved, and he made water more  easily than  he had done for many  years."  (p.
 15.)]

   1688.  In cauterizing  a  stricture from before  baclcwards,  a  common
 bougie is to be first carried down to the stricture, for the purpose of open-
 ing the canal of the urethra, and the distance-frorn the orifice of the canal
 must be marked close to it  on the bougie.   This having been withdrawn,
 a corresponding mark is to be made on  a bougie armed with lunar caustic,
 which, after having been properly oiled, must be carried down  the  urethra
 to the stricture, against which it must be moderately pressed, and accord-
~ ing to the patient's feelings, for a different length of time, though on the
 first day not for a  minute.  In this way the  armed bougie is employed
 every  other day, or in  obstinate cases, daily.  When ihe slough has been
 thrown off, an  elastic bougie  is to be introduced, and thus  gradually the
 natural calibre of the urethra is restored.
   Bougies armed with lunar caustic are made in  the following way:—In forming
 the common bougie  a piece of wire is rolled into it, extending about  half an inch
 into its substance.   When the bougie is nearly completed, the wire must he pulled
 out, and a piece  of  lunar caustic inserted in its place.   The  bougie  is to be then
 again rolled, so that  the sides of the caustic may be firmly surrounded with the linen,
 which  gives a blunt end to the bougie.
   Hunter (a) used, for applying the caustic,  a  flexible silver catheter, provided
 with a stilette, which had at its extremity a  portcrayon for holding the caustic.
    [In  the  directions which  Hunter gives  for the introduction  of the caustic, he
 mentions, it is necessary for the canula to be furnished  with a piece of silver or  a
 stilette, having a button at one end, forming a kind of plug, which should project

                              {a) Above cited, p. 139. 
STRICTURE OF THE URETHRA.                 79
oeyond the end of the canula, and give it a rounded end, to facilitate its  passage
along the urethra to the stricture, having reached which the plug is withdrawn, and
the portcrayon, which may be attached to the other end of the stilette, introduced in
its stead.  This apparatus was, however, a very bungling contrivance, and Hunter
doubtless  found  it so, for Home mentions in a note,  " that before his death Mr.
Hunter left off entirely the use ofthe silver canula,  and used the lunar caustic
inserted into the end of a common bougie," (p. 140,) the mode in which it is now,
whenever employed.   The great advocate for the  treatment with lunar caustic was
Home ; but it was soon fiercely and efficiently attacked  by Whately, who showed
the mischievous and dangerous results ensuing  from it; for, to use  Lawrence's
words, " if we are to credit the  description which Home gives, nothing would  be
more safe or effectual  than this mode of treatment.  When we  come, however, to
peruse the cases he gives in illustration of the various  points  of the treatment, we
find that serious mischief is sometimes produced  by this mode of treating stricture;
and as he (Home) is highly favourable to the plan, we may at  all events suppose
that he is not exaggerated the ill-effects of the treatment." [p. 802.)]
   1689.  This mode of cauterization has considerable objection, as espe-
cially in  strictures behind the curve of the urethra, the walls are easily
destroyed, false passages made,  and  considerable  bleedings produced.
Not  unfrequently the aperture  of  the  stricture  is closed  by the thick
slough, and complete obstruction to the voidance of the  urine produced:
and  farther,  by the hard, formless scar  which  is produced,  the  disease
again returns more  severely  than at first.      ,
   1690. It is attempted to overcome  the greater number of these dis-
advantages by  cauterizing the  walls  of  the stricture.   According  to
Arnott (a),  after the seat and condition of the stricture have been ascer-
tained by careful examination, and with a very soft  bougie, which should
be introduced through  a canula,  and  take  every impression of the stric-
ture, a pretty large canula should be carried down to the stricture.   A
piece of lunar caustic, somewhat smaller  than the  stricture,  should then
be pierced through its middle with a metal stilette, and  upon which it
 must be retained, half an inch from the tip, so  that  the stilette  may be
 surrounded with a piece of common bougie, both in front and behind the
 caustic.   The stilette is  then passed  through  the canula down  to  the
 stricture, and through it,  so  that the caustic can  be applied  to  any part
 of the stricture.   When the  caustic has been properly used, a small wad
 of linen is to be introduced by means of the same stilette  and canula, to
 sop  up  all the caustic which has become fluid.
   [It must not be  supposed, as Chelius would seem  to infer, that Dr. Arnott is
 the  original proposer of the treatment of cauterizing the walls of the  stricture with
 lunar caustic; for Whately, in his  Observations on Mr. Home's Treatment of Stric-
 tures, d>c, published in 1801, eighteen years before the first edition of Arnott's
 book on Stricture, had mentioned among the advantages of his construction of caustic
 bougies, by gluing the end of the instrument, and applying it to a given quantity of
 powdered lunar caustic, that " in the first place, the bougie may be of any size, even
 the  smallest size can by this method become the vehicle of this powerful remedy; and
 may be readily passed into, or a little beyond such strictures as are extremely narrow,- or
 such as are attended with considerable contraction of the orifice  of the urethra." (p.
 68.) And again :—" If the stricture be open enough to admit a bougie of moderate
 size, such a bougie armed with caustic may very readily be passed into or beyond it."
 (p. 72.)  Perhaps Dr. Arnott was  unaware of Whately's observations, for it is
 rather curious, that although Hunter, Home, Astley Cooper, Lallemand, Ducamp,
 and  other writers on stricture  are  mentioned  by him, the  only notice  taken of
 Whately is, that a naval captain had obtained considerable relief under his care;
 and that after his death the captain's stricture having returned, he placed himself
(a) Above cited, p. 157. 
80
TREATMENT OF
under the  care of other surgeons, but without receiving much benefit from their
Jjr. ARNOTT S new merauu 10 F'^'-"J --  .    ~~  ----. ,  ^,        -■   ..  . V°
the lunar caustic, and which  he gave up as  inefficient, with the exception that the
caustic is held on a piece of wire, by which it is pierced, instead of a portcrayon, as
in Hunter's mode; and with the  important addition, that the stilette of the plug,
instead of  having the portcrayon  attached  to the  other end, as recommended by
Hunter, has "a little dossil of lint fixed on it, which is introduced before the
caustic, to  absorb any superfluous moisture in the stricture, and after it again, to take
up any dissolved caustic which might spread in the  canal." (p. 158.)   From the
above extracts it appears that the proposal of cauterizing the interior of the stricture,
whether of much value or little, is Whately's and  not Arnott's ; nor the new
method other than John Hunter's old and disbanded one, with the  addition of a
wipe.—j. f. s.]
   1691.  If caustic potash be used for cauterizing the walls of the stric-
ture, a bougie of sufficient  thickness to  enter the stricture with  difficulty
must be chosen, and passed down  to  it.  A  mark is then  made on the
bougie with the nail, half an inch from  the orifice  of the urethra, and
when it has been withdrawn,  a little cavity about the twelfth of an inch
deep  must be made  in  its  rounded end, into  which a small piece of
caustic, less than the smallest pin's  head, must be put, and so pressed in
that the edge of the cavity project a little beyond it.   To fix the caustic,
the  bougie must be  squeezed together with the fingers, and the  inter-
space filled with lard.  Thus armed, and after having been well oiled,
the bougie  is carried down the urethra to the stricture, where it is to he
held till the caustic begin to become fluid, and  the patient feels a burning
pain.   It is then to be introduced  a quarter  of an inch farther into the
stricture, held there about a couple of  seconds, and then passed a little
further, till by a peculiar feel, or by the approach of the nail-mark to the
lips of the urethra, it appears that the bougie  has penetrated the  stricture.
If no pain occur, the bougie should be  introduced once or twice a day!;
but if there be pain, it must not be used.  The whole operation should
not exceed  two minutes.   Generally after the first use  of the caustic
there  is but little pain, a slight cutting in making water, and its discharge
in drops  during the first few days.   The bougie used should correspond
to the diameter of the stricture, the  caustic repeated after every eight
days, and the bougie increased in size till the  natural size of the urethra
is attained.
   [The use of caustic potash in the treatment of stricture, was also first practised by
Whately (a).   "It has, however," says he, "been  my good fortune to discover a
more efficacious, and, at the  same time, a less painful and hazardous  remedy (than
lunar caustic) for the disease in question.  This valuable remedy is the kalipurum,
which, if used in the manner, and  with the  precautions shortly to be described, will
be found of singular efficacy  in removing the  complaint."  (p. 23.)  The directions
for preparing.the bougie, and its mode of use, are  those above given by Chelii's.
Upon this mode of treatment Lawrence  observes:—" Mr. Whately  seems to have
been as cautious in the employment of  this substance, as Sir Everard Home was
bold m his use of lunar caustic, for he recommends you to take a fragment of potasm
fusa, not larger than the seventeenth part  of a grain.  And he says he never used a
portion larger than the twelfth of a grain. * * *  I  should conceive, according to
the description Mr. Whately  has given  of it, that it is just capable of doing that
good which the simple introduction of a plain bougie  can effect; and I cannot think
it had any effect whatever as an escharotic."  (p. 802.)]
(a) An improved Method, &c., above cited. 
STRICTURE OF THE URETHRA.
SI
   1692. Although these two modes of cauterizing the interior of the
 stricture have considerable advantage over that of cauterizing from before
 backwards, yet they have little certainty in practice, and in many respects
 are deficient, especially the  caustic potash.   Ducamp has the great credit
 of having proposed a  method of cauterization and destruction of stricture,
 which is distinguished from all the previous modes by its accuracy and
 certainty.
   1693. According to Ducamp's method, the seat of the stricture is first
 found with  a bougie  or sound,  and the situation  and  condition of its
 aperture ascertained by an exploration-sound, the end of which is covered
 with modelling wax,  which being gently, but steadily pressed against the
 obstacle, a perfect impress of the stricture is obtained.  Its  length is
 also determined by a thin bougie, with a little bulb, and covered with
 modelling wax, which is fastened to a thicker conductor.  For this pur-
 pose Charles Bell has recommended a thin metallic sound with a  but-
 ton, Arnott a thin tube, with a very short leather button, and Amussat (a)
 an explorer.  For this object Ducamp has proposed a peculiar instru-
 ment, which, however, does not appear suitable.   It is oftentimes neces-
 sary, to enlarge somewhat  the very narrow opening of the  stricture by
 gradually  thicker bougies, wThich may be left in half an  hour.
   1694. The cauterization is performed  with  a  cautic-holder, which,
 being properly oiled,  is carried down to the obstacle,  and then its inner
 shaft made to  describe a half circle, is protruded into the stricture.   For
 the purpose of cauterizing  the whole surface, the  instrument  is  gently
 turned on  its axis.  After a minute  the inner shaft  is to be drawn back
 into the canula, and the  instrument taken out.   If the ridge formed by
 the stricture be at the  upper or under part, or on either side of the urethra,
 which is shown  by the impression on the exploration sound, the caustic
 must be directed to that  spot.
   A small piece of lunar caustic is to be put into the inner shaft of the caustic-
 holder, and the flame of a wax taper directed upon  it with a blow-pipe;  the caustic
 soon melts, and completely fills the whole groove.  The heat must not be too great,
 or it will swell up the caustic; it must only be sufficient to fuse  it.  If  any points
 project, they must be removed with pumice stone.  The groove will hold about
 half a grain of lunar caustic, and,  if the  instrument be kept  in not longer than a
 minute, about one-third of it will dissolve.  As by this method the caustic will be
 easily too much swollen up, and little remain in  the groove, Hahn, according to
 Berg, proposes the following method :—Some powdered lunar caustic, from six to
 twenty grains, is to be moistened with water in  a little  porphyry dish, boiled up
 over a spirit-lamp, and constantly stirred with a silver knife  till the water have
evaporated, and the caustic remain fluid in its water of crystallization  alone, which
may be ascertained by its thin pap-like appearance, and the formation of the crystal-
lization-film.  This paste is now to be spread with  the spatula on the slightly-
heated groove of the shaft, and, when it has cooled, any projection is to be removed
with the spatula, or with pumice stone.  Whilst boiling,  the caustic  flies about
smartly, and therefore it  is  necessary to put on a glove, so that the hand be not
 spotted with black.
   1695. If there be only a single stricture, the patient feels, on the  day
of cauterization, little pain, but without passing his water  in a larger
stream;  on the  third  day the  slough separates, and the stream is then
increased.   The pain  caused by the cauterization is scarcely more than
that produced  by the introduction of a common bougie.   No inflamma-
Vol. in.—8
(a) Above cited, pi. i. 
S2
TREATMENT OF
tion  occurs; very rarely a discharge,  and, if previously existing, it is
stopped.                                   .               -vi
   1696. After  three days a new impression is to be taken with the ex-
ploring sound, which shows  how much  the opening has increased, and
what part  still  projects,  and  must be  destroyed.  A moderate-sized
bougie  must then be  passed and  carried into the bladder, to ascertain
that  there  is not another stricture.1   The caustic is now again to be
applied as before, and at  the  most prominent part.   Three days after a
third impression  is to  be taken,  and  if  the  parts forming the  obstacle
project  little, and a bougie, No. 6, can be  passed with ease, the enlarge-
ment of the canal has commenced.  If there be still any prominence, or
if the  bougie pass with difficulty, the caustic must  be applied a third
time.  If there be a second or third stricture, it is to be attacked in one
or other of these ways.
   1697. For the purpose of keeping the  scar as wide as the urethra in
its natural  state, Ducamp employs peculiar  dilators, and bellied bougies
{bougies a ventre.)  Three days after the  last cauterization, a dilator of
three lines  diameter is introduced, inflated with air, and left in not longer
than five minutes.  Next day the same dilator is passed, expanded with
air or water, and after ten minutes withdrawn and replaced by a bougie
of two  and a half lines diameter, which is left  in for  twenty minutes.
This bougie is  to be  introduced for the  same time next morning and
evening.   On the following day a dilator of four lines diameter is to be
passed, withdrawn after ten minutes, and  replaced by a bougie of three
lines, which also, on next morning and evening, is to be  left  in from
fifteen  to twenty minutes.  Two days after a dilator of four and a half
lines is introduced, and afterwards a bougie of four lines morning and
evening, each time for a quarter  of an hour.  After thus proceeding for
a week, the bougie  is  only  to be  passed once  a day, and allowed to
remain  for  a few minutes ; for the following four or five, the bougie is
to be introduced once daily,  and withdrawn immediately.  The scar is
then well consolidated, and is four lines in width, as in the  rest of the
urethral canal.    Ducamp (a).
  Dubouchet (b)  thinks that the bellied bougies, will do as well as  the dilators;
and, indeed, experience proves it to be so.
   1698. Ducamp cautions against the  application of caustic when the
urethra is inflamed ; that in long strictures it is best  to  destroy them bit
by bit,  by applying it only for two or three lines, as  a  longer  slough
separates with more difficulty, and the  canal may be stopped up.  If the
stricture be six  inches distant from the  orifice of the urethra, a curved
caustic-holder  should  be employed.   As  Ducamp's  instrument will
admit of no  twisting,  and as, on account of the different dimensions of
the urethra, the  cauterization, even up to  six inches, cannot always be
performed  without danger of  making a false passage, so Lallemand,
Amussat,  Segalas, and Tanchou have  proposed  modified  caustic-
holders, which  may be introduced  into the  stricture with  greater cer-
tainty.                                                    b
   For the enlargement of very narrow strictures, Lallemand uses catgut. As the
use of the exploring bougie, with however great care, in many  instances'produces
   (a) Above  cited  pi. i.  to iv.—F*orikp,    (b) Nouveau Traite des Retentions d'Urine,
Chirurgische Kupfertaf., pi. lxxxi.         p. 206. Paris, 1834.   8vo. 
STRICTURE OF THE URETHRA.
83
great pain, and often much bleeding, and some of the wax may get loose, and by
stopping up the canal cause retention of urine, Lallemand, if the impression of the
stricture be not absolutely necessary, introduces a bougie smeared with wax into
the stricture, which, after same time being withdrawn, by the pressure it has suffered,
shows the length and even the  situation of the obstacle.  By the  caustic bougie a
second and third  stricture may be attacked before the first is  perfectly removed.
Ducamp says  that caustic should not longer be employed after a bougie No. 6 passes
easily over the obstacle.  Lallemand's  experience shows that in  such cases it is
better to cauterize again, than to persist in  the enlargement, if changing to a larger
sound cause pain.  Lallemand does not  agree with Ducamp  in destroying long
strictures bit by bit, but advises cauterizing their whole length  at once, as he has
never noticed complete retention of urine  in such case, nor even  in that of deeper
strictures from the separation of the sloughs; and, even should it occur, it might be
easily relieved by the introduction of a bougie.  Lallemand considers  the subse-
quent widening of the urethra by dilators useless; the bellied bougies will not easily
take the  necessary bend so as to be carried over the crooked urethra, which  how-
ever I must, from experience, contradict.   Elastic curved  sounds or bougies are
most effective, which should be left in for fifteen or twenty minutes, and should not
go beyond the width of Nos. 11 and 12, as if they pass, we may be quite sure of a
successful result.
   Amussat employs both straight and curved caustic-holders (a).
   Segalas' caustic holder is distinguished  by its introduction, covered,  into the
stricture.  It consists of a graduated gum elastic catheter, in which a canula serves
the purpose of sheathing the stilette of the caustic-holder, which, with its olive-
shaped button, fits close to the mouth of the canula.  The  instrument is passed down
to the  stricture, then the canula carried down it, and, being withdrawn, leaves the
caustic-holder uncovered in the  stricture.
   Tanchou's  caustic-holder, by means of a projecting stilette, is more  certainly
introduced into the stricture, and the formation of a false passage thereby prevented.
It consists of a graduated elastic catheter, with a niche for the  reception of the
caustic, which is placed on a metal shaft, haying its extremity spiral, so that it may
be more flexible and more readily  applicable to the curves of the  urethra, and of a
silver or gold stilette, which is conveyed through the sheath of the instrument, and
also guides it in passing forwards  into the stricture (6).
   1699. Opinion is still very much divided  as to the preference of the
treatment of stricture by bougies, and their destruction by caustic.  It
must  be borne in  mind, however, in  making the comparison, that the
mischief usually assigned to the destruction of strictures  by caustic, has
occurred only by the use of  armed  bougies, (par.  1689,) but not since
the improved method of Ducamp; by which it is believed that there is
greater  certainty in the  application of the  caustic,  and that the cure is
quicker and more constant than by  dilatation ; that the  pain  is less as
experience proves; that the hardened part which forms  the stricture is
very little sensitive, and that in the cauterization there is only pain when
the sound part of the urethra  is touched with the  caustic.   These cir-
cumstances are the  more weighty, the older and tougher the strictures
are, as only in recent cases, and when the stricture  is easily extensible,
and  especially if short, can  they be soon  cured with the dilator.  In
strictures which are very close, artd  also not very long, dilatation may,
indeed, be of  some service, but the  cure is very  tedious, and  not so ra-
dical  as by cauterization.   The preference given  to bougies,  because
long, and several strictures can be treated together, applies equally well
to the improved modes of treatment with caustic.   Also in great  sensi-
bility of the urethra, in which the presence of a bougie can well be borne,
and the  above-described symptoms  (par. 1686) are to be  dreaded, the
sensibility is often  much blunted  by cauterization.   These advantages,

   (a) Above cited, pi. iii iv.                  (b) Above cited, pi. i. f. 1, 2. 3. 
84
TREATMENT OF
 however,  even in the  best modes  of applying caustic, are not  to  be
 received as general and unconditional; for even with them severe inflam-
 matory symptoms and false passages may be produced, especially  if the
 stricture be seated at the  hind part of the  urethra.  The rapidity with
 which  cauterization  brings about the cure, is  counterbalanced by the
 transient nature of its result, as the seat of  the  scar in the urethra, after
 complete subsequent dilatation, has always a decided  disposition to con-
 tract, by which the most stubborn form of stricture is produced.  I have
 seen in many instances, and even in patients who have been cauterized
 by Ducamp himself,  relapses, the  cure of which was exceedingly diffi-
 cult.   Although  the  dilatation with  the bougies  is more  tedious than
 cauterization, yet I must assign  to  them the greater certainty of a perma-
 nent Cure.  But after the natural width of the urethra has been restored
 the introduction of bougies must be  repeated from  time to time; and it
 must be  especially noticed that in  a stricture, which  has been  many
 years forming, and has been of long continuance, the canal of the urethra
 is not in the course of a few weeks to be restored to  its natural condi-
 tion.   It is especially not attending to these circumstances, that in dila-
 tation, lays the  foundation of relapses.   Only in  very old hard strictures,
 in which dilatation cannot be effected,  or is very painful and intolerable,
 do I consider cauterization to be indicated.
   Also in fungous degeneration of the  mucous membrane  of the prostrate gland,
 which occurs in long-contined strictures (par. 1675) when, besides a copious  secre-
 tion of mucus, a sort of fleshy lumps is discharged with the urine, and the urethral
 canal is  not narrowed.  Lallemand (a) has touched  every  degenerated mucous
 membrane with his sound in order to decide  on its vitality.
   [Upon the employment of caustic in the treatment of strictures Astley Cooper
 says:—"The use of caustic has certainly been very much abused, and in many in-
 stances has  produced  the very worst consequences, and I would say that it  never
 ought to be employed, exeept where the stricture  is accompanied with  fistula in
 perinaeo, and that fistula behind  the stricture; then there can be no apprehension of
 the caustic occasioning retention of urine, which it has done when injudiciously em-
 ployed." (p. 224.)
  Brodie observes:—" I very rarely use the  armed  bougie in my own practice, and
 I never resort to it in the  first instance.  My reasons  for preferring the other methods
 of treatment, in ordinary cases, are these:—first, although the caustic often relieves
 the spasm, it,also very often  induces it.  It is true, that in many instances it enables
 a patient to make water with more facility; but in  many instances, also, it brings
 on a retention of urine ; secondly, haemorrhage is a more frequent consequence  of the
 use of the caustic than of the common bougie, and it  sometimes takes place to a very
 great and to an almost dangerous extent;  thirdly,  where  there is a disposition to
 rigours, the application of the caustic is almost certain  to produce them; and fre-
 quently the  application of the  caustic  induces rigours where there had been no
 manifest  disposition to them previously; fourthly, unless  used with caution, the
application  of caustic  may  induce inflammation of the parts  situated behind the
stricture, terminating  in the formation of abscess.  I have  known  some cases of
abscesses formed  under these circumstances, which, from  their peculiar situation,
have proved more troublesome and more difficult to manage than the oriainal dis-
ease."  (pp. 61, 2.)                                                 s
  Upon the same point Lawrence says:—"From the various results which attend
the free employment of caustic in the urethra, I think that we may safely sav it is a
mode of treatment not applicable to bad cases of stricture; that is, cases where the
change of structure is considerable, and  the contraction  is very extensive • and in
cases not so serious we know that the application of  caustic is not necessary for the
simple bougie, sound or silver catheter, will accomplish the object we have in view
The use of caustic has, in general, been very little favoured on  the continent; they
                           (a) Above cited, p. 76. 
STRICTURE  OF  THE  URETHRA.
85
have generally healed strictures, there without it, and have been averse to  it from
knowing its ill effects; it has been partially employed in this country, but never got
into very great use, and I believe  has been generally less and  less used, so that at
present it  is but  seldom  adopted in the treatment of  stricture of the urethra."
(p. 802.)
   With these opinions, as  to the disadvantage of using caustic, I fully concur; and
I rarely employ it in treating strictures.   Another reason may also be given against
it, which is, that though for a time,  that time only, however, when the slough  of
the cauterized stricture has been thrown off, and the part is still sore, it may enlarge
the passage of the  urethra, yet as the  sore surface heals a new and closer scar  is
formed, by which the previously narrowed passage will be necessarily rendered still
smaller.   Every young student knows the common mode of contracting apertures
in the soft, and even in the hard palate, by producing sloughs of their margin, with
the certain knowledge that the subsequently forming scar will diminish the size  of
the hole, and that a repetition of the  same practice will at last completely obliterate
it.  And the result must be the  same by its application to a stricture, although  at
first there may be a seeming improvement.  I must confess I cannot understand the
reason why,  although objecting to the  use  of caustic under other circumstances,
Astley. Cooper allows it when there is perinaeal fistula.—j. f.  s.]
   1700.   Cutting into  the stricture, and subsequent  dilatation, has been
also recommended for  its more speedy removal; and for this purpose
various modes of proceeding  have  been advised.   The older surgeons
used the trocar and the pointed  sound {a).  Doerner {b) recommended
a  tube through which a stilette, with a  lancet point,-should  be passed,
Dzondi (c)  a  catheter open  at its  end,  through which  a  lancet-shaped
knife could be carried forwards and  backwards ; and in  like manner also
McGhie (d), Amussat (e),  Despiney (f), Dieffenbach {g), and Tan-
chou {h).   These modes  can only be employed with  safety in short and
not very tight strictures.  The proper use of bougies  and caustic  cer-
tainly  render it unnecessary, and it can only be  considered as indicated
when  neither dilatation  nor repeated cauterization have  any result, when
the stricture remains hard, and  the  urethra does  not acquire its natural
calibre.
   Jameson (i) seeks for the causes of stricture in an unnatural contraction of the
transverse fibres of the m. accelerator  urinae, at its fore part, which cross the urethra
at right angle, as well as of the same part of the m. levator ani,  in contact, with the
urethra.  For the radical cure of this disease, he cuts through the just-named parts,
partly through the penis, and  partly through the perinxum.
   Upon breaking through strictures with the conical catheter, refer to  retention of
Urine (par. 1813.)
   [Dickson, On Urethrotomy;  in  N.  Y. Journ.  of Med.  and  Surg.,
vol. 2.   1841.—g. w. n.]
   1701.  In stricture of the Urethra behind the bulb, especially if a hard,
stiff bougie be  used, if with it, or with a cather, force be employed, or if
there be abscesses near the urethra, its  walls may be easily torn, and by
  (a) Lafaye and Vigueri ;  in  Chopart,    (e) Above cited, pi. ii.
above cited,  vol. ii. p. 328.—Allies, Traite    (/) Archives generates de Medecine, vol.
de8 Maladies de 1'Uretre. Paris, 1755. p. 73.  xi. p. 146.  1826.   May.
  (b) Vorschlag eines neuen Mittels, hari-    (g) Hecker's allgem. litt. Annalen. p. 165,
nackige  HarnrOhrenverengerungen  leioht  1826. The cut should  be made from behind
und aua dem Grunde zu heben; in  von  Sie-  forwards.  Proper instruments for the dila-
bold's Chiron., vol. i. p. 259.               tation are recommended.
  (c) Geschichte des  klinishen institutes fur    (h) Above cited, pl.ii.—Stafford, On Per-
Chirurgie und Augenheilkunde zu  Halle,  foration and Incision of Permanent Stricture
1818.  pi. ii. f. 1-3.                      of the Urethra by the Lancet Stilcttes. Lon-
  (d) Edinburgh Med. and Surg. Journal,  don, 1836.  8vo. Third Edition.
vol. xix. p. 361., 1823.                      (i)  Medical Recorder, 1824, April, p. 251. 
86        TREATMENT OF STRICTURE OF THE URETHRA.
the entrance of the catheter  or bougie, a false passage formed ei her in
the spongy substance of the urethra or in the space between the bladder
and the rectum.   This is easily perceived when the instrument is pushed
forwards, with much pain, and on its withdrawal, which is done readily,
no urine, but only blood flows out.   This false passage, in most instances,
renders  the introduction of a  bougie or catheter  difficult or impossible,
because they always run into it.  The careful impress with Ducamp's
exploring  sound, and the introduction of a  straight bougie or sound, or
the application of caustic with Lallemand's sound, in the proper direc-
tion of the urethra, may render the introduction of the catheter possible.
   If this cannot be  done, and  infiltration  of urine  occur, the following
must  be the treatment.  A  sound  must be  passed into  the  urethra is
deep as possible, and a cut  made from without towards its point, which
will certainly be found behind the stricture.   If the false  passage be be-
tween the urethra and the  body of the penis, the  urethra will be  laid
open,  the point of the sound having been first bared.   A  sound is to be
introduced into the opened urethra, thrust towards the  glans, and the
stricture broken  through ; or  two  sounds must  be -introduced, one by
the mouth of the urethra, and the other by the wound to the  stricture,
and pressed  together  in  the  proper direction,  for   which  purpose a
pointed sound is best;  and  thus  the stricture is penetrated.   An elastic
catheter is then introduced from the opening of the urethra in the wound,
and carried into the  bladder.   If the false passage be between the urethra
and the external skin, the cut must be made through the latter upon the
sound, the  urethra opened,  and an  elastic   catheter  introduced."  The
treatment of the wound is  to be conducted  according to the rules al-
ready  laid down  (par. 965.)
  [I cannot agree with the method, here recommended by Chelius, of passing the
'sound into the bottom of the false passage; for, if this be done, there will be con-
siderable difficulty in finding the urethra.  The instrument  should be carried down
only to the stricture, and then its point cut upon;  which done, the stricture must be
cautiously cut  through, from before, backwards in  the mesial line, by little and
little, and the urethra  behind  the stricture continually  sought for with a probe's
point, the patient being at the same time directed to strain, so as if possible to  force
out urine, the point of escape of  which will afford a guide to the exact track of the
urethra.  Much caution is requisite, that the urethra be not completely cleft, and
the suspensory  ligament deeply cut into, by which  the difficulty in discovering the
urethra is considerably increased.   This is an accident to which young and not
much practised operators are very liable  to fall, and be sorely hampered by.  The
division of a stricture, and the re-connexion of the  two portions of the urethra by a
catheter is generally an operation of difficulty under the most favourable circum-
stances, but when the neighbourhood of the canal has been ploughed up with false
passages, the difficulties are considerably increased.  It may be  well to mention,
that the first cut should be made in the raphe, and  the whole operation continued
in the  mesial  line;  and I do not think any material damage is done  by cutting
through the bulb of the penis, which, indeed, is often absolutely necessary, although
some practitioners imagine that the generative functions of the organ are thereby
interfered with, to which, however, I do not assent.—j. f. s.]
   1702. When the urethra is closed, as  a vice  of the first  formation,
there is either only a superficial membranous  closure of its mouth, or the
growing together may be deeper situated.  In the former case, the pre-
puce is to be drawn back over the glans, till  the  tip of the glans is ex-
posed, and then a lancet thrusts in, with its edges upwards  and down-
wards, through  the closing membrane, and  reunion  prevented  by the
insertion of a piece of linen smeared with oil, or of  a piece  of bougie. 
          OF CLOSURE AND NARROWING OF THE VAGINA.       87


In the latter, a  thin trocar must be pushed in, according to the direction
of the mouth of the urethra, till it enter the  canal, which must be  kept
open by introducing a  piece of bougie ;  or if this  cannot be done, the
urethra is to be opened where the collected urine bulges it out.  I was
obliged to do this in an accidental case of growing together of the ure-
thral orifice,  arising from a  destroying venereal ulcer, in which there
was not the least trace  of an aperture in the hardened part to be dis-
covered.
  When the urethra opens at some distance from the glans (Hypospadias) it will be
necessary for the relief of impotence consequent thereon,  to perforate the glans with
a trocar up to the false  orifice, to introduce  a  canula, and to heal up  the lower
opening, which must be previously scarified.  It is rare that this union can be ef-
fected, which, however, does not always frustrate the object of the operation, as the
discharge of the semen through the new aperture will take place.   According to Wal-
ther (a), the closure of the lower aperture should riot be at all cared for.   It has also
been advised, if this operation do not succeed, to cleave  the glans from the urethra
up to its very tip, and to heal the wound over a  tube introduced for the purpose, or
to cut off obliquely a pie'ce  of the glans from the false urethral orifice to its tip.  The
cases, however, are rare in  which this degree  of  misformation becomes the cause of
impotence.  In one case, a  child in whom the urethra opened at the root of the penis,
Dupuvtren (b) formed by  means of a thin trochar, a  new canal, which he caute-
rized throughout its whole  length with the actual cautery ; and after the severe in-
flammatory symptoms had  passed by, and the slough had been thrown off, he kept
it open with an elastic sound.  The fistula closed.
  [On Hypospadias,  consult a paper  by Mettauer,  in  the American
Journ. of the Med. Sci. vol.  4, N. S. 1842,-and  Bushe, in N. Y. Med.
Chir. Bulletin, vol. 2, 1832.—g. w. n.]
      XL—OF CLOSURE AND NARROWING OF  THE VAGINA.

   1703.  Closure of the Vagina (Atresia Vagine, Lat.: Verschliessing der
Mutterschiede, Germ.: Imperforation du  Vagin, Fr.) may be either a vice
of the first formation, or may occur subsequently by its growing together.
In the former case it may depend  on union of the labia and nymphe
throughout their whole  extent, in the midst of which commonly a white
line is perceived, through the hymen,  which has no aperture, and is also
both firmer and tougher, or by a similar  membranous closure more or
less high in the vagina, or the passage of the vagina is closed by a fleshy
mass.   In the latter case, the closure of the vagina  is the consequence of
a growing together which takes place after ulceration and wounds of its
walls.
   1704.  If in congenital closure of the vagina, the  orifice  of the urethra
be not  also closed up,  it is rarely discovered  before puberty.   Then as
menstruation comes on  there  is pain in the back, pressure, straining,
weight  in  the  genitals, fullness  of the belly, frequent urging to void the
urine, sometimes complete retention, difficulty in going to stool, and the
like, and no menstrual discharge appears.   These inconveniences at first
appear  monthly, and  subside;  but  at last, when  the collection of the
blood is considerable, they no  longer  subside, but increase every month,

  (a) Salzb. Med.-Chir. Zeitung,  vol. i. p. Edit, par Sanson et Begin, vol. iv. p. 435.—
188.  1813.                           Dieffenbach; in  Hamb. Magaz. der Ausl.
  (b) SABATiER,MedecineOpdratoire. Nouv.  Liter., vol. iv. part i. 
»
88                      OF CLOSURE AND

and general symptoms  appear also, anxiety, pale countenance, pain in
the belly, faintness loss  of sleep, labour-like pain in the genitals.'  If the
collected blood can find no outlet, it gradually increases in quantity, so
that it distends the womb, and empties itself  by the Fallopian tubes into
the cavity of the belly,  or menstruation may  be set up in some unusual
way.   Local examination  always readily  discovers  the  closure  of the
vagina.  When this depends on  the hymen,  or on a  mere skin, it is ah
ways distended like  a sac, by the collected blood, descends and fluctu-
ates.
   1705.  The  narrowing  of  the  vagina extends either  throughout its
whole length,  or is  confined to one part.   In the former case it depends
on an  arrested development  of these  parts; in the latter, is usually the
consequence of injury of the vagina with  loss  of substance, in difficult
labour, in which  a  part has  been destroyed by gangrene, and the scar
contracts the canal, or bands are formed which cross  the vagina, or par-
tial union  of  the passage takes place.   There  are  sometimes  one  or
several small holes  in the membrane  closing the vagina, or the hymen,
although pervious is unusually tough.   According to the degree of nar-
rowing various symptoms may be produced,  as obstructed menstruation,
pain in connexion, and the }ike.   Although the complete introduction of
the penis into the  narrow vagina be  not  possible, yet  pregnancy may
occur.
   1706.  The cure of the closure of the vagina consists in opening it to
such extent that it  can perform its functions, and in  preventing its re-
union.   This  operation is more or less  difficult, according as its closure
is at the  orifice or higher up  in the vagina, as it is thinner or thicker, or
more or  less extensive.  The  prevention  of reunion  is  often attended
with considerable difficulty.
   1707.  In complete closure of the entrance of the vagina by the hymen,
the person must be laid on her back with the thighs drawn up and sepa-
rated ; the labia are to  be held aside by assistants, and a lancet passed
into the middle of the  stretched  membrane,  without injuring the rectum
or bladder.  The aperture is to be enlarged with curved scissors, or with
a narrow curved bistoury, introduced upon  a  director.  When the hymen
is firm and tough, some practitioners advise the removal  of the flaps thus
formed.   If the operation be performed on  a child, or in a case where
there is not any collection of blood, especial caution is requisite to avoid
injuring the bladder or rectum.   The  membrane must then be divided
with cautious  cuts, and previous introduction of a sound or catheter into
the  urethra, to prevent its being injured.  When  the  urethra is also
covered  with this membrane, the operation must be performed with the
greatest care.   If the labia be completely united, they must be stretched
as much as possible to  either side, and divided in the middle with care-
ful strokes of the knife, till a director can  be introduced, and upon it a
button-ended  bistoury must complete the necessary enlargement.   The
same proceeding must be adopted if the entrance of the vagina be closed
by a fleshy mass  (a).
   1708. If the mouth of the vagina be  only partially closed by the
hymen, or if the labia be united,  a director must be  introduced through
(a) Donauld; in  Journal de Medecine, vol. xxxvii. 
NARROWING OF THE VAGINA.
89
 the aperture, usually existing at the upper part near the urethra, upon
 which a narrow button-ended bistoury is  passed, and the connexion di-
 vided to the necessary extent.
   [In infants  it is better not to use a knife, but merely to pass a probe through the
 aperture above down to the bottom of the os externum, and then pressing the Con-
 necting skin with the probe point upon the finger-nail, till it make its way through,
 which is generally done with ease; one end of the probe must be held steady whilst
 the other is drawn forwards, and tears its way out.  A piece of lint inserted between
 the parts is  all that is needful.   And I do not  recollect a case among several on
 which I have operated, that required any further interference.—j. f. s.]
   1709.   If the closure be more or less deep in the canal of the vagina,
 its condition and extent must first  be carefully  ascertained by examina-
 tion by the vagina and rectum.   After emptying the bladder and rectum,
 the oiled finger of the left hand is to be  carried  up to  the closed part,
 placed upon its middle, and  a  narrow  scalpel, guarded with plaster to
 within an inch of its  tip, or  a. pharyngotome, or Osiander's  hystero-
 tome  (a) is to  be  introduced and thrust in the  direction of the vagina,
 through the  closed part.  The  aperture  is  to  be'enlarged, rather by
 pressure than by sawing with the knife, according to the situation,  where
 it can be done without  danger of wounding the bladder or the rectum.
 The point of  the left finger  is then  to be  introduced  into the opening,
 which is to be enlarged with a button-ended bistoury, to the extent and
 in the direction where it can  be done  most  safely, and seems most ne-
 cessary.
  In complete closure of the vagina, without  any symptoms of retained menstrual
 fluid, the operation is contra-indicated, as the womb may be wanting, and the blind
 extremity of the vagina may touch the peritonaeum.   Columbus (b), Bousquet (c),
 Mever (d), and Kleinkosck (e), have given cases of this kind.  Stein (/) and
 Busch (g) operated  on such cases, and opened  the peritonaeum, in consequence of
 which the woman died.  In a case of Qberteuffer's (h),  the woman did not  indeed
 die, but the operation was  useless.  In all these cases the women had not men-
 struated.
   1710.  When the canal of the vagina is only partially closed, a button-
 ended bistoury is to be introduced by means of the left fore-finger or a
 director,  and the  connexions divided  to the proper  extent,  without
 wounding the bladder or rectum.   Membranous bands are best divided
with blunt-ended  scissors,  which are introduced upon the left fore-finger.
 If closure of  the vagina  accompany pregnancy, the  operation must  be
first performed, when,  the pains coming  on  the membranes present,
which can be  easily felt through the  vagina or through the rectum  {i).
  [My friend Dr. Locock informs  me that he  attended a lady who, in consequence
 of previous difficult labour with tearing of the perinaeum and vagina into the rectum,
 had as  she recovered numerous bands-formed across the vagina.  She became again
 pregnant, and great fear was entertained as to the result of the delivery.  He allowed
 the  labour to go on as usual, and as the child's head descended, and the  bands
  (a) Neue Dendwflrdigkeiten fur Aertze
und Geburtshelfer, vol. i. p. ii. f. 4.  Getting.
1757.
  (b) De re anatomica, book xv. p. 495.
  (c) Journal de M6decine, vol. vi. p. 128.
1775.
  (d) Schmucker's  vermischte  chirurg.
Schrift., vol. ii. p. 299.
  (e) Dissert, de Utero  deficiente.  Prag.
1777.
  (/) Hufeland's Journal.  May, 1819.
  (g) Rust's Magazin, vol. x, part 2.
  (h) Stark's neues Archiv. vol. ii. p. 227.
  (i) Naegle,  Erfahrungen und Abhand-
lungcn aus dem Gebiete der Krankheiten
des  Weiblichen Geschlects.   Mannheim,
1812, p. 334!—von Seibold, £., Handbuch
zur Eikenntniss und Heilung der Frauen.
zimmerkrankheiten.  Frankf.,  1821.  Se-
cond Edition, vol. i. p. 216. 
90
OF CLOSURE AND NARROWING
became stretched, he divided them carefully with a bistoury, and the case did well.
A second pregnancy and delivery followed under similar circumstances.  If no ope-
ration be performed, and the child's head cannot descend, the womb will burst, and
as in the case related by Kennedy (a), a triangular flap of the mouth and neck of
that organ be thrown  down into  the vagina.  In another case, which  occurred to
Labat7 one band had  been divided, and whilst waiting for pains to force the other,.
the whole recto-vaginal septum gave way, and  the rectum and vagina  became one
cavity, leaving, however, the sphincter ani unhurt.—J. v. s.]
  1711. If the vagina  be only narrowed,  it may be attempted  to enlarge
it gradually with bougies, sponge tent, relaxing injections, and the like.
If pregnancy occur during such narrowing, the vagina often yields during
that period, and during labour, to  such extent, that although previously
it had not the width of a quill, yet the expulsion of the child is effected (b).
In cases where this yielding does not follow, some sufficiently  deep cuts
must be made in the narrowed parts (c) ; and, if possible, they should
be made on the sides, as if they be directed from before backwards,
there is danger on  account of the growing together of the vagina with
the  bladder and the rectum, of wounding  them.  If  the vagina  be ex-
tremely narrow, opening the head by a cut through the perineum may
be  required (d).
  1712. If the menstrual blood be collected behind the closed  vagina,
it escapes after the opening  is made, and  is  black and free from smell.
It must be  completely emptied  by injection, otherwise it will  putrify on
the admission of air, and unpleasant symptoms will be  produced.  At
first the most  proper injections  are those of luke-warm water,  of  decoc-
tion of mallows or  marshmallows ;  but so soon as there is the least smell
tincture of myrrh should  be added, or injections of bark, with the addi-
tion of acid,  spirits of camphor, solution  of chloride of lime, and the
like.   If there be active inflammation, smart antiphlogistic  treatment
must be employed.  In order to  prevent reunion, it is  sufficient,  after
dividing the labia, to keep them separate  with a piece  of oiled linen.
After division  at  the entrance of the vagina, a sufficiently thick plug of
lint must be introduced.   Where  the narrowing was high up  in  the va-
gina, and tough, its  reunion is much to feared; in such cases it will be
necessary to oppose this disposition by the introduction of thick plugs of
lint, sponge tent, elastic  cylinders, and the  like.   The  use  of dilators
often  very  considerably  assists this  means.   If  it happen that, under
these circumstances, symptoms of violent irritation ensue, a correspond-
ing cooling and soothing treatment must be had recourse to.
 XII.—OF CLOSURE AND NARROWING  OF THE MOUTH OF THE
                               WOMB.

  1713.  The closure of the mouth  of the womb is either a vice of the
first formation,  or  first occurs  at a  later period,  and may depend on a
membrane closing the aperture, or on its growing together.  The symp-
toms thereby produced depend on the retention of the menstrual  blood,
  SnJiaQo°N'S Med-Chir- Jour-> vo1 x*xi.    (e) Petit, J. L-, Traite des Maladies chi-
p. o/U, lBc(9.                          rugicales, vol. vi. p. 110
  (6) Antoine ; m Hist, de l'Academie des    \d) Champenois ; in Journal de Medecine,
Sciences, 1712, p.  48.—Obs. Anat. 2.—Toi-   vol. xli.
son, ibid., 1748, p.  83.—Obs. Anat. 1. 
OF THE MOUTH OF  THE WOMB.
91
or if the closure first occur during pregnancy, on  the obstruction of the
labour.
   1714.  In the former case the closure of the mouth of the  womb may
be presumed, if on the appearance of the symptoms accompanying men-
struation, no blood flows; if this,  again, happen regularly, the womb
gradually enlarges, and the belly swells.   On examination the vagina is
found perfectly free, the distended mouth of the womb descends into the
pelvis, and may be pushed upwards  and backwards  by introducing the
fingers into the vagina.  If the mouth of the womb be closed by mem-
brane, it is often  found filled out  like a sac.   The closure of the outer
mouth of the womb may be distinguished,by the finger, and that of the
inner by the careful introduction of a sound.
   1715. If the blood  collected in the womb cannot escape, it may, as
it continues increasing, make  its  way through the Fallopian  tubes into
the belly, and cause fatal symptoms.  But if the mouth of the womb be
closed by membrane, the  membrane may be torn  by the pressure of the
blood which  will escape.  The  only remedy consists  in  opening the
closed part.
   1716. When the outer rnouth of the womb is closed,  the forefinger of
the left hand, with its palm or surface upwards, must be introduced up
to the part to be opened, upon it  a  curved trocar, pharyngotome, or
Osiander's hysterotome is to  be  passed, and the  membrane closing the
mouth of the womb pierced.   But if the canal of the neck of the womb,
or its inner mouth, be closed, then must the pharyngotome or  hystero-
tome, introduced in  the way  described, be  carefully thrust through the
part to be  opened, and when the  cavity of the wound is penetrated the
opening must be enlarged sufficiently with the bistoury.
   1717. The discharge of the menstrual fluid  must  be favoured by in-
jections, as was done in opening the vagina, and its reunion prevented
by a sufficiently long plug /oi lint inserted into  the new opening, or by
the introduction of an elastic tube.   The after-treatment must be guided
according to appearance of inflammatory and spasmodic symptoms.
   The inflammatory symptoms after this operation are so severe that Dupuytren
decides upon entirely giving it up, and rather to allow the patient to die more quietly
and slowly than to speedily hasten her death by the operation, which always results
 from inflammation of the womb, and which is the more violent in proportion to the
 distension of the womb.   (Pigne.) Successful cases following this operation have,
 however, refuted Dupuytren's assertion.  Du Cumin (a) employed Dupuytren's
double lithotome in a case of secondary union of the mouth of the womb, and the
result was permanent.   The greatest care must be exerted for the complete discharge
 of all the decomposed blood.
   1718. When the mouth of the womb has grown together during preg-
nancy, or is so changed by hardening and schirrhous degeneration, that
it will  not dilate during  labour,  perhaps the  whole lower part  of the
 womb may descend so low, that there may be  dread of it tearing, then
the opening or enlargement of the mouth of the womb must be  resolved
on {Hysterotornia vaginalis, Lat.; Scheiden-Kaiserscenitt, Germ.)
   1719. In  schirrhous degeneration, or hardening of  the mouth of the
womb, a button-ended concave bistoury must be  introduced into it upon
the forefinger of the  left hand, a cut made  into it, and continued from
(a) Gaz. Med. de Paris, vol. viii. p. 91. 1840. 
 92  OF CLOSURE AND NARROWING OF MOUTH OF THE WOMB.

 two-and  a half to three inches into the substance  of the womb.  The
 direction of the cut should be to the left, or  right, or forwards, or back-
 wards, or in any other way, for the purpose of giving the wound proper
 size, according to the  position of  the womb, and, as far as possible, to
 cut into the part least changed.  A cut has  also been made  in stricture
 of the mouth of the womb, during labour, throughout its whole length (a).
 The labour proceeds maturally* or may require to be finished by manual
 and instrumental assistance.
   1720. If the mouth of the womb be completely  closed, or cannot be
 felt, a blunt-ended scalpel  is to be  introduced on  the forefinger of the
 left hand, and  division of the protruded mouth of the womb made care-
 fully from before backwards, or from one to the other side.  When its
 cavity is reached, the cut  must be  made by the button-ended bistoury
 in the direction laid  down, and if the cut cannot be  made of sufficient
 size a second must be made to cross the former.  The farther treatment
 is the same as  in the former cases.
  See also upon  this subject—
  Lauverjat, Nouvelle Methode de pratiquer POperation Cesarienne.  Paris, 1788.
  Berger, F. G., Ad. theoriam de fcetus generatione Analecta. Praemissa est rarioris
 embryulcise casus brevis historia.   Leipsiae, 1818.
  Rayner, F. B.; in Salzb. Medic-chirurg. Zeitung, 1821,  p. 398.
  Wheelwright; in Medical Recorder, 1821, p. 361, April.
  Cafe; in the Journal hebdomadaire.  1824, May.

  (a) Moscati; in  Omodf.i, Annali Uni-  in Med. Jahrbuchern des^isterl. Staates,vol.
versali, vol. xi. p. 257.   IS!9.—Wagner;  xxii. p. 367. 
[   93   ]
FOURTH  DIVISION.
  DISEASES  DEPENDING  ON THE PRESENCE OF  FOREIGN
                              BODIES.

   1721. Under the term foreign bodies are included  not merely  me-
 chanical bodies conveyedy>om without into our organism, but also those
products which, generated and retained in  our organism, react  upon  it
 injuriously.
   1722. They may, therefore, be treated of according to the following
 division:—

   I. Foreign  Bodies brought  into our organism from without,
            1. Into the nostrils.
            2. -------mouth.
            3. -------oesophagus and intestinal canal.
            4. -------air tube.
   II. Unnatural collections  of natural products.
       a. In their natural cavities and receptacles (retentions.)
            1. Ranula.
            2. Retention of urine.
            3.------------the foetus in  the  womb  or in  the belly
         (Cesarean operation, division of the pubes, Gastrotomy.)
       b. External to their proper cavities and receptacles(extravasations.)
            1. Blood-swellings in newly-born children.
            2. Hematocele.
            3. Extravasation of blood in joints.
  III.  Collections of diseased products.
            1. Lymph swellings.
            2. Dropsy of the mucous bags.
            3.---------joints.
            4.---------the chest and empyema.
            5. ---------the head and spina bifida.
            6. Collections of pus in  the breast-bone.
            7. Dropsy of the pericardium.
            8.-------------belly.
            9. -------------ovaries.
          10. Hydrocele.
  IV. Formations of stony concretions.
  Here are reviewed all those  diseased conditions which have been already con-
sidered, on account of the close relation in which they stand to  others; for instance
foreign bodies penetrating from without, and the extravasations in the various cavi-
ties, the retention of the bile, of  the spittle^in the Stenonian duct,  and the like
  Vol. iii.—9 
94         FOREIGN BODIES IN THE NOSTRILS, MOUTH,
   First Section.—OF FOREIGN BODIES INTRODUCED INTO THE
                      BODY  FROM WITHOUT.

   1723. What relates to foreign bodies, which in various ways compli-
cate wounds, has been  already treated  of, (par. 306 and 338,) both as
regards their  effect, and the necessity, and  the kind and  mode of their
removal.   Here  only will be considered those which penetrate into the
open cavities of our bodies.
             I._OF FOREIGN BODIES IN  THE NOSTRILS.

    1724. Foreign bodies which get into the nostrils, are retained either
 by the swelling which they undergo, as beans, peas, and the like, which
 children frequently'thrust into their nose ;  Or,  if they do not themselves
 enlarge, are enclosed by the swelling of the mucous  membrane of the
 nostrils, which they set up.
    1725. The removal of these foreign bodies is not very difficult if there
 be not much  accompanying  swelling ; it is  often, however, rendered
 easier by the  softness  which most  of them acquire  as  they swell up.
 For their removal, curved, dressing or polypus forceps are used; and
 if they cannot be got out whole, we endeavour to break them to pieces.
   When, in gun-shot wounds of the face, balls remain lodged in the nostrils, they
 in general so quickly produce violent swelling and inflammation that it is impossi-
 ble to get them out.   In many cases they may remain till discharged by "suppuration.
 But if, by their presence, violent symptoms  are produced, they must be removed;
 and if, on account of the peculiar form and size of the foreign body,Jhe opening' of
 the nostrils offer much obstacle, it maybe necessary to slit up one or other of them,
 and after the removal of the foreign body, to reunite  them by the application of a
v stitch.
   The position and size of foreign bodies is often such that  they cannot be seized
 with the forceps; in these cases Dupuytren (a) advises that they should be pushed
 backwards, so as to drop  into the  mouth, which is the way they generally take if
 left alone for a time  to escape of  their own accord.
   [Astley Cooper  used to mention an  instance pf a ball having been received in
 the frontal sinuses, which for a time remained quiet, but at last its weight caused
 ulceration; it descended through  the nostrils, and passing through the floor of the
 nose into the mouth, caused severe bleeding from the palatine artery—j. f. s.]
            II.—OF FOREIGN BODIES IN THE  MOUTH.

  1726. Foreign  bodies which  remain sticking  in  the  inside  of the.
cheeks, in the tongue, or  in  the palate, may cause  severe  pain, diffi-
culty in swallowing, and very  considerable  swelling of the  tongue.
They can  be easily discovered  by careful examination,  and removed
with the forceps.   If allowed to remain, they are generally soon got rid
of by suppuration.
  [I have very recently operated on a case in which a piece  of  tobacco-pipe, an
inch and a half long, had been lodged in the cheek for'ten months, without the pa-
tient being ayv are of it.   He had fallen with his pipe  in  hand, and wounded the
outside of his cheek; much swelling ensued, and after  a few weeks the wound

    (a) Blessures par Armes de guerres ; publ. par. Maux ct Paillard, vol. ii. p. 232. 
AND OESOPHAGUS.
95
healed, but he could not open his mouth completely nor without pain.  Twice
during the following twelvemonth the swelling, which still remained, became very
painful, increased, and suppurated.  The last time he came to me, and the piece of
pipe was readily discovered, running  from half an inch behind the angle of the
mouth horizontally back  towards  the angle of the jaw, the  mouth  could not be
opened more than half an inch, and  each time the jaw was depressed he had great
pain at the angle of the jaw.  I cut upon  the scar, which was very apparent, but
had some little difficulty in detaching the end of  the pipe, as the scar had probably
sunk into its hollow;  this done, however, it was  easily drawn out with dressing
forceps, like a dirk from its scabbard, and was  evidently  smeared with a mucoid
secretion from the  sides of the cavity, which it had made for itself.   In a few days
the effects of the operation ceased ; he opened his mouth freely, and without pain,
and the sinus filled up.
  Bodies may sometimes  be thrust into the mouth, within the arches of the teeth,
and when there become so fixed by the elevating muscles of the lower jaw, as to be
incapable of removal without assistance ;  I  knew a case of this kind in which a girl
thus fixed an apple in  her mouth, which was only removed by the medical atten-
dant cutting it to pieces.—j. f. s.j
          III.—OF FOREIGN BODIES  IN THE OESOPHAGUS.

   Hevin, Precis d'Observations sur les corps etrangers arretes dans l'GSsophage,
 et dans la Trachee-artere, avec des remarques sur les moyens qu'on a employes ou
 que l'on peut employer pour les  enfoncer ou pour les retirer; in Mem. de l'Acad.
 de Chirurg., vol. i. p.  44 1.
  -Bordenave et Destremeau, De corporibus extrancis  intra ffisophagum haeren-
 tibus.  Paris, 1763.   4to.
   Venel, A., Nouveau secours pour les corps arretes dans l'03sophage, ou descrip-
 tion de quatre instrumens  plus propres qu'aucum des anciens moyens, a. retirer ees
 corps par la bouche.   Lausanne, 1769.
   Monro, Alex., Jun., M. D., The Morbid Anatomy of  the  Human Gullet, Sto-
 mach, and Intestines.  Edinburgh, 1811.  8vo.
   Guattani, Essayes  sur l'GSsophagotomie; in Mem.  de l'Acad. de  Chir., vol.
 iii. p. 351.
   Eckholdt, J. G., Ueber das Ausziehen fremder Korper aus dem Speisekanale
 und der Luftrohre.   Kiel und Leipzig, 1799.  Large 4to; with plates.
  Nauta, Dissert, de corporibus  peregrinis ex CEsophago removendis.   Workum,
 1803.
  Vigxardonne, J., Quelques propositions sur l'CEsophagotomie.  Paris, 1805.
  Vacca Berlinghieri, Delia Esofagotomia  e di un nouvo methodo di eseguirla.
 Pisa,  1820;  with a plate.
   [Bond, H., Observations on the removal of Foreign Bodies  lodged in
 the (Esophagus; in North American  Med. and Surg. Journ., October,
 1828.—g. w. k.]
   1727.  Bodies  may remain  sticking  in  the oesophagus  on account of
 their  size  or hardness, or  their irregular  pointed surface.  Bodies  are
often  retained in  the oesophagus, which  as  regards their size   and cha-
racter, might without  difficulty have  passed through it, in which case it
would seem that  their  fixture must  be  ascribed rather to a spasmodic
contraction of that  tube.   The stoppage  is  commonly at  the upper or
lower part, and rarely in the middle of the oesopliagus.
  [I recollect several years since examining the body of a man who was brought to
 the hospital, and supposed to have died of apoplexy.  On  accidentally removing the
tongue, pharynx, and neighbouring parts, an enormous lump of beef was  found com-
pletely filling  up  the  whole pharynx, and  compressing  the  epiglottis.  Inquiring
about the circumstances of his death it was  ascertained that, whilst eating soup for
 his supper, he suddenly rose from the table, went out of doors, and shortly after was 
96
FOREIGN BODIES
found  dead  near  the  threshold.    The  preparation is  in  the Museum  at  St.
Thomas's.                           .                       ,    ,  ,  ,
   I have known an instance  occurring twice in the same person, who, had  he not
been a medical man, would probably have been suffocated before assistance could
have been obtained.  In eating his breakfast  quickly, he suddenly felt choked,
could not swallow the morsel  in  his throat, and could not breathe;  he thrust his
fingers back to try and pull out the morsel, in which he succeeded, and found  the
small portion of meat  swallowed was attached by a thread  of cellular tissue to
another portion, which  had  become entangled in his teeth, and  the  thread  had
pressed down the  epiglottis, so  that every effort to swallow made  him still worse.
The same accident occurred to him a second time, but was in the  same way re-
lieved.—j. f. s.]
   1728. The symptoms produced  under this  condition are, local pain,
spasmodic  contraction of the oesophagus, disposition to vomit, choking,
or less difficulty in swallowing, symptoms of suffocation, and frequently
actual suffocation, which  depend partly on compression of the windpipe,
partly on the spasmodic contraction of the  glottis.  Sometimes, and, if
the body be small and painful, there  is merely a local painful  sensation.
The inflammation may also be so violent, that it may run on to gangrene,
though this in  general only occurs when forcible  efforts  are  made  for
the removal of the foreign body.
   1729. It is often  very difficult to decide  upon the presence of a  fo-
reign body in the cesopJiagus.   When a body more or less bulky, or with
an irregular surface, is swallowed, if the  patient feel pain at  a  particular
spot, if swallowing  be difficult and  painful, and  the respiration inter-
fered with, yet these symptoms may be  merely the consequence of the
descent of the foreign body, of wound  of the wall of the oesophagus at a
particular spot, and of the inflammation resulting therefrom.   If a bulky
body remain  sticking in the upper part of the oesophagus, it may often  be
felt externally ; or, if the tongue be strongly depressed, it's presence may
be ascertained either by seeing it, by feeling it with the finger,  or with
a  whalebone or elastic sound, or with  Dupuytren's (a)  oesophageal
sound  of   elastic  silver, with a little  spherical ball at its extremity.
These examinations  must be  always made with exceeding  carefulness,
and  especially may be only  made when active inflammation has not yet
set in.
   [It not linfrequently happens that, after a person has had a fish-bone stick in his
oesophagus, though  he can take food, yet a soreness remains, which is generally sup-
posed to arise merely from the  scratching of the lining membrane, and will subside
in a few days, it being presumed that, as he swallows solid food,  there cannot be
any thing lodging; and this more especially if an  oesophageal  bougie have been
passed into the stomach. That this opinion may be too hastily formed, is proved
by the following example.  A friend of mine, whilst  eating fish, suddenly felt that
he had swallowed  a fish-bone, and became so uncomfortable that he was obliged
to leave the table, and within a couple of hoars went  to his medical attendant, who
pulled out a piece of fish-bone with forceps.  On the following day he still continued
very uneasy, his throat being very sore, and felt assured that he had still a piece of
bone in his throat; his  medical  friend, however, very naturally considered the sen-
sation depended merely on the scratch of the bone he  had removed.  For four days
the symptoms of obstruction continued, and  he was much harassed,  anxious, and
became  very ill.  On the fifth  day his son, a very able  surgeon, passed  an  oeso-
phageal bougie without the least hindrance, and it was then thought quite  impossi-
ble there could beany thing in the passage,and that the symptoms merely depended
on the previous irritation.  On the evening of the very same day he suffered much
pricking in  his throat, was attacked with  a violent  cough, and  threw out another
                 (a) Sabatier, Medecine Operatoire, vol. iv. p. 52. 
IN THE OESOPHAGUS.
97
bone, immediately after which he  became easy, and all  the symptoms quickly
ceased.  It is presumed that this second bone had  lain obliquely across the oeso-
phagus, and that, as the bougie descended, one end  of it had been disengaged, as
the instrument distended the canal, and being thus more conveniently and loosely
seated, the bone had been shot  out by the cough.  The remembrance of this inter-
esting case will  induce caution  in giving a positive opinion of a  foreign body not
being present in the oesophagus, although  swallowing may be effected, and even a
bougie passed without obstruction.—j. f. s.]
  In the College Museum there is the whalebone handle of a punch-ladle, marked
"It had been in the oesophagus sixty-eight hours without doing mischief;" but no-
thing more is known about it.   It was in Heaviside's collection.
  Monro indeed mentions the case of a boy who had attempted to swallow a half-
penny,; it  remained in his oesophagus  " three  years, and possibly it might  have
remained there for a much longer period had he not been seized with consumption,
which proved fatal to him.  Upon examination the  gullet was found closely em-
bracing the halfpenny, and considerably expanded by it.  A halfpenny stuck  in the
gullet of another boy for six months, and was afterwards extracted by Monro's
father with a blunt-hook." (p. 18.)   He also  mentions an instance in which  an ex-
traneous body, detained at the origin of the gullet, became lodged in a sac of some
length which descended behind the oesophagus, (ib.)
   1730.  Foreign bodies in  the oesophagus may either be drawn  upwards,
or  thrust down into the stomach, or removed by  a cut  into the  oeso-
phagus.
   1731.  The  removal of the body upwards may be effected by vomiting,
produced  either by irritating  the throat, or  by  the  exhibition of an
emetic, if swallowingbe not entirely prevented, or by the injection of a
solution of tart3rized antimony  into  a vein (a).  It must,  however, be
observed, in reference to the vomiting, that  if the  body firmly close the
oesophageal tube, and will  not  be moved by  the  sickness, the mischief
is increased, and even tearing of the oesophagus  may ensue.
   If the foreign body be at the upper part of the oesophagus, it may often,
if the tongue be strongly depressed, be seized with  the finger, or with a
pair of oesophageal forceps,  and  withdrawn.   If it be lower down, it may
be  removed also by the forceps, or a blunt hook, formed of  a piece of
wire bent together: or by  a whalebone  sound  with a piece of sponge
attached to its extremity, which  is to be passed below the body, and
when the sponge has swollen by the absorption of the moisture, may be
withdrawn.  Little pointed bodies, as needles, fish-bones,  and pieces of
bone, are generally more easily  removed with the  sponge.  A flexible
sound, having its extremity armed with several loops of metal, has been
recommended for this purpose.   Bulky bodies, which completely fill the
oesophagus, are very difficult of  removal, because the instrument cannot
be passed  beyond them.   Attempts at removal must always be  made
with great  care and consideration.  Delpech {b) objects to  the  use of
the hooks and metallic loops as inefficient and dangerous.
  The peculiar operation of the vomiting is not merely the commotion but the in-
verted contraction of the muscular  fibres of the oesophagus.   For the purpose of
making the oesophagus slippery, mucilaginous and oily remedies,  melted butter, oil
with  camomile  tea, or yolk of egg and the like must be administered.  Tobacco
clysters are often advantageous in producing vomiting and  diminishing the spasm.
The removal of a fish-hook, which had been swallowed, the line of which remained
hanging out  of the mouth, by means of a perforated bullet through which the thread

  (a)  Kohler ; in Schmocker's vermischten  Hufeland's Journal, 1811, vol. vi. p. 116.__
Schriften, vol. i.  p. 335.—Balk; in  Mur-  Graefe.
senna's Journal,.vol. ii. p. 64.—Kraoss ;  in   (b) Precis Eleraentaire, vol. ii. p. 59-
                                    9* 
98
TREATMENT OF FOREIGN
was passed, and the bullet allowed to drop down into the curve of the hook so as to
shield its point, is mentioned by Bright (a).
   1732.  In thrusting down foreign bodies into the stomach, a whalebone
sound, with a piece of sponge at one end, commonly called a probang,
first smeared with  oil, is employed.   This  mode  is to  be  practised
especially if the foreign body be soft and have a smooth  surface ; but if
it  be  rough  or pointed, considerable injury to  the oesophagus may be
effected by thrusting it down, and it may be  even of such character, that
on account of its mere presence  in the  oesophagus,  dangerous symptoms
may  be  dreaded.   Under these circumstances,  only the most urgent
symptoms, and the impossibility of getting rid of the body in any other
way, will determine that it should be thrust down.  The patient may be
allowed to swallow mouthfuls  of chewed bread,  and the  like, which
often drive the body down, and a blow  between the shoulders will  often
loosen it.
  If a body capable of being broken up, as for instance, a potato remain sticking in
the upper part of the oesophagus and cannot be  thrust down into  the stomach,
attempts must be made to  press it upwards, with the fingers upon the surface of the
throat,  as Dupuytren did very successfully,  and quickly relieved the patient after
all other efforts had been in vain. (Pigne).
  Before1 proceeding  to thrust an extraneous body down  the oesophagus, a careful
examination should be made with the finger,  to ascertain if it be within reach, and
can be  removed ; the importance of doing this is proved by the following case,
which  Astley Cooper was accustomed to relate (b).  A child, whilst dining with
his parents on his birthday, swallowed a fish-bone, and was  attacked with violent
cough; Cooper not being in the way, another surgeon was found, who passed a
probang; the symptoms,  however, became worse, were followed by convulsions,
ajid, between ten and  eleven o'clock of the same evening, the  child died.  Having
obtained permission, Cooper opened the larynx with a lancet, and found a piece of
fish-bone situated just at the glottis, which he readily hooked out with  his finger-
nail.
   Dr.  Brown  (c) mentions the case of a woman who, in eating oatmeal porridge,
swallowed a piece of a broken delf plate, whieh pierced the oesophagus on the right
side, midway between the eriooid cartilage and the  breast-bone.  She soon made an
effort to vomit, and a  discharge of blood from  the mouth ensued and repeated on the
passage of a probang, which she thought displaced the bit of delf.   On the day
following she was seen by Brown, and had then inflammation and swelling of the
external fauces in the line of the oesophagus,  with  total inability to swallow.  The
foreign body could not be felt externally; and a  probang was twice passed with
facility. Leeches and cold lotion were applied, and on the sixth day the inflamma-
tion hadalmost ceased, and she swallowed well.  On the ninth day she was attacked
with pain in the stomach, which lasted two  days,  and on  the tenth she vomited a
pint of dark foetid blood, which continued in smaller quantities. On the twelfth day
she  spat up more than a  pint of brown foetid  sputa, and  died at midnight.  No
examination was permitted.   Brown considers that the bit of plate was at first thrust
down into the stomach, and that the inflammation of the oesophagus depended on the
violence with which this was done.   He imagines  that the  fatal symptoms resulted
from the hard substance wounding the stomach, especially as that ortran was com-
paratively empty from the accident to her death.   And that the pain in the left
hyphochondrium pointed out  injury to the left extremity  of the  stomach, near the
cardia, where some krge  branch  of the coronary, or left gastroepiploic artery must
have been divided, as the  quantity of blood: poured  out was so large as to colour the
faecal discharges.
   [My friend^and pupil  Tunaley, of Camden Town, has given  me the following
ease, which-shows the propriety of Astley Cooper's advice, and which, but forthe

tJ?^^/^11 MediCaJ Record<^  1823«    (0 Edinburgh  Med. and Sur* Journal,
   (i) MS. Lectu-cs. 
BODIES IN THE OESOPHAGUS.       ,           99
prompt and judicious  treatment,  would also probably have terminated fatally,
although the foreign body was merely a piece of bristle from a brush, about an inch
in length.  A lady, whi,lst eating bread and butter, felt something in her mouth
which seemed like a piece of wood, and not choosing to spit it out, as she  was in
a party, determined to swallow it with the morsel in her mouth.  In doing this, the
sharp substance lodged  in her throat, produced a constant pricking, and in the course
of a few hours cough and repeated attempts at deglutition.  She was seen  shortly
after by a medical man, who  examined the throat, and, finding nothing, considered
it merely a case of local irritation, and treated it accordingly.  Next day she was
worse, and an emetic was given, which quickly aggravated the symptoms to such an
extent, as to threaten immediate suffocation.  Twenty-four hours after the accident,
Tunaley saw her, and it was then necessary at once to perform tracheotomy, which
he did immediately below the cricoid cartilage; and, scooping out its under edge,
he introduced an elastic catheter, which relieved  her directly.  Four hours after,
when the  spasm had subsided,  he made an examination, with  his finger,  by the
mouth, and could  just feel, when  an  attempt to swallow was  made, the point of
what he took for a pin;  but it was not under command  of  the finger.  He then
passed a pair of dressing forceps, bent; for  the purpose, into the throat, and, after
persevering efforts, as the patient's exhaustion would, admit, during two  hours, at
last succeeded in pulling out a bristle, which, he  considers,  had  penetrated the
mucous membrane at the root of the epiglottis, and, by its continued irritation, had
produced the  spasm of  the glottis.-   The patient speedily recovered.—j. f. s.]
   1733.  When  the  body has  caused  severe  inflammation and diseased
contraction  of the oesophagus,  all  attempts  at  its removal must be given
up, and the treatment confined simply to.-blood-letting,  leeching, oily in-
jections,  and if there be accompanying spasm, opium.  When  by these
means the inflammation,  swelling and contraction of the oesophagus have
 diminished, it not unfrequently happens that  the  body gets loose, and
 can be removed  one way or another.
    1734.  Whether the body he  drawn up or thrust down,  frequently
local inconveniences remain in the oesophagus, as wounds, inflammation,
 and suppuration, which require corresponding antiphlogistic and  soothing
 treatment.   Narrowing  of the oesophagus may result  at a  subsequent
 period, and if the body be bulky, suppuration even may ensue.
   1735.  Thin and pointed  bodies, needles for example, may penetrate
 the walls of the  oesophagus  and  gradually make their  way through the
 neighbouring  parts,  so that they often reappear at very  distant parts.
 This more  frequently occurs   when the  bodies have  passed  into  the
 stomach, and  then travel  through the different  organs, sometimes accom-
 panied with no pain, but at other times with great  pain.
    1736.  When  the  foreign body can neither  be  pulled up nor thrust
 down into the stomach, if it produce  urgent symptoms, and be  not very
 low in the  oesophagus, or. if it be  of such kind  that its descent into the
 stomach  would  be productive  of great danger, then it must be  removed
 by cutting into the oesophagus {(Esophogotomia.)^  This operation  is always
 one of the most  difficult and dangerous, though under the circumstances
 it must be  held to be the Only  means  of relief, and by  observing  certain
 rules, is  much facilitated.   The parts of which injury is to be feared are
 the carotid  artery, the internal  jugular vein, the recurrent nerve, and the
 thyroideal arteries.
   Callisen (a), as well as  Benjamin Bell and Richerand,  only allow cesopha-
 gotomy when the foreign body can be felt externally, and in the Contrary case will
 have  an  opening made in the windpipe to prevent the danger  of suffocation.
 According to Zang (6), however,  the  operation may be undertaken, if nothing be
      (d)  Systerna Chirurgias, vol. ii. p. 421.      (6) Operationen, vol. iii. p. 40. 
100
FOREIGN BODIES
felt externally, if only the place be known where the body is situated.  In these
cases also the mode of operation laid down by Vacca Berlinghieri may be safely
performed.                                          .          ...
  [As the more serious symptoms which occur when a foreign body  sticks in the
pharynx or oesophagus, depend  on the  pressure it makes  upon that part of the air-
tube to which it is opposite, I think it would be advisable to  perform tracheotomy
in preference to the difficult and dangerous operation of cutting into the oesophagus.
This mode of treatment has been successful, as in the case of the boy who attempted
to swallow nine pistoles wrapped in  a piece of cloth, mentioned by Habicot (a).
The packet stuck in the narrow part of the pharynx, and he was almost suffocated.
Attempts to thrust it down were made ; but in vain.  Habicot, therefore, to relieve
the  most urgent symptoms, cut into the  windpipe;  the difficulty of breathing, the
swelling and blueness of the face ceased  immediately; and the money then thrust
down with a leaden sound in the stomach, was passed by stool a few days after.]'
  1737. According  to Verduc-Guattani,  the  operation is  to be per-
formed in the following manner^   The patient having been placed in an
arm-chair, or laid upon a table, and his head properly held by  an assis-
tant, a cut from two and a  half to three inches in  length  must be made
vertically through the skin and cellular tissue, upon the left side of the air-
tube between the larynx and the collar-bone.   Then, the assistant having
drawn the edges of the wound asunder with  blunt hooks, and the blood
being  absorbed with a  moist sponge, it must be endeavoured to dig
under the edge of the thyroid  gland with the handle of the scalpel, and
keeping still, on the one side  of  the air-tube, and  using the blade of the
knife as little as possible, the oesophagus is to be laid bare, and so cut into
that the foreign body may be removed with a pair of straight  forceps,
without tearing the  edges of the wound.   If the foreign body be a little
distant from the opening, a pair  of curved forceps must  be  used for its
removal.   Any spirting vessels must be immediately taken up during the
operation,  as well also the  thyroideal arteries, if they  come in the way,
before cutting  them through.
  Eckoldt's method, in which a cut is made through the skin, close to the middle
of the m. stemo-mastoideus, and the division of the cellular tissue in the triangular
space formed by the division of this muscle before its insertion into the breast and
collar-bone, and the oesophagus laid bare and. cut into, is  manifestly less  safe than
that just described.
  1738. In those cases in  which the foreign  body forms no perceptible
swelling externally, and for the purpose of especially projecting the wall
of the oesophagus, it has been recommended to introduce a silver catheter,
or a forked curved sound, through the mouth into  the  oesophagus, and to
raise its left wall into the wound.   The arrow-sound has also been advised
for  this purpose.  Richerand (b) objects to  the  introduction of any in-
strument into the oesophagus, as a guide.   Vacca Berlinghieri (c) has,
however, proposed an instrument by which cesophagotomy is more easy
and effectual than by any other mode.
  1739. The patient is  placed on  a low  stool;  the  head  held firmly
against the  chest of one  assistant, and  the rest of the body by another.
The skin-cut is to be made on the left side of the neck, in the direction
of the thyroid and cricoid cartilage, on a fold of skin from the upper edge
of the thyroid  cartilage  to  two  inches below it; if  the m. platysma

oAa) ?J?'-de,o Acad> de Chin' vol> xiL P'    <c> J^nal von Graefe und von Wal-
  rM Soo-rLhiTrh-    ■'  , •   ,  .»     T,HER'  VoL V> E' 712--Chirurg. KupfertaC.
  (6) JNosographie Chirurgicale,. vol. iii. p.  pi. cxxxv.                &    r
260.                                r 
IN THE CESOPHAGUS.                   101
 mybides be not then cut through, it must be divided with a second stroke
 of the knife into the underlying cellular tissue.   The ectropcesophag, with
 the spring thrust fully forwards and thus completely closed, is to be in-
 troduced so deeply into the oesophagus, and so directed that its lower end
 corresponds to  the  lower angle of the wound.  The fore and  middle
 fingers are  now to be  introduced into the side  rings of the canula, and
 the thumb into that of the shaft, which  being drawn back, its spring end
 is set free, and with its olive-shaped knob, the  wall of the oesophagus is
 thrust into the wound.  The instrument is now held steadily by an assis-
 tant, the cellular tissue carefully cut into, and the oesophagus laid bare by
 drawing the m. sterno-mastoideus backwards, the m. sterno-hyoideus  and
 sterno-thyroideus forwards, (with the assistance  of the  finger  or  a blunt
 hook,) and  then the m. omo hyoideus, which crosses the wound obliquely,
 is divided on a director.  The oesophagus now appears  to more than the
 extent of an inch, and must be cut into on the side, and a little forwards,
 between the canula  and  the diverging arms of the shaft, for two  lines
 above the olive-shaped knob of the latter, and the cut enlarged upwards
 as far as may seem necessary.   A blunt hook is then introduced into the
 oesophagus,  to keep it steady.  The ectropcesophag is now taken out, and
 the foreign  body moved with the finger or forceps.
   The ectropcesophag may be so easily arranged, that  it may be used even if the
 operation be  performed on the right side.
   1740. According to  Begin .{a), it is impossible to  operate upon the
 oesophagus in the region prescribed by  Verduc-Guattani's plan,  or pro-
 perly to introduce the instruments  recommended for  introduction by
 others, and  to retain them in suitable position, as the irritated parts  can-
 not  bear constant touching, and  the breathing  has  already become
 difficult.  His method, which is founded on  the most careful considera-
 tion of the anatomy of the parts concerned, and  which has been  several
 times performed on living persons, is the following:—The patient is laid
 upon a narrow bed, his shoulders and chest slightly raised, the head a
 little bent back, and supported with a  pillow, and  the neck moderately
 stretched.   The operator standing on the left side, makes a cut through
 the skin, along the groove between the sterno-mastoid muscle and the
 windwipe, which he begins a finger's breadth above the sterno-clavicular
 articulation, and carries up as high as the  upper  edge of the thyroid car-
 tilage.   He  now divides with long strokes the m. platysma-myoides and
 cellular tissue, and descends deeply into the  cellular space between  the
 windpipe and  oesophagus within, and the deep  vessels and nerves without,
 which are covered by the sterno-mastoid muscle, and the assistant, stand-
 ing on the patient's right side, draws inwards the parts on the inside of
 the wound with his fingers or with a blunt hook, and the  operator, with
 the fingers of his left hand thrust in more deeply draws outwards the parts
 on the  outside of the wound, and with  the point of his finger covers the
 vessels and nerves.   The m. omo-hyoideus is then seen running obliquely
 outwards and downwards in the upper half of the wound, which, a director
 having been introduced beneath, must be divided.  The oesophagus now
 appears, and is known by its position behind the windpipe and larynx, its
round  fleshy surface, its movements and hardness in  the attempts to
  (a) Diet, de  M6d. et de Chirurg.  pratique, vol.  xii.  p. 152;  and Nouv. Elem. de Chirur-
gie et de Med. Operat., vol. i. p. 260.  Second Edition. 
102
FOREIGN BODIES
swallow.  If the foreign body form a projection, it must be immediately
cut upon;  but under  contrary circumstances, the knife is to be carried
boldly in the middle of the wound parallel to the axis of the oesophagus,
into it, and an opening made about half an inch long, from which imme-
diately some mucus and spittle flow out, and in which, by the contraction
of the circular fibres, the mucous membrane becomes visible.   A button-
ended bistoury is now introduced  upon  the forefinger, and the wound
enlarged sufficiently upwards and downwards to admit the  introduction
of the  forceps.   It  is  better  to, enlarge the wound  upwards rather than
downwards, as wounding the superior is less dangerous than wounding
the inferior thyroideal artery.   Every bleeding vessel must be immediately
taken up during the operation.
   1741. No precise rules are laid  down for the removal of the foreign
body; it must  depend on the delicacy of the touch, manual dexterity,
and  thought of the operator upon  the  moment, to determine how the
difficulties'  may be  best overcome.   Curved and pretty  strong polypus-
forceps, with double  curves, are  in general most convenient,  and  a
sufficient number of them, of various form and size, must be in readiness.
(Begin.)
   1742. After the  removal of the foreign body,  quick union should be
aimed at according to the usual mode, with dressings; the  edges of the
wound are to be brought close together with sticking plaster, and the
head kept inclined  a little backwards and to the right side.  For the first
eight days  the patient must be supported only with nourishing clysters
and  baths;  and then  with gelatinous substances in small quantities by
the  mouth; at first the  patient's tormenting thirst must be quenched
with Seville orange strewed with sugar, (par. 473,) and taken into the
mouth.  But, according  to Begin, should  the wound unite  neither by
sticking plaster, and still less by suture, as in the condition of the walls
of the oesophagus, from the more or  less severe inflammation  and so on,
agglutination, as in ordinary wounds, is not to be expected, but the
edges should only  be brought together, covered with perforated cloths
spread with  cerate, and  wadding with compresses, fastened with a cir-
cular  bandage.  As the patient subjected to oesophagotomy becomes
wasted by his incapability to  swallow,  want of rest and  so on, some
nourishing broth should be conveyed into his stomach  by  means of an
oesophageal tube, the  day after the operation.
IV.—OF FOREIGN "BODIES IN THE STOMACH  AND  INTESTINAL
                             CANAL.
                      Hevin, above cited, p. 520.
  1743. When bodies, insoluble by the  powers of the digestive organs,
are thrust down or swallowed into the stomach, they may produce differ-
ent symptoms, depending principally on their form and nature.  Bulky
bodies often  pass without any  difficulty through the whole intestinal
canal; pointed bodies are easily retained, and produce frequently in-
flammation and ulceration. 
IN THE STOMACH AND INTESTINAL CANAL.           103
  [Of the foreign  substances  received into  the stomach, the  most  remarkable
account is that given by Dr. Marcet (a), of the sailor who swallowed a number of
clasp knives.  In June, 1799, after having witnessed a display of jugglers' knife-
swallowing, he, in  a drunken fit, boasted he could do the same, and accordingly
swallowed four pocket-knives successively.   On the following afternoon he passed
one knife by stool, and on the following day two more, but the  fourth knife never
came away, nor gave him inconvenience.  In March, 1805, in the course of a couple
of days,he swallowed fourteen knives more;  but  on  the following morning was
attacked with constant vomiting and pain at his stomach, which  compelled him to
go to the hospital, and in the course of a month,  "he  was safely delivered  of his
cargo."  In  December of the same year, he swallowed on one day five, and  on the
next fourteen more.   He was very ill the next day, and  obliged to. put himself under
medical care, but without benefit till three months after, when having taken castor
oil, he felt the knives "dropping down  the bowels," and  became easier, but was
not aware of  having passed  any.  In  June, 1806,  he  vomited a knife-handle; in
November he passed some fragments, and again in  February, 1807.  In August of
the same year he was admitted into Guy's Hospital., where at first his account was
not believed, but he held fast to his story, and as he  suffered intense pain at the
region of the stomach, and a hardness was thought to be felt, some credence was at
last given, and his stools being noticed were found of  a deep black, indicating an
accumulation of ferruginous matter in his bowels.  On  examining the rectum, a por-
tion of the knife was felt lying  across it, but could not be extracted on account of
the great pain he suffered in the attempts to grasp it.  Various attempts were made
to dissolve the knives, but without success, and at last, in March, 1809, he died in
a state of great emaciation.   On examination, one of the blades and one of the back
springs were found in the  intestines,  the  latter, four  inches and a half long, had
transfixed the colon opposite  the left kidney, and projeeted into the cavity of the
abdomen, while the other was stretching across the rectum, with one of its extremities
actually fixed in the muscularparietes of the pelvis.   No stool had, however, escaped,
nor were  there any signs of  active inflammation.  In  the  stomach were thirty or
forty fragments, of which thirteen or fourteen were evidently blades, much corroded
and diminished in size.  They are all in the Museum  at Guy's Hospital.
   Another instance  is also related by Dr. Barnes, of Carlisle (b), of a juggler, who,
on 17th November, 1823, accidentally swallowed a table-knife with a bone handle,
together nine inches in length.  The account given by the man was, that "having
offered for a small sum of money to swallow a table-knife, a new one was accord-
ingly brought from a neighbouring shop.  The method  by which  I pretended to
swallow it was, to'pass the handle and part of the blade down my throat, and hold
the point of the knife fast with my teeth. When I was on the point of drawing it
out again, some person, coming unexpectedly  behind  me, gave  me a smart stroke
on the back, the surprise of which caused me to lose hold of the point, and imm'e4
diately the whole knife slipped  into  the.  stomach.  I directly  made very violent
efforts to throw it up, but in vain, and  the endeavours of the surgeon were equally
useless." The  man immediately became very  much alarmed, expecting instant
death.  Attempts were made with the fingers and with long forceps to seize the
knife, but it  was far beyond their reach, and could not be felt on the external surface
of the  stomach.  Next day he complained of pain in his stomach, for which he, was
bled, and a clyster given; and afterwards, having pain in the left shoulder shooting
across the chest to  thfe stomach, he was bled  again.   Soon after the handle of the
knife could be felt very distinctly by pressing gently  on the  navel, though slight
pressure gave him considerable pain; but a single cup of tea or a little food of any
kind distended  the stomach so much that it entirely disappeared.  Various  sugges-
tions were made, and among others gastrotomy, but the patient would not consent to
it.  He was able to walk about a little during the day, and could sleep at night on
his back, but not on either side.   He was frequently squeamish and sick at stomach,
and sometimes felt a severe twisting pain in that organ.   He kept quiet till 28th
December, when he  left on  his  way  to London, but died at Middlewich on the
16th January following.  From the account it is very evident that he never laboured
   (a)  Med. Chir. Trans., vol. xii. p. 52, 18Q2.
   (b)  Jameson's Edinburgh Philosoph.  Journ., vol. xi. p. 319,1824.—Hadfield, A State-
ment of the Case of VV. Dempster, a juggler, who died in consequence of having swallowed
a Table kife.  Middlewich.  A pamphkt. 
104
FOREIGN SUBSTANCES
 under any urgent symptoms, and seems to have been worn out rather by terror and
 anxiety.  "On opening the  belly," Hadfield says, "my first  attention being of
 course directed to the stomach, I found the  knife beginning to protrude through a
 Gangrenous opening about two inches and a half from the beginning of the duodenum,
 on which part the knife had lain.  After opening the stomach, I found that the point
 of the knife rested on that part of the greater curvature, almost exactly opposite to
 the cardia, and had  likewise very nearly perforated the coats. *  *  * The  handle
 of the knife was completely dissolved, the rivets had disappeared, and a considera-
 ble portion (at least one-third) of the blade also.   What was left  appeared exceed-
 ingly rusty and  black."  This knife is in  the Museum of the  Royal College  of
 Surgeons.  In  the  same collection are  some knives  voided  by a soldier  in St.
 George's Hospital.
   1744. Bulky bodies are most commonly retained in the  stomach  and
 at the ileo-colic valve.   They may remain in the stomach a considerable
 time without causing symptoms, which, however, they easily produce in
 the intestinal canal, even if they be not fixed.   The symptoms especially
 depend on the stoppage of the  alimentary canal, or on the inflammation
 and injury which  the foreign  body produces by its peculiar form.  In
 (he first case symptoms of ileus arise ;  in the second, more or less severe
 enteritis.  Oxidizable  metals for example;  copper coins produce no
 peculiar symptoms, as their oxidation, whilst resting  in the  alimentary
 canal,  is exceedingly slow and not  to that extent,  which  produces
 dangerous effects {a) ; indeed,  in general, they are  not long enough re-
 tained.
   [In the College Museum there is a very  interesting preparation from a woman
 who had long suffered under symptoms of gall stones, and at  last died exhausted.
 On examination, the  gall-bladder was found  thickened, contracted, and both  it and
 the liver intimately adherent to the duodenum and adjacent organs.  Between the
 gall-bladder and duodenum was a large ulcerated ragged  opening of communication,
 through which a large gall-stone had passed, and, getting into the ileum,  had
 blocked it up.   Above this part the gut was  distended with air  and biliary fluid.
 In the Museum at St. Thomas's  there is a portion of small intestine from a  child,
 which is in two or three parts  completely filled  with  lumps of hardened stool, in
 appearance resembling album  Greecum,  the result  of  quantities of carbonate of
 magnesia, which becoming entangled with  the mucus of the  bowel,  had formed
 complete plugs of an inch or more in length.
   The College Museum also possesses an example  of cherry-stones lodged  in the
 caecum, which had been swallowed  by a boy twelve years of age, at least sixteen
 months before his death, during which time he continually suffered from symptoms
 of chronic enteritis.
  Langstaff (b) gives an  account of a madman who swallowed a silver table-spoon
 in October, 1827. Soon after his health gradually declined.   Although he lived
abstemiously his digestive organs were disordered; he suffered from dyspepsia,and
 frequently complained of an acute pain in the region of the caecum; and  he persisted
 in declaring that all these  symptoms were occasioned by the spoon  he had  swal-
 lowed.  His account was disbelieved, especially as cautious  examination  of the
 belly was made without  detection  of any  foreign body.   He continued to suffer
 from the effects of pain in the situation of the caecum and colon, and frequently said
he felt the motion of the spoon.   He was teased with diarrhoea, and the evacuations
 were often mixed with blood and pus.  Symptoms  of diseased liver came on, and
were followed by ascites and oedema of the lower limbs.   Under these circumstances
 Langstaff tapped him, drew off a bucketful of  water, and, as  he  was "greatly
 emaciated, I was induced," says Langstaff, " to  carefully examine with the hand
 if I could feel the spoon, when, to my astonishment, I detected  a solid suhstance in

  (a) Claude Rene Drouard,  Experiences     (b) Catalogue of the  Preparations  &c,
 et Observations  sur  1'EmpoUonement par  constituting  the  Anatomical  Museum of
 POxide de cmvre (ver-de.gris.)  PHris, 1802.  George  Langstaff.  London   lfc42  Svo.
Orfila, Traite de Poisons, vol. i. p. 243.     p.  228-32. 
IN THE STOMACH AND INTESTINAL CANAL.           105
 the situation of the caecum, which  induced me to believe that it was  the spoon he
 had swallowed."  He died about twenty months after, and on examination it was
 found that "the mucous coat of the stomach, as well as the duodenum, jejunum,
 ileum and caecum were more vascular than natural, and there were evident signs of
 their having been ulcerated  on different portions, and that nature had put a perfect
 stop to the ulcerative process, by uniting the boundaries to the submucous tissue.
 The  greatest degree of mischief had  been  effected by the passage of the spoon
 through the ileo-caecal valve,  which was greatly dilated and the  circumference
 thickened.  The  mucous coat  of the caecum was nearly destroyed by ulceration.
 The spoon was found in this intestine, with  the bowel downwards,  where it had
 formed a large  sac, which prevented its passage into the colon."  The  preparation
 is now in the Museum of the College of Surgeons.]
   1745.  Pointed bodies,  when they remain hanging in the  walls of the
 intestines, excite inflammation to such extent as to produce union of the
 surface with the peritoneum or any other part, so that when  suppuration
 takes place by the continued operation of a foreign body, it may make its
 way in different directions, and proceed either to the surface of .the body,
 or even into any other cavity, as, for instance, into  the bladder.
   [In rare instances a foreign body  will make its way through the walls of the in-
 testine and belly, as in the case of the boy ten  years old,  from  whom plum and
 cherry stones were  discharged by an abscess communicating with  the  gut, and
 which are in the College collection.]
   1746.  In order to protect the stomach and intestinal canal against the
 effects of any such body, mucilaginous ensheathing food, and especially
 antiphlogistic treatment and  purgatives,  to hasten  the  passage  of the
 foreign body through the alimentary canal,  must be employed.
   [This is the ordinary practice usually employed; but I am not sure that the late
 Sir Francis Chantrey's proceeding under similar circumstances is not preferable.
 He had accidentally swallowed  the  gold fastening of one of his teeth, and, being
 much alarmed, came to my friend Green, to consult with him about the matter, at
 the same time  suggesting the propriety of eating freely of suet pudding, with the
 hope of entangling the little  gold plate,  and favouring its  passage through the
 bowels.  Green saw no particular objection to this proposition, and accordingly a
 due quantity of the medicinal  pudding was swallowed.   Nothing more  was heard
 or seen of the tooth-plate, and whether passed  or not is unknown, but it never  gave
 any inconvenience.—j. f. s.]
   1747.  If there be a foreign body in the  stomach, or in the alimentary
 canal, which will not pass off by the usual wTays, and if it cause great
 danger to life, it must be removed by cutting into  the stomach {Gastroto-
 mia) or into the intestine {Enteromia.)   To decide on this very dangerous
 operation  is  always extremely  difficult; it should  only be  undertaken
 when  most positively called  for by the situation of the foreign body,  and
 on this point the symptoms are very doubtful.   The  intestine  in  wrhich
 the foreign body is may be far from the wall of the belly.   As long as no
 very severe symptoms occur, the operation  should not be rashly decided
on; and  if they have  already set  in, the result of the operation  is the
more  doubtful.   Gastrotomy has,  however, been  performed  success-
fully (a).

  Delpech (6) considers that there never can  be such certainty of the situation of a
foreign body in the stomach and intestinal canal as to  decide on gastrotomy or en-
terotomy.  If there be a swelling, with fixed pain, the treatment should be confined
only to a superficial cut, when the skin is distinctly pressed up by the  suppuration,
  (a) Baldinger's  Neues Magazin filr Aerzte, vol.  xiii.  p. 567.—Rust's Magazin, vol.
vii. pt. i.
  (b) Precis Elementaire, vol. ii. pp. 67, 68.
     Vol. hi.—10 
106        FOREIGN SUBSTANCES IN THE STOMACH,  &C
 because there is no certainty to what extent union is effected, and whether extrava-
 sation of fecal matter can be prevented.
   There is a remarkable case in which a fork having been swallowed, excited sup.
 Duration, and by enlarging the opening of the abscess, was removed (a).
   For the removal of poison from the  stomach, Read's or Weiss's, or Graham's
 stomach-pumps may be employe^.
   [Barnes (6) quotes from Becker the case of a young peasant, who on 29th May,
 1635, whilst endeavouring to produce vomiting with the handle of a knife, let it
 slip 'from his fingers, and  pass into his stomach.  He was much  frightened, bat
 able to go about his  usual occupation.  It was, however, determined to remove the
 knife by operation,  which was  done  on the 9th of July following, by a surgeon
 and lithotomist, named Shoval.  " A straight incision was  made in the left hypo-
 chondrion, two fingers'-breadth under the false ribs;  first through the skin  and cel-
 lular membrane, then through the muscles and peritonaeum.  The stomach subsided,
 and slipped from the  fingers, which prevented it from being immediately seized;
 but it was at length caught hold of with a  curved  needle, and drawn  out of the
 wound.  A small incision was then made  into it upon the knife, which was then
 easily extracted.  The stomach  immediately collapsed.   After the external wonnd
 had been properly  cleansed, it was united with five sutures, and tepid balsam poured
 into the interstices.  Tents impregnated with the same balsam, and a cataplasm of
 bolar earth, the white of egg, and alum, were  then applied." (p. 324.)  Two sutures
 were removed next day, on the following day, two more, but the fifth is not noticed.
 On the fourteenth day after the operation, the wound had healed.  Dr. Oliver (c) saw
 this knife at Konigsberg in  1685, and  says,it was six and a half inches long.  The
 patient completely recovered.]
   [See White's Case of Excision of a silver spoon from tbe Intestinal
 Canal, in the N. Y. Med. Repository, vol. x. p. 367.  1807.—g. w.  n,]
   1748. If the  stomach contain  nothing  but the foreign body, it must
 be moderately filled, before proceeding to  the  operation, with muci-
 laginous  fluid for the purpose of bringing  it near the  wall  of  the
 belly {d).   If  by feeling, the position of the foreign body can be distin-
 guished, the cut should be made  upon that  part: but under other cir-
 cumstances, upon  the front wall of the  stomach, an  inch below  the
 sword-like  process of the breast-bone,  to an inch  and a half above  the
navel, about three quarters of an  inch  to the left of the white line, that
the cut may be between  the great and  little  curvature of  the stomach.
The wall of the belly is to be cut through with some careful strokes of
the knife ;  and then the stomach being  laid bare, search is made  for  the
foreign body, and  a knife thrust  into the stomach  at the proper place,
 and the wound enlarged by  a  button-ended  bistoury.   The foreign
body  is then to be sought for with a pair of forceps introduced upon  the
forefinger of the left hand, taken  hold of, and drawn out.   The further
treatment must be  according  to the rules laid down for wounds  of  the
stomach {par. 541.)
  Hevin  also proposes  piercing the front wall  of  the exposed stomach  with a
grooved trocar, and to enlarge the wound upon it right or left.
   1749. In enterotomy, the  wall of the belly should be cut into where
the foreign  body  is  distinguishable, though  if possible, on that  part
where the   epigastric  arteries can be  avoided, search made  with  the
finger  for the position  of the foreign  body, the  intestine  containing it
 drawn into the wound, and  then  sufficiently cut into for the removal of
             (a) Salzburg, Med. Chir.  Zeitung, July, 183S, p. 14.
             (6) Above cited.
             (c)  Phil. Trans., vol. xxii. p. 1408. 1700-01.
             (d)  Hevin, in  Mem. de  l'Acad. de Chirurg., vol. i. p. 598. 
FOREIGN BODIES IN THE RECTUM.              107
the foreign body.   The further  treatment is the  same as  in wounds of
the intestine (par. 529 and the  following.)
  Cutting into the intestine has been proposed for stricture and closure of the large
intestines, for unrelievable collection of stools, for ileus and volvulus, in which cases,
an artificial anus may be at the same time  formed (par. 1616.)   Although in such
cases the operation may be successfully performed (a), yet on account of the uncer-
tainty of the cause,and of the actual seat of the disease, as well as on account of the
symptoms, to a great extent, an  unsatisfactory issue to the operation,  is so pro-
bable (b), that practitioners are rarely inclined to it.
             V.—OF FOREIGN  BODIES IN THE RECTUM.

   Morand, Collection de plusieurs Observations singulieres sur des corps etrangers,
 les uns appliques aux parties naturelles, d'autres insinues dans la vessie, et d'autres
 dans le fondement;  in Mem. de l'Acad. de Chirurg., vol.  iii. p. 606.
   von Walther,  Beobachtung eines fremden Korpers von ungewohnlicher Grosse
 im Mastdarme; in Journal fur Chirurgie und Augenheilkunde, vol. i. p. 435.
   1750.  Foreign  bodies  may  be introduced through the anus into the
 rectum, either voluntarily or accidentally, in making  a  careful examina-
 tion for  certain  things; or  bodies  which  have  been  swallowed, after
 having passed through the bowels, may remain a longer or shorter time
 in the  rectum; the passage of the  swallowed  body, however, in general
 causes no difficulty, as it is  involved  in  a  thick mass of stool.  If the
 foreign body  in  the rectum excite  symptoms  they depend  on  its peculiar
 form or its  great size.
   [(1)  Phillips (c) mentions the case  of an old man brought into St. Mary-le-bone
 Infirmary,  who was  delirious, and complained of having a stick in his rectum, and
 being unable to sit up without pain; but as no other information could be obtained
 about it, and  no stick could be detected  on examining the bowel, it was believed he
 was labouring under some delusion.  A clyster was  however given, but no stick
 was passed.  On the third day he died, and on examination,^ six inches above the
 anus, was found the inferior extremity  of a stick, which was about as thick  as an
 ordinary, indicator finger;  it was' covered with its  bark, and carefully rounded  at
 each end.   Its  superior  extremity had  passed  through the sigmoid flexure of the
 colon into the peritoneal cavity to the extent" of four inches.  The peritonaeum was
 highly inflamed through its whole extent, but there was very  little  thickening about
 the,tissues in the immediate vicinity of the perforated point.  There was no appear-
 ance of disease in the rectum."
   McLaughlan (d) relates the history  of a Greenwich pensioner, aged forty-nine,
 who having introduced an immense  plug of wood fitted to the anus, for the purpose
 of stopping a  diarrhoea, fell accidentally upon a stool, and forced it up  into the gut.
 Eight days after he applied for assistance, having  in the  meanwhile suffered se-
 verely from continual efforts to void  his stools and urine, which last was done with
 great difficulty.   The whole belly was  considerably enlarged, and  felt knotty from
the stools so long retained.  The end of the forefinger could  barely reach the plug
on account of the inflamed and swollen  state of the gut, which had begun to suppu-
 rate.  The ordinary instruments were unavailing for its removal, and a  peculiar pair
  (a) Velse, C. P., Dissert, de mutuo Intes-  ture du bas-ventre dans les cas du volvulus
tinorum ingresu.   Lugd.  Batav.,  1742.—  ou de l'intussusception d'un intestin;  in
Odier, Manuel de Medecine pratique.  Ge-  Mem. de l'Acad. de  Chirurg., vol. iv.—Hk-
neve, an xi.                             benstreit's Zusatze  zu Bell's W. A. K.,
  (b) Hoegg, A., Observationes medico-chi-  vol.  ii.  p.  359.—Fuchsius ; in  Hufeland's
rurgicae.  Jenee, 1762.   Observ. iii.; in  San-  Journal, 1825, Feb.,  p. 42.
difort, Thesaurus Dissertationum, vol. iii.    (c) London Med.  Gaz.,  vol. xxix. p. 846,
See also, Leclerc, D., Ilistoire de la Mede-  1842.
cine, p. i. 1. iv. ch. vi.—Hevin,  Recherches    (d) Ibid., vol. xxx. p. 462. 1842.
Historiques  sur la Gastrotomie, ou l'ouver- 
108             FOREIGN BODIES IN THE RECTUM.
 of forceps were invented for the purpose, and fitted upon it with a screw.   The ope-
 ration was very painful and required much force.  In the course of a fortnight he
 completely recovered.                                  .             .
   A case is reported by Johnson (a) of a man who died immediately after being
 admitted into King's College Hospital;  he had been labouring under obstruction of
 the  bowels for five days, having eaten a large quantity of peas on the previous day;
 and  during the last three days had also suffered from retention of urine.  During the
 whole time he had had severe pain in the belly, costiveness, and bilious vomiting;
 purgatives were given without relief; and when admitted he was much debilitated,
 his  features pale and shrunken; skin cold, and pulse feeble.  On examination, the
 bladder was found distended, its base nearly at the brim of the pelvis, and its top
 reaching to the  navel.  The intestines  were  distended  with air; but the rectum
 contained upwards of a pint  of gray peas, which had  been swallowed dry and al-
 most without mastication, and had not undergone any other alteration than becoming
 swollen; some were mixed with stool in the colon, but the greater number were on
 the rectum, where they formed  a  solid  mass, occupying almost the entire pelvic
 cavity, pushing up the bladder and prostate, and compressing the urethra, so that
 there was considerable difficulty in passing the catheter.
   (2)  Brodie (b) mentions the case of a person who had obstruction of the rectum,
 caused by a piece of apple core which  he  had swallowed on the day previous.
 Welbank tells me that on a similar occasion he pulled out a piece of vertebra and
 rib about an inch and a half long, part of a mutton chop which had been unwittingly
 swallowed.]
   1751. The  symptoms occurring under such  circumstances are, ob-
 struction, or entire prevention of passing stools, very severe tenesmus,
 great  inflammation, and  swelling of the inner wall  of the rectum,  extend-
 ing  to the neighbouring parts and to the bowels, violent fever, tympanitis,
 and the like.   The danger  is always great, and  the foreign  body must
 be removed as quickly as possible.   The removal is often  exceedingly
 difficult, on account of  the  seat  and form of the foreign  body,  and the
 degree of inflammation and spasmodic contraction  of the sphincter.
   [Abscesses by the side  of the  rectum are occasionally formed by hard substances,
 which  have been  swallowed, making way through its wall.  Brodie (c) mentions
 an instance in which a very large abscess was found; it was opened, and sticking
 across  it was a long fish-bone, which he extracted.  Green tells me another instance
 of a  female, in whom the abscess was so distended with pus, that when punctured
 it flew across the room ; from it part of, the pelvis of a snipe was removed.
  But  still more  serious  consequences  than abscess occasionally happen when a
 foreign body remains fixed in the rectum;  it may cause complete closure of this gut,
as in a case which occurred to Coulson.   The woman, previously in good health,
was thirty-four years of age, and between the fourth and fifth month of her pregnancy,
when she was attacked with sickness, constipation, pain, and distension of the belly.
These symptoms increased in severity, faecal matter was rejected from the stomach,
the belly became more distended, and  no relief from the bowels could be obtained,
injections which were attempted  to be thrown up the rectum, being immediately ex-
pelled.  She gradually sunk, and on the  ninth day from the  commencement of the
attack,  died.  On examination, the colon was found exceedingly distended, especially
its descending part, and between three and four inches from the anus, a foreign body,
believed to he a small portion of fish-bone, found adherent to  the lining membrane
of the rectum, and in this situation pressed on by the  gravid womb.  Immediately
below the bone, the gut was completely closed to the extent of three inches.  The
preparation is in the College Museum.]
   1752. When  the position  of the body in the  rectum  has  been  ascer-
tained by the introduction of the left forefinger  oiled, a pair of polypus
or stone-forceps are to be  introduced upon it, the foreign  body seized
and  withdrawn.   The removal may be always facilitated by injecting oil
  (a)  London Med. Gaz., vol. xxx. p. 605.      (c) London Med. Gaz., vol vii d 27 183G
  (6) Ibid., vol. xvii. p. 27.   1836.                                    ' P* '*'•louu 
FOREIGN BODIES IN THE LARYNX AND  WINDPIPE.     109
into the gut.   In violent inflammation, blood-letting  should be resorted
to, and in spasmodic contraction of the sphincter, suppositories, with the
addition of extract of belladonna or hyoscyamus.  In a case in  which the
size of the foreign body was very great, a pair of forceps with a  moveable
lock were employed, so that each blade could be  separately introduced
(a).  In  case of a very frangible body, as glass and the like, in which
danger was dreaded  from its pieces, the hand of a child was  employed
for its removal {b).  The use of the various anal specula  can render easy
the grasping foreign bodies ; but the force accompanying the use of these
instruments,  renders them  dangerous, if there be  much  inflammation.
In these cases it is better to  cut through the sphincter ani, and thereby
relieve the obstruction which prevents the removal  of the foreign body.
(Delpech.)
  Marchettis (c), in a case in which a swine's  tail, with the thick end upwards,
had been introduced  into the rectum, used a hollow tube, which protected thjp inner
membrane of the rectum from injury.
   [Custance (d) mentions the case of a man who fell on an inverted blacking pot,
and had the whole of it forced up the rectum.  Attempts were made for an hour and
a half to dilate  the  sphincter, and remove it with forceps, but in vain.   The small
end of an iron pestle was then introduced, till it touched the bottom, and  being held
there firmly, was struck with a flat iron.   At the second blow, the pot was broken
into several pieces, which were removed piece by piece with the forceps, or with
the fingers.  Next morning he laboured under severe  intestinal inflammation, with
incessant vomiting and excruciating pain over the whole belly; and he died at night.
The pot was two inches and three eighths at the brim, an inch and a half at its base,
and two and an eighth in depth.
  Lawrence, had a case in which a man had broken the neck of a wine-bottle into
his rectum; he gradually dilated  the sphincter, introduced  his whole hand, and re-
moved it.}
    VI.—OF FOREIGN BODIES IN THE LARYNX AND WINDPIPE.

  Hevin, Precis d'Observations sur les Corps etrangers arretes dans l'GHsophage,.
et dans la Trachee-artere, etc.; in Mem. de l'Acad. de Chir., vol. i. p. 565.
  Louis, Memoires sur la Bronchotomie—Second Memoire  sur  la Bronchotomie,
ou l'on traite de Corps etrangers dans la Trachee-artere; in Mem.  de  l'Acad. de
Chir., vol. iv. p. 455.
  De la Martiniere, Observations sur un Corps etranger qui percoit la Trachee-
artere;  in Mem. de l'Acad, de Chir., vol. v. p. 521.
  Lescure, Sur une portion  d'Amande de noyau d'abricot, dans la Trachee-artere ;
in same, p. 524.
  Suite d'Observations sur  les Corps  etrangers dans la Trachee-artere;  in  same,
p. 527.
  Porter, Will. Henry, Observations on  the Surgical  Pathology of the Larynx
and Trachea, &c.  Dublin,  1826.  8vo.
  Stokes, William. M.D.   A Treatise on the Diagnosis and Treatment of Diseases
of the Chest,   Dublin, 1827.  8vo.
  Wendt, Historia Tracheotomiae.   Vratislav., 1774.
  Ficker, De Tracheotomia. et Laryngotomii.  Erfurt, 1792.
  Desault, C3uvres Chirurgicales, par Bichat, vol. ii. p. 255.
  Klein;  in  Chirurgisch.  Bemerkung.  Stuttg., 1801; in von Siebold's Chiron.,
vol. ii.  p. 649; in von Graefe und von Walther's Journal,  vol. i. p. 411; vol. vi.
p. 225.
  (a) Messerschmidt ;  in Waltber, above   (c) In Morand.
cited.                                   (d) London Medical Gazette, vol. iv. p. 18.
  (6) Nolet ; in Morand, above cited.      1823.
                                   10* 
110                       FOREIGN BODIES
  Michaelis ; in Hufeland's Journal, vol. ix. pt. n.; vol. xi. pt. ill.
  Pelletan, Memoire sur la Bronchotomie; in Clin. Chir., vol. 1. p. l.
  Lawrence, Will, On some Affections of the Larynx, which require the operation
of Bronchotomie; in Med.-Chir. Trans., vol. vi., p. 221.
   [Case  of a shot in the Trachea by Hopkins, in Potter's Medical Ly-
ceum.— G. W. N.]
   1753.  Foreign bodies usually get into the windpipe, when during the
act of swallowing, the epiglottis is raised by speaking, laughing, and the
like, or when they are thrown into the mouth.  The symptoms produced
depend on the obstructed passage of the air, and the irritation of the lining
membrane of the windpipe.   Immediately there occurs a severe  con-
vulsive cough, with danger  of choking, with a whistling and rustling in
the throat, which sometimes relaxes for a space;  the patient points to the
seat of pain with his  finger, has more or less painful effort in swallowing
and imbreathing; his voice is altered and becomes hoarse, or is com-
pletely lost; by the obstructed return of the blood from his head, the face
at last becomes puffy and  bluish, the eyes start out, the veins of the neck
are swollen, and above the collar-bones there appears an emphysematous
swelling.   These symptoms sometimes continue  with the same  violence,
sometimes cease, but recur at  irregular periods;  occasionally only some
of them diminish, considerable pain, oppression., and difficulty of breathing
remain.   The consequences specially to be feared from foreign bodies in
the windpipe  are, suffocation, if the entianee of the  air be  completely
prevented;  emphysema  of the lungs if the position of the body prevent
the escape of the air; inflammation of the windpipe  and  lungs with their
outlets, and apoplexy from the collection of blood in the brain.
  [Porter (a)  well  observes:—"This accident never happens at  the time it is
generally considered as most likely to occur, namely,  in the act of swallowing.
When a person is engaged in the performance of this function the root of  the tongue
is depressed, whilst the  larynx is elevated: the epiglottis is thus mechanically thrown
as a bridge across the larynx, and so effectually closes it that the smallest morsel, or
even a drop of water, can find  no admission.  * * * But it is different when a man
attempts to draw a full inspiration  whilst any foreign body is within reach of the
current of air about to pass into the lungs.  At this time the epiglottis is raised, the
rima glottidis is  distended, and every thing appears to favour the entrance of the air,
and, of course, of whatever it bears along with it.  Thus, a person holding a sup of
wine in his mouth to enjoy the flavour, incautiously attempts to breathe, a drop of
the fluid enters the larynx, it produces great irritation and the spasmodic cough, that
ensues throws it out with great violence, perhaps even through the nostrils." (pp.
184,  185.)
  One of the most remarkable instances of a foreign body getting into the windpipe
without passing through the rima glottidis is mentioned  by De  la Martiniere (b).
A child, nine or ten years of age, amusing himself with cracking a small  whip, was
suddenly seized  with extreme difficulty of breathing, and  soon exhibited all the
symptoms  of approaching suffocation.   He complained, by gesture, of some impedi-
ment in the trachea.  The  surgeons who saw  him, aware that he had never been
left alone, and that he could not have put any thing into his mouth, did not suspect
the existence of a foreign body impeding respiration."  He was bled, the throat ex-
amined, and an.oesophageal bougie passed, without making any discovery.  The
symptoms  became  more urgent, and De  la Martiniere saw him  an hour  after.
"On examining the neck externally, I found," says he, " a small red spot on its fore
part, like  the middle of a  flea-bite, immediately below the ericoid  cartilage, and
beneath it was felt deeply a little circumscribed ganglion as large as a lentil, corres-
ponding to the red spot,  and of unnatural brightness;  the sensation could not have
(a) Above cited.           (b) Mem. do l'Acad., above cited. 
IN THE  LARYNX AND WINDPIPE.               Ill
been more distinct through the thickness of the parts.  I at once  determined to cut
through the  skin and fat upon this spot.  The  finger having been introduced into
the wound, and touehing the tubercle, which was close to the windpipe, I deepened
it with a second stroke of the knife, and laid bare the cartilaginous rings of that tube.
I felt with my nail an irregularity, projecting at least a line above its convexity, and
endeavoured in vain to seize it with the dressing  forceps.  Luckily I had  with me
a pair of hair-nippers, and with these caught hold of the  body, which I drew out,
and, to my great surprise,  found it to be a large copper pin without a head, about an
inch and a quarter long, which had pierced through the windpipe from left to right."
The child got well in a few days.]
   1754.  The difference of the symptoms depends on the particular seat,
form, and condition of the foreign body.   If situated in the rima glottidis,
and completely closing it, the patient is suffocated, if not  quickly re-
lieved, or the foreign body do not change its place by the violent inspi-
ration and expiration,  which, however, is rarely the case, on account of
the spasmodic contraction of the rima.   If the  rima be not  completely
closed  by the foreign body, violent convulsive cough comes on, and the
patient points to the seat of the  body with  his  finger.  A foreign body,
if not of large size, may remain lying in either of the laryngeal ventricles.
Its symptoms are at first less severe, but the continued  residence of the
foreign body will, in the end, be fatal (1).   If it be loose in the windpipe,
it moves up and down  with every inspiration and expiration; symptoms
come on at intervals; the pain is severe; changes its place ; the cough is
frequent and convulsive, so that, in very rare cases, the  foreign body is
coughed out; danger of suffocation occurs if it  b*e forced up against the
rima glottidis.    Foreign  bodies  rarely  drop into either bronchus (2).
Pointed rough bodies cause violent symptoms;  the mucous  membrane
of the  windpipe  inflames,  swells, and the  passage narrows  where the
foreign body is  fixed.   The same happens with those bodies which  swell
with moisture.  In rare cases the foreign body, after remaining a long
while in the air passages, and producing symptoms of phthisis, is thrown
out, and the case terminates satisfactorily (3).
  [(1) A foreign body, to  be lodged in the ventricles  of the larynx, must be  ex-
tremely small; and I apprehend suchas are generally described as so situated are not
so, but only in the body of the larynx, of  which there are two  examples in  the
Museum of St. Thomas's Hospital.   In one a piece of mussel-shell lies lengthways
in the left side of the larynx, with its upper end jammed into the base  of the epi-
glottis.   I cannot get more  information of it than that the child lived a fortnight after
the accident.  The  other, a case related by  Bullock (a), was a girl of  six years,
who swallowed a pebble.  " She was seized with a most violent convulsive cough,
so that she became black in the face and was nearly suffocated; the paroxysm con-
tinued for half an hour and then subsided.   The throat was examined, and  an
oesophageal probang introduced, but without, however, discovering any  extraneous
body.  The three or four following days the child merely complained of a sense of
soreness  in the throat  with  nausea, which  was accompanied by occasional  slight
paroxysms of cough with a copious mucous expectoration; she was also hoarse, but
had no pain or difficulty in deglutition.  Aperients and an emetic were prescribed;
she was not benefited, and, as. she still persisted that the stone remained in the throat,
was again, on the fifth day, very carefully examined, yet there did not appear to  be
any evidence  of its existence either in the oesophagus or trachea."  As she had not
had hooping cough  and was constantly playing with children who were labourino-
under that disease, it appeared to warrant the  conclusion that no  foreign body had
passed either into the oesophagus or trachea, and that the cough was among the first
symptoms of a severe form of pertussis.  At the end of the fifth day she had marked
(a) London^Medical Gazette, vol. xviii. 1836. 
112
FOREIGN BODIES
symptoms of inflammation of the mucous membrane of the bronchi, namely, cough,
generally occurring in paroxysms six or seven times a day, attended with a kind of
whooping inspiration and a copious expectoration of tenacious mucus; the hoarseness
was likewise increased, while over the trachea and upper part of the chest there was
a loud mucous rattle, which was  in  part sonorous."  Leeches  and calomel, and
antimony were used for some days, and in a month from  her first attack she was
stated to be "quite well,"  having regained  her flesh and  healthy appearance.   A
fortnight after this, however, " she was attacked with symptoms of pneumonia," and
she died in twelve days, "eight weeks from the supposed accident; but from the
time she was reported quite  well to the day of her death there was no return of the
convulsive  cough nor any uneasiness about the throat.  On the day of  her death,
however, she again said she could  still feel the stone, and in the same  place as  at
first.  Examination.—On laying open the larynx and trachea a quartz  pebble was
exposed, lying partly in the  cricoid cartilage and partly in the trachea, of the size  of
a horse bean, of irregular figure and smooth surface ;  it was retained in its situation
by a layer of apparently organized lymph of very considerable thickness.   On re-
moving the stone the mucous membrane was in a state of ulceration  (and the front
of the thyroid and cricoid cartilages bare.—j. f. s.)   The calibre of the  tube was so
nearly obstructed by the presence of the  stone and lymph as to render it difficult  to
pass an ordinary-sized  probe downwards.  The whole of the mucous membrane  of
the trachea was thickened and  its vessels congested.  About a pint of  turbid fluid
was in the right pleura, containing flakes of adventitious membrane, with which the
pleura pulmonalis of that side was also  covered.   Nearly the whole right and the
lower part of the left lung were in  the several degrees of hepatization and purulent
infiltration,   (p. 952.)
  (2) When the weight of the foreign body has carried it low down into one of the
bronchi, most commonly the right  on  account of its  larger size, as first noticed by
Key, it may block up the passage  so  completely that no  air, or but little, can pass
into the lung below it, and consequently it remains fixed by its own gravity, causing
pain in the chest opposite the part  where  it is  lodged, which is increased  on deep
inspiration, and is accompanied with " a catching."  Violent cough and a disposition
to vomit, or actual vomiting, occur immediately after the  accident, but after a time
subside, and an occasional dry cough comes on at irregular periods, and in the inter-
vals the patient may be tolerably well and able to follow his ordinary occupation, or
the symptoms may become more urgent, may be accompanied with repeated attacks
of haemoptysis and terminate  in phthisis, even although the foreign  body have been
retained weeks or months.   Some  remarkable cases of this kind will be presently
referred to.
  (3) The time which a foreign body, after the first severe symptoms have passed
by, may remain lodged in the air passages varies very considerably.  The  longest
period of which I am aware  is that of the female mentioned by Sue (a), who when
in her ninth year, had the rump-bone  of a pigeon slip into her windpipe; she be-
came subject to attacks of haemoptysis and other symptoms of pulmonary disease,
but without wasting, till her twenty-fourth year, when she began to decline rapidly.
Two years after she threw up  the  bone in a violent fit of coughing; but she died
eighteen months after with profuse pumlent expectoration.  Dupuytren (b) gives
an account of a man who lived ten years, after a small coin had got into his air-tube,
and  on  examination it was  found  imbedded  in a tubercular  cavity in the lung.
Louis (c) also relates another  case, in which after swallowing  a  louis-d'or, a man
lived six years and a-half, and then died with  his  right lung'completely destroyed
by suppuration.   My friend  Sutton, of Greenwich has mentioned to me a case of
haemoptysis, which he attended many  years since.  The  man had  frequent attacks
for  more than a twelvemonth, from each  of which, however, he rapidly recovered.
Upon the last occasion, he was summoned suddenly to see the man who was said
to be in a dying state.  On his arrival he found the patient had had a  very  severe
attack of dyspnoea,  and  threatening suffocation, from which, however, he had been
immediately relieved on rejecting from his windpipe a common lathe nail, much cor-
roded.  The man was a plasterer by trade, and  now remembered that  some time
before first requiring Sutton's assistance, he had  swallowed a nail whilst lathing
  (a) Mem. de l'Acad. de Chirurgie, vol. v.    (c) Mem. de  l'Acad. de Chir, vol. v.  p.
533.                                   529.
  (6) Lecons Orales, vol. iii. p. 584. 
IN THE LARYNX AND WINDPIPE.
113
 a ceiling, but had thought no more about it till it was thrown up.  He died  some
 years after of diseased lungs.  Dr. Paris (a) relates the case of a girl twelve  years
 old, who " having put a small cowrie shell in her mouth, was seized with a violent
 choking fit, in consequence of its having been supposed to have gone the wrong way
 in the  act of swallowing it.  The  spasmodic paroxysm  was described as  most
 alarming, and continued for several seconds, which induced her father to  thrust his
 finger with considerable force down her throat, which afforded immediate  relief, and
 therefore convinced him that he had thrust the foreign body into the oesophagus, and
 that it had passed into the stomach.  *  *   *  In the course of four or five days a
 slight cough came on, but it was  not  characterized by any symptom which would
 lead to the suspicion of it having been provoked by the presence of any foreign body
 in the air passages, and this opinion was confirmed by its  speedily yielding to the
 ordinary treatment."   Between three weeks and a month after she had " a return of
 the cough much more violent than usual, and accompanied with slight haemoptysis.
 This, however, again subsided, and she remained for many months in perfect health;
 her breathing was never disturbed, she indulged in her usual active habits and  daily
 exercise, and declared that she was  perfectly  well.   *   *   *  About twelve
 months after, she had danced at a ball during the whole evening, and at its conclu-
 sion, in  the  act of moving briskly, she was  suddenly attacked by a violent  spas-
 modic cough, which threatened suffocation, when by a sudden and convulsive  expi-
 ration, a substance was ejected from her mouth with such force as to be carried to a
 considerable distance.  This proved to be the remnant of the shell, the animal prin-
 ciple of which had disappeared, and its earthy matter alone remained." (pp. 116,17.)
 In the younger Traver's case  (b), a girl of six years, who was suddenly thrown
 back whilst eating cherries, " was immediately seized with a violent fit of choking
 and every symptom of impending suffocation.  This condition  lasted an  hour, and
 then she fell asleep."  On the next day she had some spasmodic pain in  the chest,
 and on the following  " morning the breathing was very difficult, and other symp-
 toms of inflammation present,-" which were relieved by blood-letting, a calomel and
 jalap purge, and calomel  and opium.   On the afternoon of the fourth day  " she had
 a violent convulsive seizure, with cough, small quick pulse, a livid surface, suffused
 eye, and every sign  of threatened suffocation.   It was stated  in evidence of the
 violence of the spasm, that the stools and urine 'flew' from the child during these
 attacks." She grasped and pulled her throat in a peculiar manner, " crying  in  a
 half whisper 'take  it out! take  it away!'   The spasm subsided after  two hours'
 continuance," and a few hours after  she was so tranquil as to lead to the belief
 |'that no stone could  have passed into the trachea,"   In the middle of the follow-
 ing day the fit recurred with "violent jactitation and abundant flow of frothy mucua
 from the mouth.  When it had subsided, the probang was introduced, and the child
 swallowed with  greater facility."  On the seventh day there  came on  a similar
 attack; on the thirteenth and  from that time daily, till the nineteenth day, when
 Travers saw her, and she had then "frequent paroxysms of croupy cough, attended
 by great restlessness and the peculiar grasping of the throat."   Under these cir-
 cumstances, he performed  tracheotomy;  but the  stone was not  thrown  out; the
 breathing, however, became tranquil, and the cough also ceased.  It returned, how-
 ever, on the twenty-sixth day, but less severely.  Ahout six weeks after, the wound,
 which had been tented healed, and soon after  " the child coughed incessantly, had
 night sweats, with loss of strength and appetite."  In this condition she continued
 till the ninety-sixth day after the accident, when she threw out " the stone, together
 with a table-spoonful of pus, during a violent paroxysm of cough; having expecto-
 rated pus in small quantities for many days previous.  From this time the cough
 never returned and the general health was soon re-established."  (p.  108-12.)
   1755.  As foreign bodies  in the oesophagus produce  the same symp-
toms as those in the windpipe, it  is always necessary, by examination of
the throat,  by the introduction  of a sound, with a piece of sponge upon
its end to be sure of the oesophagus (1).
   Foreign bodies are  only in very rare instances, thrown out by violent
coughing: on this account a severe emetic  or artificially  excited sneezing
increase the  danger (2).
          la)  Med.-Chir. Trans., vol. xxiii. 1840.               (b) Ibid. 
114
FOREIGN BODIES
   The only remedy for the certain removal of the foreign body is opening
the windpipe, (Bronchotomia,  Tracheotomia,) or opening the larynx, Laryn-
gotomia.)   This operation must be undertaken  as quickly as possible,
because if  put off,  such symptoms as violent inflammation  of the lungs
and windpipe, emphysema of the  lungs and the like  arise, which  even
after the removal of the body may cause death.   The operation is in all
cases required, where  suffocation presses,  or an asphictic condition has
set in ; further, if dangerous symptoms occur from time to time, and the
foreign body be observed rolling  up and down in the windpipe; or if
fixed pain point out  its  seat.   But if the patient be free from all these
symptoms, and the seat of the  foreign  body cannot  be discovered,  we
must wait till there are symptoms of change  in its  situation, and a possi-
bility of its removal.
   [(1) In reference to this  subject Stokes (a)  mentions one instance in which a
piece of money lodging in the oesophagus produced croupy breathing and laryngeal
symptoms.  And in  his Lectures he used to speak of  another case in  which such
symptoms were produced by a foreign  body (a plum-stone) in the oesophagus, that
his first impulse was  to perform  tracheotomy with  his  penknife.   An  oesophageal
bougie was,  however, introduced, and the substance  having  been  pushed into  the
stomach, the symptoms ceased, and  a  day or two after  the plum-stone, with which
the child had been known to be  playing previous to the accident, was voided by
stool (b).
   (2) Occasionally it may happen that although violent fits of coughing having
failed to expel  the foreign body from the windpipe, yet by some accidental change
in the patient's  position,  the foreign body is removed from its lodging place, and is
then thrown up with little effort.   Such seerns to me the explanation of Cock's
case (c) of a sixpence slipping down the throat, and at  first lodging in the larynx;
"violent coughing, with  the most distressing sense of suffocation, immediately took
place, and during the  paroxysm he threw up a quantity of blood.  On his admission
he was still  struggling for breath, coughing incessantly,  and suffering great pain
and irritation, which  he  referred  to the larynx, where the coin appeared to have
lodged."  Shortly after  "the sixpence  had left the larynx, and descended into the
trachea ,•  its change of position being immediately followed by an abatement of the
previous urgent symptoms.   He still coughed almost incessantly, stated that he
could feel the sixpence moving up and down the windpipe, and complained of pain
and soreness in the chest in  the seat of the right bronchus, and also just below the
larynx."  Towards the  end of the same  evening  the  symptoms subsided, and he
went to sleep.   On the following day he was in much the  same state, and "as long
as he remained calm and quiet, he complained of nothing but a feeling of general sore-
ness along the larynx and windpipe."   The same evening the sixpence was thrown
out without surgical aid.  "I was asleep," said the patient,  "and dreamed I was
drinking a pot of porter,  and the  attempt to swallow it  made me cough.  I awoke,
and found the sixpence in my mouth."  Cock  observes:—"It is  perhaps worthy
of remark, and not destitue of practical interest, that the  foreign body, which had
retained its position during the most violent expiratory efforts, should at length be
ejected, at a period when the muscles of the glottis were  probably in a state of
quietude, and  being taken unawares, allowed its expulsion, under a gentle act of
coughing."  (pp. 554, 55.)]
   1756. Opening  the larynx or  windpipe is also  required  to assist the
entrance of the air  into the lungs, when it is obstructed under any other
circumstances, and  suffocation  is  dreaded; in great swelling or other
degeneration  of the structures about the  throat; in diseased  changes of
the epiglottis; in great swelling of the  tongue, if the danger cannot be
relieved by bleeding, scarification, and the like;  in fracture of the thyroid
   (a) Above  cited, p. 265.                  (c) Medical Gazette, vol. i. New Series,
   (6) Wells ; in Diet,  of Prac. Surgery, vol.  1845.
i. p. 516. 
IN THE LARYNX AND WINDPIPE.
115
 cartilage, if the dislocated pieces cannot be otherwise brought into place;
 in inflammation of the epiglottis {Angina laryngea);  when foreign bodies
 are in the oesophagus, and cause suffocation ;  in compression of the wind-
 pipe by tumours ;  in  gun-shot  wounds of the throat, which, on account
 of  the  great swelling, are  attended  with  danger and suffocation ; in
 drunken or  suffocated persons; in croup, if  the membrane.be  loose and
 cannot be coughed  up.
   According to Desault (a), in the greater number of these cases in  which it is
 only necessary to assist the entrance of the air, the introduction of an elastic tube
 through the nostril renders the  operation superfluous.   No  other person, however,
 but Desault holds this notion.  Samuel Cooper (b) objects to it in drunkards and
 suffocated persons, and considers opening the windpipe to  inflate the lungs, most
 efficient.  However, the  benefit  of cutting into  the windpipe,  undertaken in this
 spirit, is not supported by precise reasoning.
   In Angina laryngea, which is characterized by difficult breathing, with pressing
 suffocation, very hoarse  and only whispering voice, and frequently accompanied
 with pain in the oesophagus and difficulty in swallowing, without apparent swelling
 and redness  of the throat, the operation must riot be long delayed, if relief be not
 soon afforded by general and local blood-letting, blisterings, and the like (c).  In
 Angina membranacea, laryngotomy and tracheotomy are  generally useless, because
 the mass blocking up the air-tube, is not. merely in  the larynx, but extends through
 the whole windpipe and even into the bronchi (d).   In  more modern times, how-
 ever, many cases have been published in which this operation has been  successful.
   Nevermann (e) has collected all the cases  of laryngitis and trachaeilis, in which
 tracheotomy has been performed ; and the result is that out of one hundred and forty
 cases, twenty-eight have been cured, and one  hundred and twelve died.
   Bretonneau (/) considers that tracheotomy can only terminate favourably, if the
 opening be made moderately large between the thyroid gland and breast-bone, and
 the free> entrance and escape of the air maintained by a sufficiently large and wide
 canula.   At  the same time he introduces calomel dry, or  moistened with  water,
 through the wound into the windpipe.  In one case he succeeded:
   Trousseau (g)  also  recommends the introduction  of  a thick catheter,  and
 scraping out the windpipe with a probang, and  dropping in a  watery  solution of
 nitrate  of silver, four grains to a drachm of water.   Gerdy (h) also advises the in-
 troduction of a weak solution of lunar caustic.
   [Kirbv (i) is decidedly opposed to  bronchotomy for croup;  he says:—I have
 performed the operation myself on the child, and  have seen it frequently done by
 others,  and in no one case has the life of the patient been saved."  (p. 63.)]
   1757. The  proceedings vary in laryngotomy and tracheotomy, in refer-
 ence to the special object desired, according as the entrance of the air is
 to be assisted, or a foreign  body removed.
   1758. In  laryngotomy, after placing the  patient's  head in  such a
 position as that his uneasiness shall be at least, and the front of the neck
 free and accessible,  the skin is to be moderately stretched on both sides
   (a) Above cited.                        Journal, vol. xxix. p. 75,1828.—Beco.uer.el;
   (6) Diet, of Pract. Surgery, p. 1262.        Bulletin dp Therapeutie, 1842, Jan., Feb.
   (c) Farre; in Med.-Chir. Trans., vol. iii.    (/) Des Inflammations speciales du Tis-
 p. 84.—Percival, E.; Ibid., vol. iv. p. 29.—  sumuqueuxet en paTticulier de la Diptherite,
 Wilson,  Thomas; Ibid., vol. v.  p. J56.—  ou inflammation pelliculaire, connue sur le
 Arnold; Ibid., vol. ix. p. 31.—Hall, Mar-  nom de Croup, d'Angine maligne, d'Angine
 shall ; Ibid., vol. x. p. 166.—Porter; Ibid.,  gangreneuse, p. 217—395.  Paris, 1826.
 vol. xi. p. 114.—Wedemeyer ; in von Graefe  8vo.
 und von Walther's Journal, vol. ix. p. 107.    (g) Journal  des Connaissances  Med.-
   (d) Sachse, vol. ii. p. 277; the best'writer  Chirurg., 1834, June.
 on Croup.                                (h) Archives generates de Medecine, vol.
  (e) Berliner  Med.  Centralzeitung, 1836,  v. p. 577,  1834.—Stilling; in Berlin Med.
 July.—Also, Cullkn, V., On the Causes of Centralzeitung, 1835, May 9.
 the Fatal Termination of certain cases of   (i) Observations, cited at the head of arti-
Bronchotomy; in Edinb. Med.  and Surg.  cle. 
116
LARYNGOTOMY.
 with the fingers of  the left hand, and the larynx at the same time fixed;
 a cut is then  made lengthways, about an inch in length, the middle of
 which corresponds  to the crico-thyroid ligament.   A second cut divides
 the cellular tissue between the sterno-hyoid  and sterno-thyroid muscles,
 and lays bare the crico-thyroid ligament; the bleeding must be stanched
 with a  sponge  dipped  in cold   water.  The larynx is then  to  be
 fixed with  a finger on  each side, and the forefinger  of the same hand
 placed  on the upper third of the ligament; after which a lancet is thrust
 in,  and  a wound of sufficient extent  made, which  is to be kept open by
 inserting lint between the  angle of the skin and of the muscular wound,
 and the whole covered with gauze, and the patient allowed to bend his
 head towards his chest.
   This method appears preferable to using the tracheotome and introducing a tube
 into the aperture made in the crico-thyroid  ligament, for the tube always excites in-
 convenient, and frequently unbearable irritation, is frequently stopped up, and cannot
 be properly fastened.   The cases in which cutting  into the  windpipe is performed
 are urgent, and the tracheotome cannot be  sufficiently commanded.  If the opening
 into the cricoid-thyroid ligament be sufficient, the cut must be lengthened through
 the cricoid cartilage.   For  the purpose of effecting expectoration, if much tough
 mucus collect, the wound must occasionally he held with the fingers, and the patient
 allowed to cough.  If a canula be used, it should always be sufficiently large.
   For the purpose of avoiding an often not inconsiderable arterial branch upon the
 crico-thyroid  membrane, we-must feel with  the finger if the membrane be quite bare,
 and  when it is exposed, we must endeavour to avoid it, for which purpose the mem-
 brane is to be divided transversely at the upper edge'of the cricoid cartilage.
   [Some persons are in the habit of introducing a tube into the larynx after having
 opened it. This as a general rule is quite unnecessary, as if there be any fear of the
 wound closing before the air can recover its usual course through the rima glottidis,
 it is better to cut out a  piece of either the laryngeal or tracheal  cartilage, as may be,
 according to Lawrence's recommendation.   And it  is also improper, as a fistulous
 opening will  be formed, which on the subsequent removal of the canula, may con-
 tract so as to require a second operation,  and  often cannot be done without.  If,
 however,  such practice be adopted,  it will be necessary that the instrument should
 be taken out from time to time to ascertain that it has not been  corroded; for if not,
 it may break, and the part within drop down the windpipe, whilst that without falls
 from the wound, without notice.  A  case of this kind  was admitted into St. Thomas's
 Hospital  in December, 1844;  a tube had been introduced about two and a  half
 years previously, and on the morning of his admission whilst walking along the
 street, it  slipped out broken.   No symptoms of ^consequence, however, appeared till
 towards evening, when the breathing became difficult, and attended with a whistling
 noise; the veins of his  head and face distended, and the surface covered with cold
 perspiration.   My colleague and assistant, the younger Travers, therefore, thought
 it necessary to pare the edges of the opening, and dilate it upwards and downwards,
 upon a director.  Some blood running into  the windpipe caused violent expirations,
 and in one of them two fragments, which formed the remainder of the canula, were
 expelled, surrounded with a clot of blood, and the relief was immediate.  Another
 canula was introduced.  The patient did well; and the broken corroded instrument,
 is in St. Thomas's Museum.
  Occasionally it happens that after a severe cut throat, the aperture remains, from
 some cause or other, fistulous; and  as the scar  contracts, the passage for the air is
 so narrowed as to cause great difficulty of breathing, and require surgical aid.  Ihad
 a case of this  kind some years ago, in a Hindoo woman, who, in her voyage to  this
country, had  attempted suicide, and nearly cut through the larynx, between the
 thyroid and cricoid cartilage.  She had  been  very  refractory, and the skin  had
 turned over the lower edge of the wound,  and become connected with the back of
the organ, so as materially to diminish the  passage,  and cause  her breathing to be
very  laborious, and with a loud hiss.  As from the account given, these symptoms
were daily becoming worse, I cut through the front of the cricoid cartilage vertically, 
TRACHEOTOMY.                        117
and inserted a short but pretty wide tube, through which she breathed freely and
did well, leaving the house some time after to return home.—j. f. s.]
   1759.  If laryngotomy be undertaken for the removal of a foreign body,
the crico-thyroid ligament is, after the bleeding has been stanched, to be
cut through its whole length, from  the  thyroid  to the cricoid cartilage;
and if this be insufficient to allow the  foreign body to  be removed  or
withdrawn through it, a director somewhat curved is  to be introduced,
by means of which a button-ended bistoury is passed in, and the thyroid
cartilage sufficiently divided upwards in its centre, or the cricoid cartilage,
and the upper part of the air-tube so far cleft as the removal of the foreign
body may seem to acquire.
   1760.  After the opening is made, if the edges of the wound be gently
drawn apart  with  blunt hooks by the assistants, the foreign body usually
appears and  is thrown out  by coughing; but if this  do not happen,  its
position  must be  sought with  due  care, and it must be  removed  with
straight or curved forceps.   The treatment, after removal of the foreign
body, must be precisely similar to that already laid down for longitudinal
wounds of the windpipe, {par. 467.)
   1761.  In tracheotomy, where the  entrance  of the air merely is to  be
assisted, a cut should be made through  the skin and muscle on the mesial
line of the windpipe, beginning below the cricoid cartilage and continued
down to the  edge of the breast-bone.   The edges of the wound are to  be
held asunder with blunt hooks, the blood sopped up with a moist  sponge,
the cellular tissue and vascular net upon the third and fourth cartilaginous
rings divided, and thus the windpipe laid bare.   Bleeding is stanched  by
cold water, or, where possible, by tying the vessels; the lobes of the thy-
roid gland, which are a little in the way, are to be turned aside,  andtwTo
or three rings of the windpipe divided vertically.   The further treatment
is the same as after opening the larynx.
   The same reasons against the use  of the tracheotome  and the  introduction of a
tube, which have been already given, (par. 1758) also apply here. Lawrence (a)
advises, if after opening the windpipe, the introduction of the tube cannot be effected,
to cut off half  an inch through the cartilage, and to remove a small slip  from the
edges of the wound, so that the opening may continue to gape.
   1762.  If tracheotomy be performed for the removal of a foreign body,
the air-tube must  be exposed and cut into  in the way just described, only
the size of the cut must be proportioned to that of the body to be removed.
The removal itself must be managed as  in laryngotomy.
   [When the foreign body is lodged in the bronchus its removal should be first  at-
tempted by reversing the patient's natural position, and placing  him upright, or
nearly so', with his head downwards, and then striking his back or  shaking  the body
smartly, by which it may be hoped the foreign substance will move from  its situa-
tion, and, dropping  through the windpipe, be  ejected at the rima glottidis.  Of the
two very interesting cases in which this practice  was successfully adopted,  Brodie's
patient (b) had first attempted it on the sixteenth day after the accident, by "placing
himself in  the  prone position, with his sternum resting on a chair,  and his head and
neck inclined downwards, and, havirfg done so,  he immediately had a distinct per-
ception of a loose body slipping  forward along  the trachea.   A violent convulsive
cough ensued.  On resuming the erect posture he again had the sensation of a loose
body moving in the trachea, "but in an opposite direction, that is, towards the chest."
The experiment was repeated six days after,  more completely; "he was placed, in
the prone position, on a platform, made to be  moveable on a hinge in the centre,  so

          (a) Above cited, p. 249.                    (b) Above cited,
   Vol. iii.—11 
118
TKACHEOTOMY.
that on one end of it being elevated, the other was equally depressed.  The shoulders
and body having been fixed by means of a broad strap, the head was lowered until
the platform was brought to an angle of about 80 degrees with the horizon.  At first
no cough ensued;  but on the back, opposite the right bronchus, having been struck
with the hand, the patient began to cough  violently; the  half-sovereign, however,
did not make its appearance.  This process was twice  repeated  with no better re-
sult;  and on the last occasion the  cough was so distressing, and the appearance of
choking  was so alarming, it became evident it would be imprudent to proceed further
with this experiment  unless some precaution  were  used  to  render it more safe."
Tracheotomy was therefore determined on two  days after, and "in proposing this,"
says Brodie, " we had a twofold object; the one, that if the coin were-lodged in any
part from which it might be safely extracted  by the forceps, this method might be
had recourse to; and the other, that, if relief could not be obtained in this*manner,
the artificial opening might arfswer the purpose of a safety valve, and enable us to
repeat the experiment of inverting]the body on the moveable platform without the risk
of causing suffocation."   The operation " being completed, some attempts were made
to reach  the coin With the forceps  introduced through the opening.  The contact of
the instrument with the internal surface of the trachea, however, induced on every
occasion the most violent convulsive coughing.  The coin  was not seized, nor even
felt."  The attempt was therefore given up for the time, and repeated five days  after
with no better success.   He was left quiet for ten days to recover from  the exhaus-
tion he suffered, and the probe was passed  occasionally into the wound to keep it
open.  At the end of this period, on the thirtieth day after the accident, " the patient
having been placed on the platform, and brought into the same position as formerly,
the back was struck with the hand; two or three efforts to  cough followed, and pre-
sently he felt the  coin  quit the bronchus,  striking almost  immediately afterwards
against the incisor teeth of the upper jaw, and  then dropping out of the .mouth. A
small quantity of blood, drawn into the trachea from the granulations of the external
wound, being ejected  at the same time.   No spasm took place in the muscles of the
glottis, nor was there any of that inconvenience and  distress  which had caused no
small degree of  alarm on the  former occasion,  (p. 288-91.)  The case did well.
Macrae  (a) did not make any opening into the air-tube of his  patient, but, on the
third day after the  mishap, had him " strapped  securely to  a common chair, that he
might be easily suspended from the rafters  of the roof, with his  head downwards,
in order that his chest might be conveniently shaken bya rapid succession of sudden
smart jerks, and that the weight of the bullet.might favour its  escape from its seat
in the lungs.  He was kept depending as long as he could endure such an uncom-
fortable position, and  then placed in the horizontal posture for a few minutes to rest.
When sufficiently recruited he was hung up  again.   Upon being taken down the
first time he described the pain in his breast as having moved nearer to the top of
his chest; and during the third suspension he joyfully exclaimed, " thanig a! thanig
a,!" ("it has Come! it  has  come!" in  the Gaelic  language,) immediately after a
smart shaking and a few convulsive retching coughs, and spat the little  bullet from
his mouth.  The diameter of it is three eighth  parts  of an  inch, having its surface
ruffled by the chewing it underwent previously to slipping into the windpipe.  He
felt immediate relief from every uneasy feeling, except the dry cough and deep-seated
pain in his breast, which  continued rather  sharp for  two  days, after which, and a
dose of laxative medicine, he found himself restored to his former health, and by
the end of the week pursued his usual avocations on  the hill."  (pp. 421, 422.)
  If this mode of  treatment be insufficient to dislodge  the foreign  body from the
bronchus, it will be  necessary to attempt its removal by opening the  windpipe  and
drawing  it out with forceps.  This operation was first performed, and successfully
by  Liston in 1833 (b), on a female of thirty-eight years, who " got a piece of mutton
bone entangled in the glottis, whilst eating some hashed meat.  By a great effort,
during a fit of threatened suffocation, she succeeded in dislodging it;  but it passed
downwards into the trachea," * *  * and lodged permanently under Ihe right sterno-
clavicular articulation.  An attack  of bronchitis supervened, followed by cough and
expectoration, and the inflammatory attack was  repeated  several times; from one of
these  she had just recovered. * * * The inspiration was somewhat noisy, and there
  (a)  Ltston's Practical Surgery.  Fourth p. 419.—Also Liston's  own notice of it, in
EdA\10^1846*  ■  t    .  ,0000,    ,  •■  his Practical Surgery; from which I  have
  (b) Duncan; ih Lancet, 1833-34, vol. ii. quoted. 
TRACHEOTOMY.
119
was some degree of peculiar sonorous rale perceived on applying the ear to the chest
at the point described as where the foreign body had become fixed.   The operation
was performed ;  one pair of forceps opening laterally were introduced ; a hard sub-
stance could be felt,  but not grasped; the patient was re-assured, and  allowed to
recover the effects of the exploration and attempt  to seize it.  Another  instrument
with the blades differently arranged, was then passed down the tube, at least three
or three and a half inches,  and  the bone immediately seized  and extracted. * *  *
The result of the case was  most satisfactory.  The length of the forceps was seven
inches,   (pp. 415, 16.)  The second operation was performed also  successfully by
Dickin, of Middleton, near Manchester, in 1832 (a), on a boy of eight years, who
having "found a bell button, which he placed in  his mouth, and during the act of
jumping, it passed  backwards into the windpipe.  He instantly fell down, to all
appearance  in a  state of suffocation, and was taken home, a few  yards distant,
making the most violent efforts to respire; after which his breathing became easy,
but with  repeated dispositions  to  cough,  which alarmed him, threatening instant
suffocation. * * * He complained of a sense of constriction across the chest, * *  *
had fits of coughing, which came on at intervals of two or three hours, during which
he was comparatively easy.  The face presented a purplish hue, with great anxiety
depicted."  Three days after, on  examining the chest, its "appearance was most
remarkable. On the right side a loss of symmetry, with evident depression and
altered action in  breathing.  The  stethescope  indicated  no respiratory murmur;
whilst on the left side there was the plump symmetrical beauty of a youthful chest,
with the  common action of that side in respiration. * *  * On the sixth day.the
cough ceased,  and also the fits of suffocation, which evidently indicated a fixed
position of the foreign body."  On the  tenth day it was determined to perform
laryngotomy between the  cricoid  and  thyroid cartilages;  which done, a  pair of
forceps invented for the purpose were introduced, and " acted as a sound, for on their
introduction Dickin detected the presence of a metallic  body.   They were intro-
duced again without the slightest  inconvenience to the patient (at least  apparently
so,) when again the point came in  contact with the button, which was laid hold of,
and removed in their  grasp. * *  * For  seyeral  days a  considerable quantity of
muco-purulent  matter was discharged through the wound, having  accumulated
around the  button in  the bronchus."  (pp. 419, 20.)  In  a fortnight the boy was
well, and returned to school.                          '
  If, after opening the larynx or windpipe, the foreign body be jerked up into the
wound, or shot through it, immediately after the free admission of the air, the wind-
pipe be examined by passing a straight sound through it towards the chest, and no
obstruction  be found  it will be  right to examine the larynx itself, and the rima by
passing a sound upwards into the throat.   The necessity for doing this is seen from
the case related  by Pelletan (b), in which a person suffered  severely from having
a portion  of tendon of veal lodged in his  throat:  it was  so  large that it was pre-
sumed to have  lodged in the oesophagus,• no relief, however, was obtained by the
introduction of instruments, and Pelletan therefore opened the larynx by division
of the thyroid cartilage, and on introducing his  finger,, unawares thrust the tendon
upwards, after  which with the probang it was forced down the  throat, and the
patient recovered.—j. f. s.
   1763. If bronchotomy be considered in reference to the three parts at
which  it may be performed, namely,  on the  thyroid cartilage, on the cri-
co-thyroid ligament, and  in the windpipe, the following circumstances
must be borne in  mind with reference to the  special object of  the ope-
ration.
  In cutting through the thyroid cartilage, it may be  feared, in addition
to the  possibility of it being ossified, and therefore  difficult or incapable
of being cut through, that the  laryngeal ligaments may be wounded, and
that in those cases in which the operation is undertaken, on account of
a swollen  and thickened condition of the inner membrane of the larynx,
the air may not obtain a sufficient entrance  ;  the voice also may remain
(o) Liston j just cited.             (b) Clinique Chirurgicale, vol. i. p. 13. 
120                          RANULA.
for a long while, or even permanently hoarse, if the operation be under-
taken in the larynx. (Pelletan.)
   Tracheotomy, to wit, the cutting  into  the windpipe from the cricoid
cartilage to the upper end of the breast-bone, is always dangerous; the
cut always interferes with the anastomoses of the thyroideal arteries;  if
the arterial plexus of the  thyroid  gland be wounded, it is very difficult
to stanch the bleeding, and the blood flowing into the windpipe causes
violent cough.   In thick-necked persons the operation maybe extreme-
ly difficult, and  even impossible.  In children it is always very diffi-
cult, on account of the thickness of  their neck and the depth of their
windpipe (1).  If there be an arteria thyroidea ima, it will certainly be
wounded.
   Opening the crico-thyroid ligament, and enlarging the wound down-
wards through the cricoid cartilage, and  the first two or three rings of
the windpipe (LaryngOrtracheotomia)  seems  therefore to  be the most
advantageous proceeding, both where it is desired to assist the  entrance
of the  air, and  to remove a foreign  body, because by this method the
arterial plexus and the deep position of the windpipe are best  avoided.
Even if the foreign body be  lower down in the windpipe, it may be
either  brought near the opening, by breathing or coughing, or it may be
with proper care taken out with a blunt curved director or with the for-
ceps.   If it be found fixed in the  larynx, the cut  may even be extended
from the crico-thyroid ligament along the  middle of the thyroid cartilage.
By this mode of proceeding, then, the  object of  the  operation is best
attained in all the conditions of the disease Which have been mentioned
{par.  1756) ■ and a deeper cut into  the windpipe would be  required
only in those cases where the  situation of a foreign body in the oesopha-
gus, or other tumours,   which  compress the  windpipe  may render  it
necessary.
  (1) According to Allan Burns (a), the  position of the thyroid gland should he
determined by the cricoid cartilage,  and in children the space between  this gland
and the upper part of the breast-bone is great, therefore tracheotomy is easier.
   1764. The varieties observed by Allan Burns in  the vessels  of the
neck always renders careful observation necessary during the  course of
the operation.  Be found the  arteria innominata near the under edge of
the thyroid cartilage, and even the carotid itself crossing  the windpipe.
Second Section.—OF UNNATURAL COLLECTIONS OF NATURAL
                          PRODUCTS.

    A.—IN THEIR PROPER CAVITIES AND RECEPTACLES.
                          I.—OF RANULA.
  Louis, Sur les Tumeurs Salivaires; in Mem. de l'Acad. de Chir., vol. iii. p. 462.
  Ibid., Sur les Tumeurs Sublinguals; in same  vol. v. p. 420.
  Murray, De tumoribus salivalibus.  Upsal, 1785.
  Breschet,  Considerations sur la tumeur nominee Ranula ou Grenouillette; in
Journal Univers. des Sc. Medic. 1817, vol. vii. p. 296.
  Reisinger,  Bemerkungen iiber die Froschgeschwulst; in his Baier'schen An-
nalen, vol. i. p. 1618.
(a) Surgical Anatomy of the Head and Neck, p. 415. 
RANULA.
121
  Kell, Beobachtnngen fiber Froschgeschwiilste; in von Graefe und von Wal-
ther's Journal, vol. xxvi. p. 588.
  1765.  Ranula  {Ranula, Lat ;  Froschgeschwiilste, Germ. ;  Grenouil-
lette, Fr.) is a tumour beneath the tongue, sometimes soft and fluctuating,
sometimes hard and firm, at  first attended with little inconvenience, but
in proportion as  it  enlarges,  it interferes  with chewing, and  especially
with speech.  Should the swelling attain a  very considerable size,  it
occupies the greater part of the mouth, thrusts the  tongue upwards and
backwards,  occasionally also the front teeth  outwards, and at  the same
time forms a swelling beneath the jaw.  In this state the symptoms just
described are very marked, the swelling itself becomes painful, and may
inflame and suppurate.    Ranula  is sometimes developed not towards
the mouth, but downwards,  forming beneath the jaw  and on the front
and sides of the neck a very  considerable swelling, which may be easily
mistaken for an  abscess.
   [The elder Cline used to mention in his Lectures that he was one morning
alarmed by the noise of a person  breathing with great difficulty in the next room  to
his consulting room, and on hastening in he found the man stretched on a chair, and
almost suffocated.   On being inquired of as to what was the matter, he pointed to
his mouth; upon looking into which Cline observed a large ranula thrusting back
the tongue, which he  instantly punctured with a lancet, and relieved the  patient
from the threatening suffocation.—-j. f. s.]
   1766. Passing over Pare's opinion  of the nature  of ranula, that  it
consisted of a cold, moist,  clammy matter,  which proceeded from the
brain to the tongue, two different views have been  taken of  it.  First,
It has been considered as  an encysted  swelling by Fabr. ab Aquapen-
dente, Dionis,  Heister,  Meckel, in part, von Winter, Syme, and
others.  Secondly,  As a  stoppage or closure of the  Whartonian  duct,
from which  results  the retention of the  spittle of the submaxillary gland
and the distention of the walls of the duct in consequence of the spittle
collected in it; an  opinion first started  by Munichs (a), afterwards more
especially declared by Louis, and up to the  present time  held by most
writers.   This opinion  rests specially upon  the state  of the  fluid con-
tained in the swelling, which, similar to white of egg in colour and con-
sistence, by long continuance in  the swelling, becomes viscid, dusky,
and frequently mixed with stony concretions (1); and upon  the possi-
bility, in many instances, by opening  the obstructed Whartonian  duct
with  a probe, to discharge the  fluid and effect the cure.  Reisinger,
who  frequently found, by examination  with a delicate probe, that the
Whartonian duct was still pervious, supposes, on the contrary, that the
thickening of the spittle was not merely the  consequence of it being re-
tained, and that this was always in proportion to the  time the swelling
had existed, but that unnaturally secreted spittle perhaps  accompanied
with  atony  of the  duct, caused the development of ranula, and that  it
was not merely formed by the distended Whartonian  duct, but that not
unfrequently the  distended  Whartonian  duct  burst,  and  the secreted
fluid  poured out, and was contained in a sac of cellular tissue, not un-
like a cystic tumour ; in which way the various forms  of ranula, as well
as the often occurring transparency of the Whartonian duct could be ac-
counted for.  This opinion  has also been  more recently put forth by

                      (a) Praktyke der Heilkunde, p. 141.
                                  11* 
122
TREATMENT OF
Hennemann {a).  Kyll endeavoured to deny that ranula depends on
distention  of the duct; inasmuch as it is impossible, that so small and
thin a duct could  bear so great  a distention  as is  observed in large
swellings of this kind ; that  the fluid contained is not at all similar to
spittle, but of the consistence of fat oil, brownish, like yellow olive oil,
clammy, clear, and transparent; and according to the statement of the
patient after the  operation, tasteless, and that these conditions are really
from the first, and not  as  Louis  supposes similar  to the white of egg.
When swelling has existed a longer time the submaxillary glands swell,
inflame, and harden, by which their functions  are destroyed.  Lastly,
If the  spittle continue to flow, as after Dupuytren's mode of operating,
the disease diminishes, at least it never  increases, which, however, is
not always the case.   Upon these grounds Kyll holds  to the  old opi-
nion ; according to him, the swelling has a sac which is probably an
hydatid.
  [(1) The elder Cline himself had a stony concretion in one of  the submaxillary
ducts, which was readily removed by a slight cut through the membranes covering
it.  I am not aware, however, that it was accompanied with any degree of ra-
nula.—j. v. s.]
  1767. As unfortunately up to the present  time pathologico-anatomical
observations upon the seat of ranula are entirely wanting,  it is impossi-
ble to give a very decided judgment upon these  different opinions,  and
still more  as  several swellings beneath the tongue  are known, to which
the term ranula has been applied, which have nothing in  common with
it but their seat beneath the tongue.  In the  entire absence of anatomical
observations on  the  nature of this disease, chemical examination  of the
fluid can alone be  useful in more satisfactorily deciding  whether it be
spittle or not.  I have  found this fluid, both  in recent and long-continued
ranula, pale yellow, or brownish  yellow,  clear, thickly fluid, like white
of egg, very fibrous, so that  it could not be  poured in drops, but hangs
together like mucus.  Its chemical examination showed no resemblance
to spittle ; it  consisted  principally of albumen.   If, therefore, it  be not
admitted that the fluid  which the submaxillary and  sublingual glands
secrete, differ from the  spittle of  the parotid gland in its composition;
or if,  when  ranula exists, there  be not  an accompanying qualitative
change in  the secretion of these glands, then manifestly ranula must be
considered as the collection  of a  peculiar fluid external  to the Whar-
tonian duct, beneath the mucous membrane  of the mouth, or in  a  proper
sac (mucous bag) which latter opinion I consider most likely, and there-
fore ranula must be ranked with dropsy of mucous bags.
  According to the chemical examination of the  fluid from a ranula of a boy of
twelve years old, which my respected friend and  colleague L. Gmelin has  pub-
lished, it consists of water 94-6,  of soluble albumen with a very  small quantity of
stearine, osmazome, Salivary matter (?), and carbonate, nitrate and acetate  of potash,
5-4, in 100  parts.   Hence  the fluid has no resemblance  to spittle, as it wants the
sulpho-cyanite of potash, and almost the entire salivary matter; on the other hand,
it contains a large proportion of  albumen, which does not exist in healthy spittle.
Opposed to this is  the examination by  Dr. L. Posselt, of a stone weighing 0*623
of a grain, which  I removed from the Whartonian  duct, from which it appears that
in 100 parts  were  contained 7*8  of matter soluble  in water, which showed the re-
action of salivary matter;  13-3 of matter insoluble in water (salivary mucus); 68-87
of phosphate of lime, and 9-93 of carbonate of lime.  Poggiale found a stone from
            (a) Beitrftge Meklenberg. Aertze zur Med. und Chirurg.,  vol. i. 
RANULA.
123
the Whartonian duct to  consist  of 94f of neutral carbonate of lime, 4 per cent, of
animal matter, and 2 per cent, of water.                    * »
  According to Fleischmann, there are a pair of mucous bags beneath the tongue,
upon the m. geneo-glossi, where they enter the tongue, a little distant' from its front
edge, in the fraenulum linguae, and behind the opening of Bartholin's duct. They
are some lines  in length, very distinct, and  of  unequal size on the  two sides, the
right being generally larger than the left.   In  one instance it was divided on  the
right side by a partition  into two parts.
  When a salivary stone forms in Wharton's  duct, inflammation and suppuration
must arise in its gradual enlargement, by which the stone will be  spontaneously
thrown out,.as I have twice seen; but never, even when the  duct  is completely
closed by the stone, is there any condition similar to ranula.  There is inflammation
and swelling of the glands, which if the abscess be discharged by bursting or cutting
soon subsides, only a hardness in the surrounding cellular  tissue remains for some
time.
   1768.  According to the difference of opinion  as the nature of ranula
is the aetiology different.  An altered  condition  of the spittle has been
assumed  by which it  is disposed  to the deposition of stony concretions,
or simple thickening  of the  spittle, and thereby stoppage of the Whar-
tonian duct is set up, or union of the duct by inflammation and  the like.
In no case have  I been able to ascertain  any decided causal condition.
Ranula is not unfrequently observed in newly-born children, and occurs
more frequently in early than in later years.
   1769.  The treatment of ranula consist  either in opening  the  swelling
and discharging its fluid,  with which  also it must be sought to prevent
the complete closure of this opening, so that the  ever-collecting fluid
may have a  continual escape ; or in putting a stop to the  secretion by
exciting a sufficiently smart  inflammation, by destruction of the  swelling
with caustic, or by its  removal with the knife.   With these several  ob-
jects various modes of treatment have been proposed.   First.  Opening
the  swelling with the actuaLcautery, (Pare,) or  with caustic, in persons
 who fear the knife with butyr of antimony (Zang.)   Second. Puncture
 or  cutting  through its whole length (Louis.)   Third. Cutting  into  the
 swelling  and filling it with caustic and irritating materials, honey of roses
 with sulphuric acid, (Heister,  Dionis,)  lunar caustic, (Camper,) muri-
atic  acid, (Acrel,) stuffing  with lint  (Callisen,  Schreger.)   Fourth.
 Partially cutting  away the external  wall, (Boyer,) with cauterization of
 the  hinder wall, (Sabatier, Vogel, Wilmer, Chopart, Desault,  and
 others.)   Fifth.  Introduction  of a seton  (van der Haar  and  others.)
 Sixth. Introduction of  a  leaden thread,  or of a bundle  of lint (Louis,
 Sabatier.)  Seventh. Extirpation of the whole sac (Marchetti, Richter,
 and  others.)   Eighth.  Opening the swelling and in healing  a little cylin-
 der of two flat small silver, gold,  or platina plates, or a similar instrument
 of elastic gum. (Henning.)
   Richter (a) recommends, in the ranula of children, cauterization with lunar
caustic.  After a clean  good wound has been  produced  by the  first touching the
 whole surface, the caustic is to be repeated as often as the wound diminishes.  This
 is never required more than ten  times.
   When the ranula is not large and old, and its membranes are thin, the opening of
 the salivary duct sometimes appears  like an aphthous spot, and is only closed with
 viscid matter or with a stony  concretion;  in such cases the duct should, according
 to Louis Chopart  and Desault (6), be  again  rendered pervious1 by introducing a
 probe, and endeavouring to  discharge the collected fluid, with which  object the
  (a) Medicinische Vereinszeitung, 1838, No. 23.    (b) (Euvres Chirurg., vol. ii. p. 217. 
124
RETENTION OF BILE.
passage of the canal must be endeavoured to be kept open, by introducing a leaden
threa<T, which must from time to time be withdrawn to allow the escape of the spit-
tle.  All writers agree that this treatment is rarely suitable in its operation, as has
been already observed in speaking of the nature of ranula, and as in many cases the
salivary duct is found pervious, it is highly probable that a change in the condition
of the swelling will take place without it.
   1770. Of  the several modes of treatment, that proposed by Dupuy-
tren is the most simple and certain.  A small cut,  or a puncture with
a lancet is made in the swelling, and after the fluid has  been emptied,
a silver, gold, or, best  of all, a  platina  cylinder, three inches long, an
inch and a half thick, composed of two little elliptical plates, externally
convex, and internally somewhat concave,  and  then the edges may be
fixed about  the  cylinder.  My own practice confirms  this  mode  of
treatment; I have in every case  succeeded in  effecting a permanent
cure; the inner cylinder  produced no inconvenience; and when after
some time it was displaced and thrown  out, the  edge of the inner plate
having  produced union, and there was no return of the disease. Others
have not had success by this method (von Graefe, Kyll.)   And if the
swelling should afterwards return, the removal of its front wall is most
efficient, for which purpose it  must be  lifted up with forceps, and cut
off with Cooper's scissors (a).
  Reisinger's modification of Dupuytren's cylinder, which he  provides with an
aperture to allow the constant escape of the fluid, I  have found without objection.
  [On the Whole, I think the  best method of treating ranula is by hooking up with
a tenaculum a portion of its wall, and cutting it out with a pair of scissors;  which
done, the edge of the wound should be found and freely cauterized with lunar caus-
tic.  But it is often necessary to repeat this operation two or three times before a
permanent opening can be established.  I have, in a few  instances, passed a  needle
and thread through, and including a quarter of an inch of the wall of the swelling
in the thread, tied and allowed it to ulcerate out.  The success of this mode of treat-
ment is, however, less than that of the former.—j. r. s.]
                   II.—OF RETENTION OF BILE.

  Petit, Remarques sur les Tumeurs formees par la bile retenue dans la vesicule
du fiel  e.t qu'on a souvent prises  pour des abces au foie; in Mem. de l'Acad de
Chirurgie, vol. i. p. 155.
  Morand, Observations sur les Tumeurs k la vesicule du fiel; in same, vol. iii.
  Bloch, M'edicinische  Bemerkungen.  Berlin, 1774.  iv.
  Sebastian, A. A., Dissert, de Hydrope vesiculae fellis.  Heidelb., 1827.
  1771.  The already  mentioned {par.  912) overfilling and distention
of the  gall bladder when  the outflow of the bile by the ductus choledo-
chus is prevented, always occurs gradually.  The patient, having pre-
viously lost his appetite, feels, for a  longer or shorter time, a  dull pain
under  the ribs on  the right side, which  often extends to the region of
the stomach and loins.   Afterwards there frequently occur, with pre-
viously lost appetite, disturbed digestion, costiveness, pain  in  the right
hypochondrion, and  more or less  severe jaundice, symptoms of colic,
the seat of which is, especially opposite the points of the ninth rib, ac-
companied  with frequent vomiting, febrile and  other symptoms.   If,
under  these circumstances, the painful part, of the right hypochondrion
(a) Breschet ; above cited.—Schartlbr ; in oesterr. Med. Jahrbuchern, vol. 
RETENTION OF BILE.
125
 be examined, a more or less distinct  round swelling is observed, pro-
 jecting a little below the front edge of the liver, confused with it above,
 and more or less  easily felt in different positions of the body.   The
 swelling, sometimes of  itself, at other times at the very moment when
 pressed, diminishes and is less tense, whereupon all the symptoms  dimi-
 nish and bilious stools follow.  If the distention of the bladder  be  con-
 siderable, and have existed long, the swelling loses its mobility, becomes
 united to the peritoneum, and appears equally attached to the wall of
 the belly and to the liver.
   [In the Museum at St. Thomas's is a gall bladder equal in size to the urinary
 bladder of an ox, which was taken from a female  patient who  had  been under the
 care of Cheston of Gloucester.  She had had a projection at the pit of the stomach
 for a few years, which, as it increased, caused her much pain, and was presumed to
 be an abscess of the  liver.   It was punctured  and a considerable quantity of bile
 flowed out.  The wound was closed, but she died a few days after (a).—j. f. s.]
    1772. It appears that in this disease the flow of bile into the instes-
 tinal canal is most commonly not entirely prevented, and the patient
 has daily natural  coloured  motions.  The  disease may  terminate  in
 biliary fistula, in which case Ahe  gall bladder having adhered to the
 peritoneum, the bile collected in it makes its way out externally.   The
 gall bladder may also grow  to the colon or to any other intestine, and
 empty  itself into it;  or no  union with the peritoneum having taken
 place, it may burst, and a  fatal effusion  of bile into the cavity of the
 belly may ensue.
   [Sometimes when the ductus choledochus is obstructed, the gall bladder becomes
 adherent to the duodenum, ulceration takes place, and by this new opening the bile
 is, and continues to be discharged, and the functions of the gall bladder ceasing,
 it diminishes to the  size of an acorn, as in a preparation in St. Thomas's Mu-
 seum.—j. f. s.]
   1773. As to the treatment of this disease, at first it  is merely  con-
 fined to  the use of those remedies which soothe or remove the irritable
 or inflammatory condition.   At the same time it must be attempted, by
 rubbing, stroking, and pressing the swelling, to empty part of its con-
 tents into the duodenum, and to apply discutient remedies.   As long as
 it is uncertain that there is considerable  union of the gall bladder with
 the peritoneum (which may indeed be presumed, although  it cannot be
 asserted with perfect surety, if the patient have had frequent symptoms
 of inflammation and the swelling is  no  longer moveable,  as also by a
 slight adhesion the latter may be effected) we must not dare to under-
 take the evacuation by  opening the gall  bladder, as fatal escape of the
 bile is to be dreaded.  For this reason it appears not advisable to  open
 the swelling previous to the inflammation of the wall of the belly, and
 even of the external coverings being distinctly ascertained, that the bile
 may make its way out externally, in which case the adhesion is always
 to*a proper extent (6).
   1774.  Opening the gall bladder is best managed by making a cut  into
 the skin  an inch  and a  half long upon the  swelling, and  then smaller
 cuts through the muscles down to the peritoneum; then with the forefinger
 of the left hand it  must be  cautiously ascertained if the gall  bladder
 adhere, and at the most fluctuating part  the bistoury or lancet should
be thrust  through  the peritoneum and  the wall of the gall bladder.  If
  (a) MS. Lectures.            (b) Delpech ; Precise Elementaire, vol. ii. p. 272. 
126                   RETENTION OF URINE.
the adhesion between the gall bladder and peritoneum be not fully made
out, then, after the peritoneum has been laid bare as  just mentioned, a
trocar is to be thrust into the  most fluctuating  part and the tube left in
till  the  gall bladder and peritoneum  have  united together, or caustic
should be applied  to the peritoneum to produce this union {a).
   1775.  When the gall bladder has been emptied the opening must be
gently filled  with lint,  the  inflammatory symptoms  excited  must  be
treated with proper remedies, and in other respects it must be treated as
has been already mentioned in biliary  fistula {par. 913.)
                   III.—OF RETENTION OF URINE.

  Albrecht, G., De Ischuria.  Gotting, 1757.  4to.
  Wagner, J.,  Dissert, de Ischuria, vesicali atque vesicae paracentesi.  Argent,
1779.  4to.
  Murray, Dissert, de Paracentesi Cystidis urinaria?.   Upsal, 1771.  4to.
  Weldon, Walter, Observations on the different modes of Puncturing the Blad-
der in cases of Retention of Urine; with an Appendix on Retention of Urine, and
on Catheters.  Southampton, 1783.   8vo.
  Bonn, A., Bemerkungen iiber die Harnverhaltung und den Blasenstich liber dem
Schaambein.  From the Dutch.  Leipzig, 1796.  8vo.
  Schmid, W., Ueber diejenigen Krankheiten der Harnblase, Vorsteherdruse, und
Harnrohre (mit  Ausnahme der Blasensteine) denen vorzfiglieh Manner in hohem
Alter ausgesetzt sind.  Wien, 1806.   8vo.
  Desault, QSuvres Chirurgieales, vol. iii. p. 112.
  Soemmering, S. T., Abhandlung fiber die schnell und langsam todtenden Krank-
heiten der Harnblas und Harnrhore bei Mannern im hohen Alter.   Frankf., 1822.
8vo.   Second Edition.
  Chopart, Traite des Maladies des Voies urinaires.  Nouvelle Edition, par E. H.
Felix Pascal.   Paris, 1821.   2 vols.  8vo.
  Heinlein,  Bemerkungen iiber die  Ischurie;  in Harless Jahrbiicher der deuts-
chen Medicin und Chirurgie.  vol. i. p. 185; vol. iii. p. 102.
  Bell, Charles, A Treatise on the  Diseases of the Urethra, Vesica Urinaria, &c.
Third Edition;  with Notes by J. Shaw.  London, 1822.  8vo.
  Bingham, Robert, A Practical Essay on the Diseases and Injuries of the Bladder.
London, 1822.   8vo.
  Howship, James, On the Diseases  of the Urine and the Urinary Organs.   Lon-
don,  1823.  8vo.
  Moulin, Nouv. Traitement des Retentions d'Urine.   Paris, 1824.
   [Parrish, I., Practical  Observations on Hernia and some of the Dis-
eases of the Urinary Organs.  Philadelphia, 1836.   8vo.—g. w. n.]

   1776. Retention of Urine (Retentio  Urine Ischuria, Lat.;  Urinverhai-
tung,  Germ.; Retention d'Urine, Fr.) designates those  diseased con-
ditions  in  which the urine is retained by any  obstacle in  the canals
destined for its discharge.  This obstruction may be in the kidneys, in
the bladder, or in the urethra, and hence is named either Ischuria re-
nalis, ureterica vesicalis urethralis.   The discharge of the urine is thereby
either completely stopped, or it may be voided with difficulty {Dysuria)
or only by drops {Stranguria).

  Retention of urine from growing together of the lips of the urethra has been already
treated of (par. 1702.)
  That state  of  disease in which, on account of local disturbance in the kidneys or
(a) Richter ; AnfangsgrQnde, vol. v. p. 125-27. 
RETENTION OF URINE.                    127
by a general disease, no urine is secreted, (Anuria, Suppressio Urinae) must be dis-
tinguished frofn retention of urine (a).
   1777.  Retention of  urine in the urinary passages and in the  kidneys
may be  produced by foreign bodies which fill  their cavities, as stones,
hydatids, lumps of blood, pus, thick mucus, worms, or by inflammation,
chronic  swelling, and  spasm  of these  passages, or by  swellings which
compress the bladder.  The obstruction which prevents the passage of
the urine through the ureters is rarely on both sides, therefore complete
retention of urine is rare ;  the flow of urine may be completely or incom-
pletely prevented.
   1778.  All  the symptoms  which  manifest  retention  of urine in the
ureters are  doubtful.   The patient feels more or less violent urging,
stabbing pain, extending from the region of the kidney downwards, and
increased on  motion.   Although  there  may be a smaller discharge of
urine, yet are the signs deficient which show a collection of urine in the
bladder.  But if the patient have previously  voided some little stones
with  the urine, if with previous pain in the kidneys a stabbing pain  seem
to strike downwards, and there be a sense of weight and tension at one
particular spot,  it may be presumed, with probability, that the ureter is
stopped by a stone.  The  distention of the ureter above the obstruction
becomes gradually greater," though  externally no swelling  be observed,
which, however, is contradicted by Allan's {b) case (1).
   At last the urine collects in  such quantity that the ureter increases to
double  and triple  its  size.  If the stoppage  be only at one part, the
ailment  may  continue longer  without, particular inconvenience; under
which circumstances, by the vicarious activity of the other kidney, the
ordinary quantity of urine is passed.   The dangers which may be specially
produced by Ischuria ureterica, are complete suppression of the urinary
secretion, by  which the following  general symptoms may be caused : in-
flammation, suppression,  and  bursting of the ureters and kidneys ; in
which case extravasation  of urine into  the cellular tissue and urinary
fistule follow,  or if the urine be poured into the cavity of the belly, fatal
inflammation.
  (1)  The patient suffered  early from gravel,  and treatment was employed proper
for symptoms of stoppage of the ureter  by  stone, which passed off in four days. A
swelling  then arose on the left hip, which daily increased, whilst  the quantity of
urine  daily diminished.  Three weeks  from the commencement of  the disease the
skin and  muscles were cut through above the crest of the hip-bone, and the  trans-
versal fascia pierced with a trocar, which was thrust into the cavity beneath, from
which seven  pints  of urine escaped.  The symptoms  diminished ; no tube was left
in; the symptoms  of irritation returned, and after a week, a tube having been again
introduced, six  pints of urine and two  of pus were evacuated.   The disease sub-
sided, and recurred from time to time.   The patient  died five months and eleven
days after the operation, during which time the  urinary fistula remained.   Death
was caused by gradual wasting.  On dissection, the kidney was found expanded
into a cellular sac, the mucus membrane  of the ureter thickened, and completely
closed below with coagulable lymph (b)
   1779.  The  treatment of Ischuria ureterica,  when accompanied  with
violent pain and  inflammatory symptoms, consists only in the employ-
ment of  antiphlogistic remedies, blood-letting, soothing clysters, bathing,
stoups,  and the "like.   In  the contrary condition, shaking motions, as
  (a)  Abercrombie, J.; in Edinb. Med. and    (b) London  Medical  Gazette, vol.  xix. p.
Surg. Journ., vol. xvii. p. 210. 1821.         888.  1837. 
128
RETENTION OF URINE.
riding, and even  vomiting may be successfully employed, in order to
favour the descent of the stone  in the ureter.
   1780. When the urine is retained in ihe bladder, various  symptoms
occur according  to  the  degree and duration  of the  collection.  The
patient feels a constant urging to void his urine, but is unable to do so;
there is weight and  tension  at the lower part of the belly,  and in the
perineum;  a swelling rises  above the pubes, elastic and at times fluc-
tuating, ascends oftentimes up to the navel, and even still higher, gene-
rally in the middle of the belly, but sometimes more to one side than
the other.   As the bladder enlarges, especially from above downwards,
so it thrusts down its base, forcing it against the perineum, presses upon
the vagina and in men upon the rectum, where  on examination with the
finger introduced into the gut, it is felt as a compressible elastic swell-
ing.   Sometimes the bladder is but little distended, on account of the
peculiar rigidity of its coats.  In fat persons the swelling is not so dis-
tinctly felt as in thin ones.
  An important  symptom which is rarely wanting, and  which may be perceived
even in very  stout persons, is the dull sound perceived on percussion  from the
sword-like cartilage down along the white line, and from the iliac spine of one side
to that of the other, in the region of the bladder, by which, as well as by the shriller
abdominal sound in the neighbourhood of the bladder, the extent of that organ can
be ascertained.  Another important pathological sign  is the fluctuation of the fluid
in the bladder, which is perceived when, with one finger in the rectum or vagina, and
the other hand placed over the region of the bladder, it can be produced and felt by
the alternate pressure of one  or other (Pigne.)
   1781. If the urine  be  not passed in  the usual way, the distention of
the bladder becomes greater, and  the result of the disease varies.  The
bladder may burst by partial gangrenous destruction (1), and the urine
be poured  forth into the neighbouring  cellular  tissue, in  which  case
either urinary fistule. are formed, or death  ensues as the consequence
of gangrenous inflammation of  the bowels.  The bladder may  be vio-
lently inflamed, and  the  inflammation spread over the abdominal intes-
tines.   Sometimes, when the bladder has attained its greatest  distention,
the ureters are also considerably distended  up  to the kidneys, which on
account of the oblique entrance of  those canals  into the bladder, has
been doubted by some persons.  From the decomposition of the urine,
and  its reaction  upon the whole  organism, severe fever  arises, with
speedy sinking of the powers, extremely quick pulse, dry tongue, coma
and  delirium;  the perspiration of the whole body has anurinous smell;
all the excretions are altered; often there  is watery vomiting with an
urinous smell,  and the patient soon dies.   Sometimes the urachus opens,
and  the urine flows out through the navel (2).                         ^
  [(1) Bursting of the bladder from retention of urine either without or with gan-
grene is of very  rare occurrence; I have never seen nor had personal knowledge of
such a case.   Nor, as far as  I am aware, is gangrene even of the bladder often met
with.  Cheston indeed mentions (a) an instance, which however I think seems
very doubtful.  A woman thirty-five years of age, and four months gone with child,
had suppression  of urine, for which a catheter was passed, and five pints of water
drawn  off.  Seven or eight days after she again had retention, but then only half  a
pint  of water could be withdrawn by the instrument;  after this, however, water
continued to pass.  On the fourteenth or fifteenth day-from the first attack she died,
the bladder having risen up to the navel.  On examination, it was found to contain

    (a) Pathological Inquiries and Observations in Surgery.  Gloucester, 1766.  4to. 
RETENTION OF URINE, FROM PALSY.             129
a quart of foetid, thick, purulent urine, and the fundus of the bladder is stated to have
been completely sphacelated.  The walls of the bladder had doubled by the pressure
of the womb, so as to form two cavities, and this fold had prevented the entrance
of the catheter.
  (2) The opening of the urachus, I think, must be admitted with very considerable
doubt.  I  have on one occasion, however, seen  in a healthy woman a very small
oozing of  clear fluid  entirely free from smell or acridity from the navel, which I
thought might have been from the urachus.  It had existed for a considerable time.
Astringents were  used for  some time without advantage, and she ceased coming to
to me.—j. f. s.]
   1782.  If a retention of urine have been slowly produced, so that for
a long time previous, only part  of the urine has been voided, whilst the
bladder itself still remained  full, the  symptoms are less active.   From
the  urine collected in the bladder, which  becomes decomposed, a slow
inflammation is produced, which specially attacks the mucous membrane,
and alters its secretion.  The general health  is disturbed, the digestion
suffers, the countenance  pales, the muscles  become flabby, the patient
suffers from fever, and the like.   The walls of the bladder often become
much thickened, and frequently folds, and all the deepenings are pro-
duced by the separation of the muscular fibres (1).
   (1) These sac-like deepenings  are the first step of the spontaneous perforation of
the bladder, which Mercier (a)1 has well described, and which has been considered
to be caused by the use of the sound.  The mucous membrane of the bladder pushes
into these deepenings, and is sometimes in immediate contact with the peritonaeum;
sometimes separated  from it by a peculiar thick layer of cellular tissue.  These
deepenings occur specially on the sides, and on the under part of the hind wall of
the bladder, above the openings  of  the ureters.   After a certain time the mucous
membrane often ulcerates at  the bottom  of these sacs, and is followed by a pouring
forth of the urine; the mucous membrane  may even be torn in retention of urine,
and in the violent efforts to  discharge  it, which  cause these cell-like  deepenings,
after or even without previous ulcerative inflammation (2).  As the bottom of these
sacs  have not contractility, which  their opening, surrounded by muscular fibres,
have, the  urine contained in them, is with difficulty renewed;  it collects, decom-
poses, and produces inflammation.  Sometimes stones form in them, which gradually
enlarge, and distend the bottorn of the sac, without enlarging its opening, and thus
encysted stones  are formed, which may also excite inflammation, and  cause per-
foration.  The suppuration which results from such perforation, may spread into the
cellular tissue beneath the peritonaeum, and there form one or more abscesses, which
open into the peritonaeum, either without previous adhesion, in consequence of which
death speedily follows; or after the suppuration  has been bounded by adhesion, in
which case fatal symptoms less frequently follow.   Sometimes the abscess opens
into an intestine,  sometimes in the wall of the belly, into the flank, and so on, and
cause death only  consecutively.   Under these circumstances also urinary^s/uZ* may
be formed (Pigne.)
   [(2) The bursting of these deepenings or sacs is certainly very rare.—j. f. s.]
   1783.  The causes of retention  of urine in the bladder may he, first, palsy
of the bladder ; secondly, inflammation ;  thirdly, spasm ; and fourthly,
stoppage of the urine  depending on foreign bodies introduced into  the
urethra or bladder, or on stones, coagulated blood,  and so on, on swell-
ing and hardening of the prostate  gland,  on growths in the bladder, on
pressure  of the impregnated or unimpregnated womb, on swellings or
hardened intestines, or on strictures.
   1784.  Paralytic Retention of Urine {Ischuria paralytica) in general
comes on slowly, the urine is no longer discharged with the usual power,
the  patient  soon feels the need of voiding it again, which he can only

                    (a) Gazette  Medicale, vol. iii. p. 312,1835.
   Vol. hi.—12 
130         TREATMENT OF PARALYTIC RETENTION.
effect with the greatest exertion.  This difficulty gradually increases, the
urine at last flows off involuntarily, and the patient can by his efforts but
little or not at all increase the flow, which at last stops completely.  The
distended bladder forms the already mentioned {par. 1780)  swelling
above the pubes, which is nearly painless, and  sometimes in such de-
gree that  it may be mistaken for pregnancy or dropsy, which may be the
more possible  as  the  patient occasionally retains the power of voiding
his urine  by violent  efforts, often even in a quantity  equal to the drink
taken in the day, without, however, emptying the distended bladder. If
the filled  bladder be somewhat firmly pressed, a few drops of urine will
escape through the urethra.
   Sometimes  paralytic retention arises quickly under severe symptoms
of a spasmodic and  inflammatory affection of the neck of the  bladder,
when, if speedy assistance be not afforded, considerable distention of the
bladder, and palsy Of its walls are produced.  In the latter course of the
disease, there are  accompanying it a flow of mucus from the  bladder,
thickening of its walls, swelling of the prostate gland, and the like. This
kind of paralytic retention of urine happens most commonly in old per-
sons who  have been dissolute in various  ways, have suffered from gout
and rheumatism; and usually the gout or rheumatism is the proximate
cause.
   1785. When  the bladder in this  retention of urine has become very
much distended, the pressure of the  abdominal muscles and bowels pre-
vents its further distention ; some  urine always dribbles, and bursting of
the bladder does not take place.  But inflammatory symptoms, and more
or less severe  fever may accompany  it.   The flow of urine is then com-
pletely stopped, and the bladder may be distended to  such extent that it
may become gangrenous and tear; this, however, is a  rare termination.
  Oesterlen (a) divides paralytic retention into Ischuria paralytica partialis vesicae,
in which the powers of the bladder and abdominal muscles are very weak;  and Is-
churia parylytica universae vesicae, in which there is accompanying palsy of the blad-
der, and the sphincter muscle of that organ.
   1786.  This form of retention of urine is  peculiar to old people, and
depends  on the loss of contractile  power in the bladder,  and on the
generally  diminishing muscular activity in advanced age.  It may  he the
result of previous debilitating causes, debauched life, venereal  disease,
frequent onanism.   The bad habit of holding their water very long fre-
quently produces it in persons who lead a sedentary life, who work hard
and frequently allow the disposition to make water to  pass by without
attending  to it. It may also result from concussion and palsy of the lower
part of the spinal marrow and sacral nerves, or from organic disease of
the spinal marrow : it frequently occurs in nervous feveis.
   1787.  The prognosis of this disease is guided  by its degree and dura-
tion, by the age of the patient, and by its cause.  It is most easily cured
in young  people;  the older the patient and his disease are, the less hope
is there of cure. If the disease be caused by affections of the spinal mar-
row and sacral nerves,  the prognosis must be directed by them.
   1788.   The treatment of paralytic retention consists in emptying the
bladder of its urine, and in restoring its contractile power.  The reme-
(a) Heidelb. klinisch. Annalen, vol. viii. p. 421. 
TREATMENT OF PARALYTIC RETENTION.          131
dies which answer to the latter indication are useless without attention
to the former.
   1789.  Emptying the bladder by means of the catheter, must be per-
formed so frequently, that all distention from the collecting of the urine
must be  prevented.   The  catheter may be either introduced  afresh as
often as necessary, or an elastic catheter may be left in, which in all cases
where the patient is not under  immediate observation, is the most fitting,
as the urine often collects again with great quickness, and therefore the
bladder again becomes greatly  distended. The introduction of the  cathe-
ter is in these cases always unattended with difficulty, and generally in a
short time the patient  may learn  himself to pass it.   If the bladder  be
weak, the urine sometimes only flows through the catheter, when pressure
is made on the belly.   This indisposition of the urine to pass by the  cathe-
ter, may  lead to the mistake that the instrument is not in the bladder {a).
The catheter, must be continued till  the urine pass through it, and be-
tween it  and the urethra, in a strong unbroken  stream ; and if even the
patient should void his urine without the catheter, it should be frequently
ascertained  by introducing it, that no  urine be retained in the  bladder.
   1790.  The remedies  which answer the second indication  are, cold
bathing of the pubic region  and perineum ;  cold applications, cold injec-
tions into the rectum ; rubbing volatile salves on the perineum, and  on
the region of the bladder.  Internally  should be given arnica,  oleum ani-
mate Dippelii, cantharides to the amount  of a grain daily with  camphor
and gum-arabic, tincture of cantharides up to fifteen  or twenty  drops,
with almond milk. And in  addition to these general strengthening baths,
galvanism,  electricity, and blisters upon the sacrum.  When the patient
can again himself discharge his urine, he must not dare to allow the least
disposition  to void it to pass unsatisfied.
   1791.  In the  quickly occurring paralytic retention, where gout or rheu-
matism are  in play, warm sulphur baths, fomentations of aromatic herbs
with wine and vinegar, rubbing in  oil of juniper,  particularly on the  in-
side of the thighs; cupping and easily digestible diet are to be used.  If
violent inflammatory  symptoms be  present, leeches are to be  applied to
the perineum.  ' The  introduction of the catheter, necessary as it be, is
generally difficult  on account of the contraction of the neck of the blad-
der.
   1792.  If  paralytic retention have existed for some time, and be accom-
panied with an  inflammatory  condition,  it must,  according to circum-
stances, be treated antiphlogistically with blood-letting, clysters, diluting,
slightly astringent drinks,  as  alum milk, and the like.  If the disease
be incurable, as frequently it is in very old  persons, and if it have
long existed, the  patient should  always use a catheter for emptying his
bladder.
   A somewhat contrary condition  to  that of palsy of the bladder is that in which,
consequent on some  irritation, or bad habit, the urine is voided too quickly, and thus
the capacity of the Madder gradually so diminished, that only the smallest quantity
of urine can be made, and therefore painful  urging on the collection of the smallest
quantity of urine becomes habitual.  The gradual origin of this condition may be in-
ferred  from its history, and if on examination with the catheter, no stricture in the
urethra be found, no foreign body in the  bladder, and the catheter do not pass into
the cavity of  the bladder.
                      (a)  Oesterlen- ; above cited, p. 420. 
 132       RETENTION OF URINE FROM INFLAMMATION.

  The treatment of this ailment must consist in the gradual extension of the walls of
the bladder to their natural condition, which must be done by voluntarily retaining
the urine, or if this be impossible, by introducing a catheter morning and night for a
long while, by which Ihe intervals of relieving the bladder may be gradually length-
ened (a).   The over-sensibility of the bladder is thereby checked by compelling it
to bear a greater degree of irritation, and  by the same means also  the contractile
power of its sphincter may be increased.  In most cases this great sensibility of the
bladder is connected (when it does not depend on local disease in the urinary pas-
sages) with disturbance of the digestive organs and irregular living, and  requires
gently purgative and afterwards tonic remedies, lukewarm bathing or washing the
perinaeum with  lukewarm water, clysters with opium, purgatives, and strictly regu-
lated diet..
   1793.  Retention of Urine, depending on Inflammation, {Ischuria  inflam-
matoria,) commences with the  most violent and dangerous symptoms.
Besides great urging,  the patient feels a deep-seated pain in the bladder
and  neighbouring parts.  There is  accompanying fever, the distended
region of the  bladder smarts when touched, and is frequently reddened.
The inflammation spreads over the other bowels; eructations and vomit-
ing occur, and if they continue beyond the sixth day, the patient's life is
in extreme danger, and death is almost unavoidable.  Sometimes the in-
flammation  takes  a more insidious course, and  puriform  secretion with
thickening of the  bladder occur.
   1794.  The inflammation in this retention may be seated in the whole
canal of  the urethra, in the neck of  the bladder, in the prostate gland,
and even in the bladder itself.
  Its causes are, external violence, which attacks the perineum, and re-
gion of the bladder, stones in the bladder,  extension of the irritation  of
the rectum in hemorrhoidal affections to the bladder,  rectal fistule, and
the like ;  a high degree of inflammation in gonorrhoea, suppression of the
usual discharges,  suppressed gout, repressed eruptions on the skin, and
catching eold.
   1795.  Antiphlogistic remedies must be employed in inflammatory re-
tention of urine,  with reference to-the cause  which has  produced it.
Blood must be taken away and leeches applied to. the perineum; muci-
laginous  drinks taken, though in as small quantity as  possible, in order
not to increase the filling of the  bladder.   As in inflammatory retention,
spasmodic contraction of the neck of the bladder is always present, warm
anodyne  applications must be made  to the pubes and perineum, warm
vapour of camomile to the perineum, rubbing in volatile ointments, clys-
ters with opium,  and the like employed.   Tobacco  clysters are much
relied on.   Blisters must not be applied ; calomel and opium internally
are specially effective.
  1796.  In severe gonorrhea}  inflammation soothing applications are
also to be made over  the whole  penis, the patient laid horizontally, and
the testicles supported with  a suspender.  In hemorrhoidal affections
leeches are applied to the rectum, and internally, cream of tartar and sul-
phur given.
  1797.  Although emptying of the urine be necessary, as by its irritation
it causes the inflammation, it  must not be used till the remedies  already
recommended have been employed.   The introduction of the catheter is
  (a) Von  Winter;  uber  die  Harnbe-  Journal, vol. i. p. 309.—Hyslop;  in  Med.-
scbwerden von verminderter capacitat  der  Chir. Trans, vol.vi. p. 108.__Bingham ■ above
Harnblase; in Graefe und Von Walthkr's  cited, p. 234. 
RETENTION OF URINE FROM SPASM.            133
here always painful  and difficult; an elastic  one is  best used, and its
point should be passed far into the bladder, so that its walls should not
be irritated.   If the catheter can in no way be  introduced and mortifica-
tion of the bladder be  dreaded, puncturing the  bladder must be per-
formed without delay.
   1798. In Spasmodic  Retention of Urine  {Ischuria  Spasmodica) the
neck of the bladder,  and perhaps also the urethra, are narrowed at dif-
ferent parts, and accompanied with spasmodic contraction of the perineal
muscles.   It occurs specially in sensitive persons, in hypochondriacs, in
hemorrhoidal affections, in which there is often at the same  time  present
spasmodic  contraction of the m. sphincter ani,  from catching cold,  inor-
dinate drinking, worms, holding the water too  long, and the like.  This
retention is always peculiar in sometimes subsiding and again recurring;
it therefore has not the signs of inflammatory retention, at least in  general
they are not present, though  they may at a later period accompany it.
   1799. In this form  of retention antispasmodic remedies are usually em-
ployed, warm applications of camomile,  hyoscyamus, and the like, to the
perineum and region of the bladder;  rubbing in volatile ointments, with
opium or ol. hyoscyami; clysters of camomile,  asqfcetida and opium, to-
bacco  clysters {a), lukewarm camomile hip-baths.   Internally should be
given  Dover's  powder, or  opium, with mucilaginous  remedies, pollen
lycopodii.  According to its various  causes,  should  be employed, in
hemorrhoids, sulphur, with cream of tartar ; in colds,  diaphoretic reme-
dies, especially camphor in proper doses ; in worms, anthelmintics ; and
according to the fancy, unferraented drinks, calcined magnesia, with aro-
matics ; and the glans penis to be put in cold water.
   1800. If by this treatment the urine do not  flow, a catheter must  be
introduced, which always discovers a considerable obstacle at the  neck
of the bladder, sometimes even in the passage  of  the instrument in the
urethra.  If inflammatory accompany  the spasmodic symptoms, the  anti-
phlogistic must be added to the antispasmodic  remedies.  If the reten-
tion of urine have occurred from having  voluntarily retained it for a long
time, in which case the symptoms are always more severe on account of
its greater quantity, the  treatment must immediately commence with the
introduction of the catheter.
   1801. The retention of urine which depends on stoppage of the  urethra
may be produced by stones in the bladder, when they lie upon the inner
aperture of that canal, or if being small, they have squeezed into it (1);
by coagulated blood (2), or thickened mucus ; by  worms which pass out
with the urine (3);  by foreign bodies which have been passed from with-
out into the urethra (4).  In all these cases the  urethra is either com-
pletely closed by the foreign body, or in consequence of the irritation
and spasmodic contraction which they have excited.
  [(1)  Stones, if small enough to escape from the bladder, may, according to their
size, either pass through and be voided by the urethra, or they may be fixed  in either
of its narrower parts.  I have known them lodge in the membranous part, and re-
quire removal by cutting through the perinaeum ,• but more commonly they get jam-
med within an inch of the lips of the urethra, of which I have seen many instances.
  In the Museum at the  College  of Surgeons, there is a very remarkable instance of
a case which occurred to John Hunter, in which a narrow stricture in the mem-
  fa) Earle, Henry, On the use of Nicotiana in Retention of Urine; in Medico-Chirurg.
Trans., vol. vi. p. 82. 1815.
                                 12* 
134       RETENTION OF URINE FROM FOREIGN BODIES.
 branous part of the urethra was blocked up by a very small stone, hardly more than
 a line in diameter; it is figured, in his work, On the Venereal Disease, (pi. iv.) and
 the short notice attached to it is, that the man died of mortification of the bladder, in
 consequence of a stricture and stone in the urethra."  This preparation is interesting,
 as the  stated cause of Hunter's beginning to use caustic bougies, for he adds, "a
 canula is introduced from the glans down to the stricture, showing the practicability
 of destroying it with caustic."  In the same collection, there is also another instance
 of a stone in the urethra behind a stricture, in a boy four years  old, to which he re-
 fers,  (p. 124,) in the same work.
   (2) Howship (a) gives a good example of blood filling the bladder, in an elderly
 man, who was attacked with what was at first supposed to be  a retention of urine,
 and a catheter  having been repeatedly passed without any  urine escaping, it was
 thought not to have entered the bladder.   He died on the  following day, and on
 examination, the bladder was found entirely filled with a very large coagulum.   In
 another case, he mentions the bladder being nearly filled with blood and containing
 a stone in the centre of the clot.
  When blood is found in the bladder, it is more commonly  from  fungous growths
 either from the bladder itself, or from the prostate, of which  Bransby Cooper (b)
 gives good examples.
  The case of Mathieu's, quoted by Samuel Cooper (c), appears to me  nothing
 more than an enlarged prostate, which the catheters first used were not of sufficient
 length to reach beyond, and not retention  from a clot in the bladder.
  I have known, in two or three instances after the  operation for the stone, blood
 to flow back into the bladder, and there coagulating, prevent for a time the escape
 of urine, either from  the  urethra or from  the wound.  Indeed, if for some hours
 after the operation,  urine do  not  pass from the wound, it  may be  presumed some-
 thing of this kind is going on, and the bladder requires gently washing out, through
 the wound  with a syringe.
  (3) Lawrence (d) relates a very remarkable instance of an  undescribed  species
 of worms voided from the  urethra, to  the amount of from  eight  hundred to a
 thousand, by a woman, aged twenty-four years.
  He also mentions examples of the larvae of insects having  been passed.   Of dis-
 charges of  worms and insect larvae, and  portions of  the lining membrane of the
 bladder, which have been mistaken for them, there  is  no lack in the accounts of
 various  writers.
  (4) Foreign bodies, of various kinds, have frequently been purposely introduced
 into  the urethra, and escaping from the fingers of the holder,  have either lodged in
 it, or more generally slipped back into the  bladder.  Bougies, and elastic catheters,
 and even those of metal, have been thus occasionally circumstanced by accident, the
 whole of the former being  sucked in, as it were, by the bladder;  and the latter
 having  been broken, being pushed in by  unskilful endeavours  to  prevent their
 escape backwards.  But tobacco-pipes used as substitutes for bougies, are probably
 the most common foreign bodies  which are met with in the  urethra or bladder.
 Tvrrel (e) had a case in which the patient broke off three inches of the curve of a
 silver catheter, which slipped into the  bladder.  He walked  to  St. Thomas, a dis-
 tance of about twenty-one miles from his  residence, without much inconvenience,
except that "occasionally in stooping, walking up stairs, or raising himself in bed,
he experienced lancinating pain, as if some sharp instrument  were penetrating the
bladder. *  * * On passing a sound, it  was found  lodged  at the fundus  of the
 bladder  transversely;  its extremities being embraced  by that viscus, so as to be held
 with some firmness."  It was brought lower with a sound, but still remained trans-
verse.   Tyrrell  "then introduced one of Weiss's instruments for extracting small
calculi, which was nearly straight, and had a strong spring; by  careful examination
with which, he discovered that the extremity of the foreign body towards the patient's
right  side was free, and that the other was covered °with a fold of the  bladder.
After  several unsuccessful attempts, he succeeded in seizing the  free extremity with
 the instrument, and  by withdrawing it very cautiously, brought the piece of catheter
 into the urethra, when the forceps slipped from it.  He immediately introduced his
 fingers into  the rectum, for the  purpose of compressing  the urethra between the
  (a) Above cited, p. 5.4.                  (c) Surg.'Dictionary, p. 1375.
  (6) Guy's Hospital Reports, vol. i. p. 202.   (d) Med.-Chir. Trai>s„ vol. ii. p. 382.
                     (e) St. Thomases Hospital Reports,  p. 26, 
RETENTION OF  URINE, FROM STONE.               135
foreign body and the bladder, so as to prevent  any retrograde  movement of the
former.   This being  secured, he again introduced the forceps into the urethra, and
in the first attempt caught the piece of catheter, and drew it out."
  I am indebted to my friend Crisp, of Walworth, for the following two highly in-
teresting cases, which were treated by him :—
   Case 1.  An old sailor had been  in the habit of passing the whole length of a
tobacco-pipe  into  his urethra, for the relief of stricture, and on one occasion broke off
a piece of it, which slipped into his bladder, and  for which the usual operation for
the stone was performed in Guy's Hospital, and  he recovered.  This accident,
however, did not prevent him subsequently recurring to the same mode of treatment,
when the pipe again  broke, leaving about an inch and a half in the membranous
part of the urethra.  This he attempted to remove, by making a cut with a penknife
into the perinaeum, as he lay before a glass, and succeeded in exposing the pipe, but
being unprovided with instruments, and failing, by groping with his fingers, to get
it,  he was  obliged to send for my friend, who  drew it  forwards with a pair of
dressing forceps, and readily removed it.   The man  did well.
   Case 2. A  man in Walworth workhouse, having made frequent attempts to commit
suicide, at length, for the same object, passed  a piece of stiff wire, about five or six
inches long,  into the urethra, as far as he could, and afterwards drove it with his fist
under the arch of the pubes into the pelvis.  By pressure on the perinaeum, the ex-
tremity of the wire was indistinctly felt.  A cut was made into the urethra behind
the bulb, about  an inch and a half in length,  but the wire end not being seen, the
cut was lengthened backwards about half an inch, which exposed the extremity of
the wire.  Much difficulty was found in seizing the wire, as  at each attempt  it re-
ceded with the soft parts, when the points of the dissecting forceps (which only
could be used, on account of want of space) were introduced; but when seized, it
was readily  withdrawn, and the man recovered.
   John Hunter  says, that " bougies  have been known  to  be  forced out of the
bladder along with the water, by the action of that: viscus and in  several folds, (p.
134.)   This  is certainly a very rare occurrence, but by no means, impossible or im-
probable; for there is a preparation in St. Thomas's Museum, of a large adventitious
membrane, four or six inches long, and an inch and a half wide, which was voided
by the urethra; and it is only necessary for the bougie to be so situated, as to  form
a sort of plug, against which the urine behind may be driven forwards.—j.  f. s,]
   1802.  If a vesical  stone lie against the neck of the bladder, and  pro-
duce ischury, the same proceeding as in inflammatory ischury, must be
had recourse to, and the stone removed  from the  neck of the bladder,
either by placing the  patient  on his back,  with his pelvis raised, or by
introducing a catheter.   Lumps of blood and collections of mucus in the
urethra are also relieved  by  passing the catheter.   If small  stones or
other hard  bodies stick in  the urethra, itself,  it must be  attempted, by
employing, at the same  time,  antiphlogistic  and antispasmodic remedies,
to squeeze  them gradually out of the  urethra, or with Hunter's or
Cooper's forceps to withdraw them,  after having carefully enlarged the
passage by introducing thick  bougies,  especially of silkworm gut.  If
the object be not thus attained, a cut must be  made, where the  foreign
body is situated, and  thence it must  be removed (1):  a catheter is to be
left in afterwards,  and the edges of  the  wound tried to  be healed  with
quick union (2).
  Retention  of urine  from  small  stones,  which  have got into  the mouth of the
urethra, or  into  its  membranous  part, is probably much  more frequent,  than
generally supposed; in which case the diagnosis is doubtful, and if the catheter be
introduced, the little stone cannot be felt, and the  retention on the contrary, is  to be
considered inflammatory or spasmodic.  As symptoms of such ischuria calculosa may
be to a certain degree considered their occurrence after any mechanical movement,
without other previous influence, and their cessation after such shaking.  For the
removal of these  little stones, when the introduction of a catheter is not possible, for
instance, when there  are existing strictures, injections of water, made  with some 
136               FROM IMPREGNATED WOMB, ETC.
force into the urethra, must be  employed ; together with rubbing and shaking the
perinaeum, but the bladder must not be previously overloaded, or the urethra con-
siderably inflamed (a).
   [(1) If a stone or any other body be near the lips of the urethra, it may often be
removed  with a little dexterity and patience, by curving the eyed end of a probe,
and gently insinuating it between the stone and the urethra, till the point be got behind
it; then using the probe as a lever, it may be gently drawn  forwards, and if when
the stone reach the orifice of the canal, it will not pass, a small nick with a lancet
at that part of the aperture, where it most clings, will soon allow it to come out.  If
the stone or body be in  the membranous part, if the forceps fail in catching hold and
pulling it out, a cut must be made directly down upon it.  But in doing this it will
be necessary to introduce the forefinger of the left hand into the rectum, so as to fix
the stone and prevent  it slipping or being  pushed  back into  the bladder, in the
attempt to seize it;  for should  that happen, it will be necessary at once to perform
the usual operation for stone.
   (2) If the cut be  made  in the perinaeum, no  catheter should be left in, but the
wound allowed to heal, as after the operation for  the stone.  But if  the urethra be
opened before the scrotum, and  specially if near to it, a catheter must be left in, to
prevent the escape of the urine  into the cellular tissue.—j. f. s.]
   1803.  In retention from the pressure of the impregnated womb, or other
viscera,  the  palliative treatment consists in  introducing the  catheter: in
the former case the ischury ceases after delivery; in  the  latter the hard-
ening of the viscera must be got rid of, as well as other swellings which
compress  the urethra.   Retention from  retroversion of  the worab has
been already considered (par. 1308.)
   [I once operated for retention of urine in a case  which, after  death, was found to
depend on a large cyst, containing an acephalous hydatid, which occupied  the whole
cavity of the pelvis, and lying between the bladder and the rectum, compressed the
former between itself and the pubes, and as the bladder filled, it rose high/above the
brim of the pelvis, in consequence of which, even after cutting into the  perinaeum, the
pressure was so complete that the urine would not escape, except on the introduction
of a very long catheter, Which  was continually displaced by  the contraction of the
bladder  into  the compressed part, into which no urine descended,  and  was only
replaced with the greatest difficulty.  The  man died on the  sixth day of constitu-
tional irritation.  Besides this cyst above mentioned,  which contained 44 ounces of
colourless fluid enclosed in the hydatid, there was another, about the size of a goose's
egg, at the  lower part of the sigmoid flexure of the colon, with thick walls, and an
eschar upon it, where it had probably, at some  time  or other, burst.   The bladder
was empty between the lower  and fore part of the  large cyst  and the arch of the
pubes;, and between the cyst and the back of the fundus of the bladder were two or
three small cysts of the size of small nuts, and upon the fore part of the fundus ano-
ther as big  as a swan's  egg.  All the cysts contained each  an hydatid, except that
on the rectum, on which there were several/—j. f.  s.]
   1804.  Growths in the bladder, especially  about its  neck, are causes of
ischury, and the diagnosis is always uncertain.   Sometimes there is only
one growth  of much size,  sometimes  several: some have  a thin stem,
and others a broad base.  The use of the catheter is  the  only palliative,
Such growths when  discovered in the  operation for the stone, have been
torn away with the forceps (6).
   1805.  Swellings of the prostate gland may  arise in various ways, and
the  passage of the  urine  become difficult, or quite  impossible.  The
swelling may depend on inflammation, varicosity of the vessels, harden-
ing, and stone.
   1806.  Inflammation  of  the  prostate gland may be consequence of
   (a) Schreger, Cliirnrgische Versuche, vol. i. p. 187.—Cloo.uet, I.: in Journ.de Mede-
cine, vol. ii.  p.  19. 1818.
   (6) Desault; above cited, p. 175. 
RETENTION OF URINE, FROM INFLAMMATION.       137
gonorrhoea, of external violence, and the like;  in general, it developes
itself quickly.   The patient has a  sense of weight and  burning in the
perineum and  anus, a throbbing pain, the seat of which he refers to the
neck of the bladder.   The pain increases on pressure of the perineum,
and specially on  going to stool:  the patient has difficulty and frequent
urging to void his urine: the swelling of the prostate  is felt on intro-
ducing the finger into  the rectum.  In  proportion to the degree of in-
flammation, occur inflammatory symptoms and so on.  If the inflammation
do not disperse,  it may pass on to suppuration.   Under these circum-
stances, after the  inflammatory symptoms have  gone over eight days, a
throbbing pain is felt, increased fever towards evening, shiverings^ and
symptoms  of retention  of urine,  which  subside  a  little,  and  increase
afresh.  The suppuration rarely appears  to be seated in the proper  sub-
stance  of the gland, but rather in its coverings, and in the  cellular tissue,
connecting the lobes of the gland ; frequently several groups of abscesses
form, and in this case the patient generally sinks, some abscesses opening
within, and others without, the  abscesses burrow, and fistulous passages,
and wasting suppuration ensue.
   ["As the abscess advances, the perinaeum becomes tender," says Brodie, "and
there is a perceptible, though slight  tumefaction and hardness in  some one part of
it.   The abscess, if left to take its own course,  sometimes bursts internally, that is,
into the urethra; more frequently, it makes its way through  the fascia, cellular
membrane, and muscles  of the perinaeum, and bursts through the external skin."
(p. 144.)  Brodie, however, mentions a fatal instance of abscess in the prostate, in
which the patient, about thirty years of age, voided his  urine every twenty or thirty
minutes, complaining of an aching pain in the loins; but of no pain any where else.
The urine deposited a small quantity of  yellow puriform  sediment.   He said'that
the symptoms had begun two years ago, and that in the commencement of the dis-
ease, the urine had been tinged with  blood. * *  * About a month after his admission
into the hospital, he was seized with symptoms of apoplexy, and died in the course
of a few hours. * * * An abscess of the size of a large walnut occupied  the posterior
part of the prostate, and extended into  the space between the bladder and vasa de-
ferentia  behind the neck of the bladder.  * * * An irregular ulcerated Orifice was
discovered.behind the verumontanum, through which the probe passed at once into
the cavity of the abscess."  (p. 146.)]
   1807. The treatment of  retention of urine from inflammation of the
prostate, agrees precisely with that of inflammatory retention  already de-
scribed {par. 1795;) blood-letting, leeches about the anus, baths, soothing
clysters, poultices to the perineum and the like.   If the flow of urine be
not thereby effected, the catheter must be introduced, which, however,
can never be done without difficulty and great pain; because the swollen
gland alters the direction of the urethra, on which account also a catheter
with a  long beak  is required, and sometimes  must have a large curve (1).
If an abscess form in the prostate, the introduction of the  catheter is the
only remedy; the abscess is either opened  by it, in doing which  care
must be taken  not to make  a false passage, or it bursts  of itself and the
pus escapes with the urine (2).   The catheter must remain in the bladder
till the  urine be no longer  mixed with pus.   Desault {a) recommends
cleansing injections of barley water  at the same  time.
  [(1) In reference  to the enlargement of the prostate  gland from acute inflamma-
tion, Lawrence (6)  says :—" You should avoid, if possible, the introduction of a
catheter. There is a pretty actively  inflamed substance against which, in its intro-

    (a) Above cited, p. 229.              (6) Lectures in Lancet, 1829-30, vol. ii. 
138                     RETENTION  OF  URINE,
 duction, the point of the catheter will necessarily come, and through which it must
 pass in order to enter the bladder.  The introduction of an instrument, under such
 circumstances, must be  expected to aggravate the sufferings of the patient at the
 time;  and  therefore, if you can put a stop to the inflammation, and  enable him to
 make  water without the employment of an instrument at all, it will be very de-
 sirable for  you so to  do.  Trust therefore, to antiphlogistic means, with which
 fomentations, the  use of the hip or warm bath may he combined ; and do not have
 recourse to  the use of an instrument, unless these means fail, and there should be an
 actual  necessity for relieving the patient from the danger which the difficulty of eva-
 cuating the  urine produces.   If you come then to the introduction of an instrument,
 you should  be aware of the particular change in the urethra, which the swelled state
 of the  prostate produces.  The swelled prostate does not diminish the dimensions
 of the  urethra, but it alters the course and shape of the canal in that part which goes
 through the gland; it presses the sides of the urethra together, and the swelling of
 the  prostate, the principal part of which is situated  below the urethra, that is,  be-
 tween the urethra and rectum, pushes the urethra up towards the pubes.  At the same
 time, the enlargement of the prostate in size, an enlargement which  takes place in
 all directions, increases the length of this part of the canal.  The changes then pro-
 duced  are, first, an elevation of the urethra, pushed  upwards towards the pubes, an
 elongation of the  canal in its prostatic portion, and a pressing together of the sides
 of it laterally.  The best instrument in this case is a large elastic catheter; and, in-
 deed, I should observe to you, whether you employ an elastic or a silver catheter in
 cases of enlarged prostate, you will always find it necessary to use an instrument of
full size, which will pass on much more easily than instruments of small size. The
 best instrument is, the catheter made of elastic gum, and you should use those which
 are made to retain their curved shape without a stilette.  *  * * If, however, you
 should fail in introducing such an instrument, you must have recourse to the silver
 catheter," and "the extremity of the instrument should be  prolonged, so as to repre-
 sent more than a quarter of a circle; * *  * a third or a quarter of an inch over that,
 so as to enable the end of the instrument to rise over the elevated part of the urethra."
 (p. 811.)
   Brodie advises:—"If there  be a retention of urine, the  gum catheter, without a
 wire or stilette, may, in almost  every case, be readily passed into the bladder.  It is
 better  to use a very small catheter, and to introduce it again,  whenever it be neces-
 sary to do so, than to leave it constantly in  the urethra and bladder."  (p. 145.)  As
 to the  size of the catheter in enlarged prostate, under any circumstances I must con-
 fess I  prefer the larger, as  recommended by Lawrence,  for the reasons he has
 assigned, which have been verified by my own experience; and a silver to an elastic
 catheter, on account of its greater firmness, which prevents mischief.—j. f. s.]
   (2)  "If there be reason to  believe," observes Brodik, "that abscess is formed,
 you should endeavour to  procure an external  discharge for the matter, in order to
 prevent it bursting into the urethra.  If the symptoms described  exist, and go on
 for some time increasing, and  you discover a fulness and tenderness of theperinxum,
 do not wait  for any more certain indication of abscess; but introduce  a lancet in the
 direction indicated by the tenderness and swelling.   It will  often be necessary to
 pass it quite up to  the shoulders, or even to the handle, before you reach the abscess.
 But you may do this fearlessly.   There is no danger from  any ill consequence from
 such a puncture.  If there be  abscess, you will, by this  proceeding, immediately
 relieve the distress which the patient suffers, at the same time that you prevent fur-
 ther mischief.   If, on the other hand, there be no abscess, the puncture does not
 make the condition of the patient worse than it was before.   Indeed, partly from the
 loss of blood, partly by removing the tension of the soft parts of the perinaeum. it is
 generally useful to the patient,  even when it does not answer the purpose of allow-
 ing the escape of matter." (p. 146.)]

   1808.  Swelling of  the  prostate  gland from vancosity of its  vessels
 occurs in  general, slowly,  in old persons after  previous haemorrhoidal
 ailments,  in stoppage of the bowels, after venereal debaucheries, after
 repeated claps, with sedentary living and good living, after abuse  of heat-
 ing drinks, after frequent  efforts in voiding the urine  and going to stool.
 It is  always  developed  slowly.   Emptying the  bladder  becomes more 
FROM VARICOSITY OF THE PROSTATE.           139
difficult after violent exertion, after heating food and drink and the like.
The swollen prostate is felt on introducing the finger into the rectum, but
is free from pain, and  the patient suffers  no  pain in the passage of the
urine through the urethra.   The varicosity is situated rather in the cover-
ings of the prostate ; the substance of the gland itself is therewith some-
times soft and spongy, sometimes tense and hard.
  1809. If this disease have any distinct cause, it must be removed.  In
general, taking  away blood from the perineum, clysters of cold water or
decoction of oak bark with alum, are sufficient.  The introduction of the
catheter is  in  this  case  always difficult, and  the  circumstances above
mentioned {par. 1807) should be always borne in mind.   Sometimes a
swollen vessel is torn  in passing the catheter, in  consequence of which
bleeding occurs, which gives  relief.   The inlying of a catheter  is  here
necessary for the purpose of compressing the swollen vessels, and by its
accompanying  irritation  to excite their contractile activity.   The treat-
ment is always  tedious, and no cure is to be expected under  six or eight
weeks.
   1810. Hardening is the most common  diseased  change to which the
prostate gland  is subject.   It occurs after previous slow inflammation,
most commonly after  forty years of age,  and earlier  if the urethra be
affected, especially  in scrofulous subjects and  in those who when young
have indulged  in venery;  after repressed  eruptions on the skin, and as
the  consequence of gout and the like (1).  It always proceeds  slowly;
voidanCe of the urine becomes difficult, and is sometimes completely
stopped.   The  prostatic  humour is  sometimes exceedingly copious and
viscid.  The direction of the urethra is changed according as the right,
left  or middle  lobe  of the gland  is  swollen.   The hardened prostate is
felt  by examination through  the rectum; the patient has  difficulty in
going to stool; a discharge of  mucus-like fluid, an unusual sensation
about the rectum after going to stool, as if the  bowel were not completely-
relieved.   All the symptoms described {par. 1675) as belonging  to stric-
ture, frequently accompany swelling of the prostate (2).
  In reference to the secretion of a mucus- or pus-like fluid  which may accompany
the various diseased conditions of the urinary passages, it may be remarked that the
more mucus-like,  thick, pus-like deposit which the urine throws down, and which
remains loose at  the bottom  of the chamber-pot, shows a catarrhal inflammation of
the mucous membrane of the bladder; the mucus-like deposit which draws out in
threads, is elastic  like white of egg, and sticks to the bottom of the pot, characterizes
disease of the prostate; purulent deposit, and the prostate gland small, soft and flat-
tened mark its destruction by suppuration.  If on examination the prostate be  unin-
jured, the pus comes probably from the kidneys (a).  The mucus from the prostate
is not ammoniacal; the mucus from the bladder rarely appears in any great quantity
without containing some earthy parts.
  [(1) " Chronic inflammation of the prostate gland  is," says Astley Cooper (o),
"the consequence of age, and not of disease.  When this disease produces partial
retention of urine  it should be considered as a salutary process, for it prevents incon-
tinence of urine, which, in old people, would almost constantly take place were it
not for this preventive.  It makes the urine pass slower than natural, but  this may
be excused when  it is the means of preventing a continual wetting of the clothes."
(p. 239.)
  Brodie observes:—"When the hair becomes gray and  scanty, when specks of
earthy matter begin to be deposited in the tunics of the arteries, and when a white
zone is formed at the margin of the cornea, at this same period the prostate usually,
    (a) Lallemand ; above cited, p. 152.    (6) Lectures in Lancet, 1823, 24, vol. ii. 
140
RETENTION  OF URINE.
 I might perhaps say invariably, becomes increased in size.  This change in the
 condition of the prostate takes place slowly, and at first imperceptibly, and the term
 chronic enlargement is not improperly employed to distinguish it from the inflamma-
 tory attacks to which the prostate is  liable in early lite. (p. 151.)  The chronic
 enlargement of  the prostate may be said to be a disease of a peculiar kind, having
 no exact resemblance to what we meet with in any other organ.  It may, however,
 in some respects be compared to the chronic enlargement of the thyroid gland, known
 by the name of bronchocele.  Like the latter, it is generally slow in its progress, and
 frequently, after having reached a certain point, if proper  treatment be employed, it
 remains almost stationary for many years.  It is, on the whole, a rare occurrence
 for it to terminate in ulceration or abscess, and the symptoms to which it gives rise,
 are, with a few exceptions, to be referred to the influence which the disease exer-
 cises over the functions of the parts in  the neighbourhood."  (p.  154.)
  . Although enlarged prostate is especially the disease of advanced life, yet Astley
 Cooper says he has "known it occasionally occur in very young people. An in-
 stance of this kind happened in  Guy's  Hospital: a boy was admitted having symp-
 toms of stone, in consequence of which he was sounded, and the operation of litho-
 tomy was about to be performed; the  sounding, however, brought on inflammation
 of  the bladder, which terminated in the boy's death.   Upon dissection it was found
 that the symptoms for which he had been sounded were  produced by. an enlarged
 prostate." (p. 245.)
   "I have certainly seen a very few cases of it,"  (enlarged prostate,) says Law-
 rence, "in young persons, but the great majority of those you have to treat for this
 complaint are past the middle period of life." (p. 813.)
  The part of the prostate gland in general considered as  specially enlarged is that
 which John Hunter describes as that  " small portion of it which lies behind the very
 beginning of the urethra, swells  forwards like a point into the bladder, acting like a
 valve to the mouth of the urethra, which can be seen even when the swelling is not
 considerable, by looking upon the mouth of the urethra from the cavity of the blad-
 der in a dead body.  It sometimes increases so much as to form a tumour (of which
 Hunter gives two engravings^ V. and VII.) projecting into  the bladder some inches."
 (p. 188.)   It is this  same  part which  EverardHome has dignified with the name
 of third lobe of the prostate, and claimed the discovery of, without adding any thing
 to what Hunter had  said  about it, except that  of the five cases he  examined, and
 on  which he grounded his claim, " the  appearance," he says, " was not exactly the
 same in any two of them." (p.  10.)   And  yet this has got the name of Home's
 third lobe, and is so continually called in spite  of John Hunter's observation, and
 the knowledge that the French  anatomists  have long  since been well aware of it
 under the name trigone.  In reality, however, so far as I have had an opportunity of
 observing, the two principal or side portions of the gland are most commonly en-
 larged at the same time and in the same proportion as this small portion which lies
 behind.—j. f. s.
  " The next thing noticed is,"  says Astley Cooper, " that the urine has a particu-
 larly powerful smell, which arises from  its being ammoniated  in consequence of some
 urine remaining in the bladder after each discharge.  *  *  * The next symptoms
 are pain and numbness in the glans penis; sense of weight and uneasiness in the
perinaeum, relieved by pressure with the finger; pain in the back of one or both thighs,
 in the loins, and at the origin of the sciatic nerves, and in  the course of the ureters;
 the faeces are flattened, from the pressure made upon the rectum by the swollen gland.
 Persons having  enlarged prostate for any length of time, generally have, likewise,
prolapsus ani and haemorrhoids.  *  *  *  The ammoniacal smell of the urine as the
 disease advances,  becomes highly offensive, and at length the urine itself becomes
 white or milky; this appearance shows that the inflammation has  extended to the
 mucous membrane of the bladder.   If the urine be much retained, it has the appear-
 ance of coffee, occasioned by an admixture of blood with it; this leads many prac-
 titioners to suppose, for the moment, that the case is one of stone; but if you ques-
 tion the patient  for a few moments, your doubts  on this  point will be removed."
 (p. 240.)
  "Upon dissection," continues Astley Cooper, "the prostate is  found  enlarged
 sometimes laterally ;  but most frequently the enlargement is in ihe posterior part,
situated in the middle or third lobe. As the prostate enlarges it is pushed forwards, 
        FROM CHRONIC ENLARGEMENT OF THE PROSTATE.      141

in consequence of which the urethra becomes curved immediately before the apex
of the prostate; indeed, the coming forward of the prostate causes the urethra almost
to double upon itself.  The curve thus formed is at the symphysis pubis; and it is in
this situation that the difficulty on passing the catheter in diseased prostate is found.
Tracing on the course of the urethra, behind the curved part, that canal is seen much
enlarged, and the urethra itself is considerably elongated, that is, from an inch  and
a half to two inches ;  which increase of length is behind  the pubes, and it is owing
to this circumstance that you are  under the necessity of carrying on the catheter so
great a distance after its point has passed the arch of the pubes.   As to the prostate
itself, we find that it may increase to a most enormous size laterally, without giving
rise to retention of urine; but that enlargement which occurs posteriorly in the third
lobe, frequently occasions retention of urine, for the enlargement is situated imme-
diately behind the orifice of the urethra;  thus the urine collecting behind  the swell-
ing presses it against the mouth of the urethra, and forms a complete  barrier to its
passage."  (pp. "ill, 42.)
   "This tumour," (of the third  lobe,) observes Brodie, "varies in size from  that
of a  horse bean to that of an orange.  When small, it is of a conical form, with the
apex of the cone projecting into the bladder, and the basis being continued  into  the
rest  of the prostate.  When large, the basis is often the narrowest part, and it swells
out so as to have a pyriform figure towards the bladder.   In some instances, by the
side of that which I have just mentioned, there is another tumour, formed by one of
the lateral  portions, also  projecting into the  bladder.   The  canal of the  urethra,
where it passes through the  enlarged prostate, is generally flattened ;  and when the
latter is divided transversely, the urethra appears like a slit, rather than like a cylin-
drical  canal.  Not unfrequently  the enlargement of  the  prostate so alters the form
of the urethra, that, instead of pursuing a straight course through the gland, it is in-
clined first to one side and then to the other.   You would expect  the urethra to be
narrow, in consequence of the increased bulk of the parts by which it is surrounded ;
and  o it is in many instances; in others, however, it  is actually wider, being dilated
into  a kind of sinus, where it lies  in the centre of the prostate.  I have known such
a sinus to contain two or three ounces of fluid."  (pp. 152, 53.)
   (2) Astley Cooper asks:—" How, when diseased  prostate exists, are you to
know if? What are the  diagnostic signs'?   Why,  the enlargement laterally may
be readily ascertained by introducing the finger into the rectum ; but the  enlarge-
ment of the middle lobe cannot  be so learnt.   In what  way then 1   Why, by the
introduction of a  catheter or bougie, and  the latter is best;  it will be found to  stop
suddenly; you are then to introduce a catheter for the purpose of drawing off the
water; the instrument will be resisted in its common course, and you must depress
the handle a good deal, with  a view of tilting its point over the enlarged gland; thus
the end of the instrument will be rising perpendicularly, as it were, behind the pubes.
These, then, are the means you are to employ to obtain a correct diagnosis."   (pp.
242, 43.)
  "The symptoms of retention of urine from enlargement of the prostate, are  not
very different from those which occur where the retention is the consequence of stric-
ture, but the termination  is different.  I never saw," says Brodie, "a case in which,
under these  circumstances,  the bladder  had given way, as  sometimes  happens,
where  there is a retention  from stricture; but I am  informed that such a case  has
occurred, and that the bladder ruptured at its fundus is preserved in the Museum of
St. Bartholemew's Hospital."  (p. 155.)

   1811. The prognosis in this disease is always unfavourable.   Only in
the  beginning is there hope of being able to disperse the hardening; in
advanced  cases, the distease  may sometimes be diminished,  and  the  pa-
tient's condition may  be rendered tolerable by the  inlying of the catheter.
At the first a corresponding antiphlogistic treatment must be employed ;
afterwards  issues  and  blisters to the  perineum, rubbing in volatile lini-
ments with  camphor, mercurial ointment, iodine  salve, suppositories of
cicuta  and opium;  internally,  cicuta, mercury,  decoction of daphne meze-
reon, uva ursi,  and the like, but especially hydrochlorate of ammonia in
  Vol.  iii.—13 
142            TREATMENT OF RETENTION OF  URINE
 increasing doses (a).   If the  hardening  have a definite cause, the cura-
 tive means must be directed to it.  In introducing the catheter, the points
 already mentioned (par. 1807)  must be considered.  If an elastic cathe-
 ter  be left in, it does  not retain  its proper curve after the  removal of the
 stilette, and the urine escapes;  it is better, therefore, to use those elastic
 catheters, which have a permanent curve.
   [As to  the  treatment of enlarged  prostate, Astley Cooper says:—"Very little
 can be effected  here by medicine;  it is a disease  over which medicines have but
 very little  influence.   You may, however, give the oxymuriate of mercury in very
 small quantities, for I believe I have seen it beneficial.  But this is the treatment
 only for the enlargement  of the gland.  * ..* * When no urine whatever can be
 passed, and when there is great pain at the neck of the bladder,"  he recommends to
 "take blood from the arm, apply leeches to the perinaeum, administer purgatives,
 and  put the patient in a warm  bath.  If these means should succeed in procuring
 relief, the  best medicine that can afterwards be given for the  purpose of preventing
 a return of the retention, and at the same time oflessening the inconvenience which
 sometimes attends the complaint, is composed  of fifteen drops of the liquorpotaseat,
 five  drops  of bals. copaib., and an ounce and a half of mist,  camph.  If  you  give fif-
 teen or twenty drops of the balsam  it then produces a stimulating effect, and  does
 harm; administer it  in  the  quantity just mentioned, in conjunction with the other
 medicines, to  which may be added  two drams of muc. gum. acac.  * * * Other
 medicines,, as the carbonates of soda and magnesia, the liquor potass., with o/»'wm, are
 occasionally given, but as the latter produces costiveness it is improper.  The first
 medicine will be found the best; it will afford  considerable relief, which is all that
 you  can expect, for you must not dream of making a cure."  (pp. 243, 44.)
  Lawrence says :—" In the case of this chronic enlargement of the  prostate, we
 have not much powex of relieving  the  patient by producing any great redaction of
 the  affected part.  * * *  By attention, however, to diet, careful attention to the
 state of the stomach and bowels, by a course  of mild alterative and aperient medi-
 cines, we can keep the patient perhaps in a tolerable healthy state. Attempts have
 been made  sometimes to reduce this enlargement by seton or issue on the perinaeum
 or upper part of the thigh, but it  is an inconvenient course of proceeding, and one to
 which patients  are not inclined to submit."  (p. 813.)
  " When  from  any cause the vessels of the prostate are more than usually turgid
 with blood," says Brodie,  "the quantity may be diminished, and thus a reduction
 of size, to  a certain extent, may be  effected.   It is with this view that we recom-
 mend topical blood-letting,  the exhibition of gentle purgatives, a moderate diet, and,
above all, perfect rest in the horizontal  posture.  But we  are not acquainted with
 any  method of treatment  which is capable of restoring the gland to its original con-
 dition."  (p. 17:3.)
  "The treatment of retention  of urine from diseased prostate," observes Brodie,
 " is one of  the most important subjects in Surgery.   The patient suffers miserably;
his life is  at stake ;  he lives or dies according to the skill which you are able to
 exercise in his favour.   The case is altogether different  from one of retention of
 urine from  stricture.  Bougies are  of no service:  even if you pass one  into the
bladder,  no urine follows; the parts collapse  and close  as  the  bougie  is with-
 drawn."  (p. 174.)
  Astley Cooper lays down that when  "called upon to relieve retention from en-
 larged prostate, by the introduction of a catheter, the instrument should be fourteen
 inches in length, and a  quarter of ah inch in  diameter.  In consequence of the
 pressure within, a broad instrument will answer better than a narrow one, for being
bulbous at the end it will  readily ride over the enlargement.  When introducing the
 catheter, you will meet with no difficulty until you Teach  the curve which the en-
 largement of the gland has  produced in the urethra ;  the handle of the instrument is
 to be here slightly raised, for the purpose of insinuating the  point through the curved
 part.  Having passed this you are then to depress the handle completely between the
 thighs, so  as to occasion the point of the instrument immediately to rise perpen-
  (a) Fischer ;  in Rust's  Magazin, vol. xi.  Practical  Observations on tl^e Diseases of
 p. 2d4.—Cramer;  in Hufeland's Journal,  the P rostate  Gland, vol. i. London, 1811;
 1824, p. 35.—See  also Home, Everard;  vol. ii. 1818   bvc 
       FROM CHRONIC ENLARGEMENT OF THE PROSTATE.       143

dieularly above the pubes.  *  * *  This will cause  the point to enter the bladder
between the pubes and enlarged lobe.   * * *  "If it be deemed requisite to leave
the catheter in the bladder, I  should prefer," says Cooper, "one of peWter rather
than elastic gum, for it can be curved downkbefore the scrotum, and by plugging up
the end, the  patient  may move about as he  likes, and at any time  he wishes can
expel his urine.  *  * *  The pewter catheter should be quite new, and ought not to
be worn for a longer period than a fortnight, for the urine acts upon the metal, renders
it brittle, and may probably cause  the instrument to snap, if  the time be extended
beyond what  I have stated.  If there be  need  of puncturing the bladder for enlarged
prostate, it must be done above the^uoes,- but  it never need  be attempted at all if
you  can perform your duty."   (pp. 243, 45.)
   "  In instances where the bladder does not evacuate its contents completely, where
there is a constant accumulation of urine within it, the course you have to pursue,"
says Lawrence, " is to introduce the catheter regularly once or twice in the four-
and-twenty hours, so as to draw  off the  stale urine, and to  give the bladder the
opportunity of recovering its power of contraction; and after following  this up for
some, time, perhaps two or three weeks, you  generally find that  the evil is removed,
and that the patient recovers the power of completely emptying the bladder. * * *  It
is  necessary  that the catheter should be longer  than that which  is employed under
ordinary circumstances;  give  it the length  perhaps, of fourteen inches, curved as
already stated, and always use a catheter of full size.  * * * In such cases where
the smallest  catheter could not be  introduced, I have repeatedly  succeeded in intro-
ducing an instrument of this size with the greatest ease."  (p. 8V4.)
   Brodie " rarely uses any but a gum catheter.  It gives you rather  more trouble to
learn the use of the gum catheter, and to become dexterous in the management of it,
than it does to learn  the use of the silver catheter.  When, however, you have once
become familiar with the gum catheter, you will generally prefer it to the  other;
and  there is  always this  advantage in it, that when you have  succeeded in  intro-
ducing it into the bladder, it may, if necessary, be allowed to remain  there.  A
gum catheter may  be. retained in the  urethra and bladder with very little incon-
venience to the patient, which is not the case with a silver catheter."  (p. 175.)
   Brodie uses, as did  Home, the gum catheter without a wire, as a flexible, or with
a wire as an  inflexible instrument; and directs  that it should  not be mounted on a
small flexible straight wire, but on a strong iron stilette, having the curve of a silver
 catheter.   l!e begins with passing a gum catheter without a stilette; if it will enter
the bladder, so much the better; it gives no pain, does not lacerate the urethra, nor
produce hemorrhage; it may do all that is required, it can do no harm, even in a
rough hand ;  failure  will notrender it more difficult to pass another instrument.  In
difficult cases indeed it will not succeed, and  then the catheter with the iron stilette
must be used.  " You  ought not to use a catheter so large as to give pain ; but for
the most part you will find one which  is large enough to fill the urethra, without
stretching it, to be more easy of introduction than a smaller one, which approaches
to a pointed instrument, and the extremity of it is liable to become entangled in the
tumor of the  prostate.  The stilette ought to  be considerably curved ; the reason of
this is obvious,  (p. 176.)  Always bear in mind, in introducing the catheter, that
it  is to be used with a  light hand.   It should be held, as it were, loosely with the
fingers.  It will then, in great measure, find its own  way in that direction in which
there is the least resistance.  If you grasp it  firmly, it can only go where you direct
it, and it is likely to puncture and lacerate  the membrane of the urethra, and the
substance of the prostate, and to make a false passage instead of entering the blad-
der.  [Most  excellent directions and cannot  be too closely followed.—j. v. s.]   I
generally find,"  continues Brodie, "that  I  introduce the catheter best by keeping
the handle of it close to  the left groin of the patient.   I pass it as far as possible in
this position; then I bring the handle forwards, nearly at a right angle to the pubes,
and  not elevating it  towards the navel.   The next thing is to  depress  the handle,
which is to be done gently and slowly, by placing a single finger on it, and press-
ing it downwards towards the space between the thighs.  In depressing the handle,
you  generally find the point  of the catheter slide  into  the bladder.   Sometimes,
however, this does not happen until you  withdraw  the  stilette; and  in the act of
doing this, the introduction of the catheter is completed." (p.  177.) " I do not mean
to lay it down absolutely as a rule, that you should allow the  catheter to remain,
but I am certain that it is prudent  to do so in the  great  majority of  cases.  If you, 
144              TREATMENT OF RETENTION OF URINE
remove it, so abundant is the flow of urine which immediately takes place from the
kidneys, that you will find the bladder again loaded, and requiring the re-introduc-
tion  of the catheter within five or six, perhaps even within three or four hours.  It
will  be necessary to use the catheter again after another short interval, and it will
often happen, when there has been no difficulty in  the first introduction of it, that
there is  considerable difficulty  afterwards. You  avoid all  this by  leaving  the
catheter in the bladder ;  and there is another advantage in this mode of proceeding.
The  prostate is kept in a state  of more complete repose,  and in one  much more
favourable to recovery, so far as recovery can  take  place, that it would  be in, if
irritated by repeated introductions of the  instrument." (p.  180.) " You will very
rarely fail, by dexterous management,  to introduce the catheter, but you may fail,
nevertheless, in some instances.   What is to be done  under these circumstances 1
* *  * You may puncture  the bladder  above the pubes, or  you may proceed  thus:
When  all your efforts to introduce the  catheter  have been unavailing; when you
feel the point pressing against the tumour of the prostate, and unable to pass over
it, apply some force to the instrument at the same time that you depress the handle.
It will generally penetrate through  the prostate, enter the bladder by an artificial
opening, and relieve the patient; and, x)f course, will continue to relieve him, if
you allow it to remain ir. the bladder.  This mode of proceeding has been strongly
recommended by some very good surgeons, and  I am not aware  that it is attended
with danger, although it may not be without its  disadvantages.   There is reason to
believe, that in some  cases in which this  has been done, the natural  orifice of the
urethra has become so closed, that the patient could never  void a drop of urine by
his own efforts, being compelled to rely  wholly on the  catheter ever after.  Sir
Everard Home has published the history of a case of that kind, which was attended
by Mr. Hunter and himself." (pp.  181, 82.)
  With regard to the question of introducing the catheter twice or thrice a day, or,
after having introduced  it,  to leave it there, I must confess  I prefer the former, and
the use of a large silver catheter; occasionally,  it is true, there is some difficulty;
but, in general, so far as my experience has proved, the catheter, after having been
passed a few times, enters the bladder as readily as a sword into its sheath.  On
the other hand, I have  found that leaving the catheter in for a  time, is liable to
render  the bladder irritable  ; and that if at the end of a week or ten days, it be with-
drawn, it is almost invariably found encrusted, more or less, with calcareous matter,
which often renders its withdrawal difficult, and  generally causes much pain, if not
further mischief, by its roughness.—j. f.  s.]
  1812.  If in strictures of ihe urethra, complete retention be produced
either by the use of heating drinks or other excess,  or by the  progress of
the disease itself, the most  proper treatment is to introduce a fine wax
bougie, which when its point has got into  the opening  of the stricture, is
there  held, as is distinctly shown  in the vain attempts to draw it back.
So  soon as it will not move on without using violence,  it must  not  be
forced further, but allowed to remain, till  a  violent disposition to make
water come  on, when it must  be withdrawn,  and  the urine generally
flows out in a thin stream.  Some persons immediately introduce a bougie,
which generally passes further, and may remain till the urging to void the
urine comes on.   At the same time, according to  circumstances, may be
employed blood-letting, leeches to the anus and perineum, baths, sooth-
ing clysters, with opium and the  like.   After repeated  introduction of
the  bougie, in  general a thin  elastic catheter  may be passed into the
bladder.  If by these means the  danger  of the retention be removed,
then the treatment of the stricture  must be commenced according to the
former rules.

  Amussat (a) recommends the  employment of  forcing injections in cases of reten-

  (a) Archives  Generals de Medecine, vol. ix. p. 294,  1825.—Magendie; Journal  de
Physiologie, vol. vi. p. 97. 1826. 
FROM THE  STRICTURE OF THE URETHRA.            145
tion of urine dependent on stricture.  He introduces a flexible catheter, without a
beak, down to the obstruction, compresses the penis, and screws on to the end of the
catheter a gum-elastic bottle, by which  fluid can be injected and drawn out again.
Lallemand and Begin (a) think it must not be forgotten that forced injections may
be useful, if employed with moderation and prudence, and after the use of antiphlo-
gistics and attempts to introduce bougies have been fruitless; but that in such case
care must be taken not to use too great violence, for if a plug of mucus be the only
or principal cause of retention, it will give way without any violent efforts, and if
the parts  be dilated  by separating them, the  power exercised in their contraction
being equally on all parts of the urethra, which the fluid fills, it will produce severe
pain and increase the inflammation; or  what  is worse, may find some part of the
canal  which is more friable and weak, and tear it.
   [The treatment which a stricture producing retention of urine will admit of, de-
pends principally on the degree of distention of the  bladder, and the  irritability of
the patient.  Attempts should always be made to introduce the catheter both before
and after drawing  blood  quickly from the arm, and  placing the  patient in a warm
bath, so as to induce faintness.  The catheter should be used with great care" and
tenderness, to avoid the formation of false passages,  which are too frequently made
in striving to pass an instrument on these occasions.  If the catheter cannot be got
in, and the symptoms be urgent, it will  be  advisable to open the urethra from the
perinaeum, and if there be a stricture, to cut through it, so that the cure of the wound
and of the stricture may go on together.   It is better  to resort to this practice early,
if the retention be complete, rather than to wait  till the urethra burst behind the
stricture, and  extravasation of urine  take place;  as  by so  doing the  wound  heals
nearly as  after the operation for stone,  without much difficulty, and the patient is
saved from the trouble and danger  of sloughing of the cellular tissue and urinary
abscesses.  If, on the contrary, the symptoms be not urgent, and the retention have
not existed many hours, it is advisable to give  tincture of muriated iron in sufficient
quantity to produce  nausea, by which sometimes, the  spasm, which  almost  inva-
riably accompanies a stricture with  retention, is relieved, and the patient passes his
water.  Purging also of watery stools is also very often efficient in relieving reten-
tion, for which purpose a couple of drachms of sulphate of magnesia, with fifteen or
twenty drops of tartarized antimonial wine, with mint water, may be given every
two or three hours, till the medicine  operate freely, and then, generally, the water
begins to pass.  Cutting into the urethra, however, should never be deferred when
the retention is not, after a few hours, relieved, either  by these means, or by the
catheter.—j. f. s.]
   1813.  If by these  means no evacuation  of the urine can be obtained,
and the  symptoms become  urgent, then puncture of  the bladder is re-
quired.   For this purpose,  several  writers  have  recommended  breaking
through the  stricture, that is, with  a silver conical pointed  catheter to
penetrate forcibly through  the  stricture  into the bladder, to allow  it to
remain there  several days,  and  then alter a certain time to introduce an
elastic catheter for  the  purpose of keeping open the  canal  of the.urethra.
This  proceeding, which is especially founded on Desault's observations
and particularly  defended by Boyer, is unquestionably, even in the ablest
hands, most  highly dangerous,  as  tearing the urethra,  false passages,
perforation  of the  bladder, severe  pain  and  inflammatory symptoms so
easily follow  it.   The  firmer the stricture and the greater its extension,
the earlier are these consequences to be dreaded.   Only in strictures of
slight extent, which have not been thickened and increased by frequently
repeated  inflammation from previous attempts with bougies or caustic,
does this method  seem applicable.    Even  in these cases, the  use of a
conical, pointed sound, will easily  produce the  above-mentioned symp-
toms, and the use of a thick sound  with a rounded  end,  as proposed by
Mayor, is still  the most preferable, as  being accompanied  with much

       (a) Dtctionnaire de Medecine et de Chirurgie pratiques,, vol. xiv. p. 341.
                                   13* 
146                CUTTING INTO THE PERINEUM.
less danger of forming false passages and tearing the urethra.   Under all
other circumstances, if the symptoms be  pressing, puncture of the blad-
der deserves undoubted preference.
  Upon breaking through the stricture, the following may be compared :—Desault,
above cited,  p. 244.—Roux, Relation d'un  Voyage fait a. Londres, etc., p. 314.
1815.—Boyer, Traite des Maladies Chirurgicales, vol. ix. p. 232.—Cross, Sketches
of the Medical Schools of Paris.—Charles Bell, above cited, p. 148.—Ducamp,
above cited, p. 79.—Mayor, Sur le Catheterisme simple et force, etc. Paris, 1836.
Second  Edition.—A. Vidal de  Cassis, Lettre chirurgicale k  M. Mayor.  Paris,
1836.—Mayor, Sur le Catheterisme, en reponse k  une Lettre  chirurgicale  de M.
Vidal.   Paris et Geneve, 1836.—Principes fondamentaux du Catheterisme;  in Ga-
zette Medicale, vol. vii. p. 353.  1839.
               Of Cutting into the Urethra in the Perineum.

   In retention of urine caused  by stricture Eckstrqm (a) has proposed a less dan-
gerous method of effecting puncture of the bladder, and  has pursued it with happy
results..  After the patient has been placed as in the operation for the stone, a gum-
elastic catheter is carried down to the stricture, and held firmly by an assistant, who
at the same time, when the  stricture is behind the scrotum, as is usually the case,
lifts the scrotum up and stretches the skin of the perinaeum.  The surgeon, with a
pointed bistoury, then makes, nearly the length of the raphe, and in the direction
given by the sound, a cut an inch and a half long through the skin, lays bare the
urethra, that the course of the sound and its extremity can be  traced.  The patient
is then desired to strain for the purpose of making water, by doing which, the urethra
behind the stricture is. distended and hard, a eut is now made into  the  urethra to-
wards the sound, and the opening thus produced  is enlarged  to and through the
stricture and sometimes, behind it.  The point of the fore-finger of the left hand must
never for a moment during this operation leave the  point of the knife, but must serve
as a director.  The urine now springs out with violence, and the bladder is emptied;
but if this do not readily happen, on account of the palsy of the organ from disten-
tion, a female catheter must  be introduced  into the  wound, by the aid of which, the
tapping is effected.  If no severe symptoms of inflammation or irritation exist, which,
however, is very commonly  the case, a common  silver catheter No. 6 is  to be intro-
duced into the  bladder.  W'hen its extremity reaches  the wound, that is, the spot
where the stricture was, it must be continued deeper, the finger in the wound giving
it the proper direction, so that it may not slip from the urethra, but go directly into
the bladder.  When  this has been once effected, and the instrument has been left
in the bladder two to four hours, there is no fear of the least difficulty in its re-in-
troduction, and a flexible catheter of the same size may be used instead of the former,
the wound is bound up with lint, or a compress,  dipped in cold water, applied, and
it usually heals quickly.  For the purpose of  getting rid of the existing stricture,
catheters of large size must soon be resorted  to, but  there must not be too much
haste,-especially before the wound has healed.  On the other hand, should there be
inflammatory symptoms present, the introduction of the catheter must be stayed, in
order not to  increase the irritation.  The wound in  the perinaeum keeps open by the
escape of  the urine, and suppurates more or less.  Afterwards,  the above treatment
must be employed (1).
  Jameson's (b) treatment also resembles.this.
  Lallemand and Begin (c) object to  this operation the difficulty of finding with
certainty and cutting through the urethra behind  the bulb, especially in fat persons;
and the uncertainty of the true condition of the canal of tbe urethra, and of the point
behind which it must be opened.
•  [(1) I leave Eckstrom's description of the mode of cutting into the perinaeum for
retention of urine*just as Chelius lias given it, for  it cannot be better described, but

  (a) Froriep's Notizen,  vol  xvii. p.  155.  xii. p. 329.—Leger ; Dissert, de  Paracentesi
 827.                                   Urethras in Ischuria Perinasi.  Paris, 1778.
  (6) Medical Recorder, vol. vii. p. 25y vol.,    (c) Above cited, p. 347. 
INTRODUCTION OF THE CATHETER.
147
I must deprive him of the credit of having proposed this mode of treatment.  To
my own knowledge, it has been for more than thirty years  the common practice,
excepting that a silver instead of an elastic catheter is first introduced down to the
stricture as a guide, in St. Thomas's and Guy's Hospitals, and among the surgeons
brought up in those schools.  In the many months which Eckstrom spent with us
some twenty-five years since, he must have seen this very operation performed again
and again in the precise way in which  he describes it; and it was then so old, that
no one, that I am aware, laid any particular claim  to the discovery of it.  He must
not, therefore, run away with the credit of having proposed not only the best, but the
only operation for retention of urine which ought to be performed, with the single
exception of retention from enlarged prostate, in which, if an  operation for retention
be ever required, that above the pubes must be performed.—j. f. s.]
                   Of the Catheter and its  Introduction.

   1814. The catheter is a cylindrical tube of different thickness, straight-
ness and curve, corresponding to the extent  and curve of the urethra.  It
may be  either firm or flexible ;  in the former  case it is best to be made
of silver, and in the latter, of elastic gum or caoutchouc.   The* length
of the catheter is different;  for adult women six, and for  young females
five inches is  sufficient;  for adult men from  ten to eleven, and the seve-
ral periods of boyhood from five to  seven inches.   The  thickness  also
varies ;  for women two lines, for girls a line  and a half, for men two and
a half lines, and for younger males a line and a half.   The front third of
a small  catheter is slightly curved, and  corresponds to the segment of a
circle  of which  the  diameter  is  six  inches.(l); the other  parts of the
catheter are straight, and its upper end is provided with a ring on each
side.  The female catheter is only slightly curved at its front  extremity.
The front end of the instrument is rounded, and has on  either side a
pretty large and well rounded hole.  The walls of the catheter should not
be very  thin, and its surface should be well  smoothed and  polished (2).
AH catheters  should be furnished with a stilette fitting into their cavity,
and  in elastic  catheters it is best that this should be made of iron.
  A large catheter is in general more easy of introduction than a small one, because
it properly distends the walls of the urethra, and is not so easily caught in its folds
as a smaller one.  In cases, however, where considerable obstruction has to be over-
come, as  in stricture, a small catheter is passed more easily.  One oval opening on
the side of the front end of the instrument is better than several smaller ones, or than
two on opposite sides ; the little holes being easily stopped up in the former, whilst
in the latter the  necessary strength of the  instrument is interfered  with.  The prac-
tice of closing the  open end of the catheter with a round plug attached to the stilette
is unnecessary.  The curve, already directed, of the front third of the instrument, is
the most  proper; the surgeon must, however, be provided with catheters of different
curves, which are  often necessary on account of the particular seat of the obstacle.
Elastic silver catheters are useless.
  Elastic catheters, with a permanent curve, so that they can be introduced without
a stilette, are in  many instances advisable.
  The  double S (shaped) curved catheter of Petit is of no value.
  Berton (a) recommends the use of catheters, one having a curve at an inch, and
another at an inch  and a half from its tip,  so that the lengthening of the axis of the
body of the instrument makes, with the prolonged  axis of its vesical extremity, an
angle, in  the former of from 9° to 10°, and in the latter of from 14° to 15°.  These
curves  do not exceed  the smallest diameter of the urethra, which varies between
three and four lines.
           (a)  Archives Generates de Medecine, vol. xi. p. 66.  1826, May. 
148
INTRODUCTION
  Straight catheters were already known to the ancients, as proved by those which
have been dug up at Pompeii; they were but very little curved (a).
  Pare, also the two Fabricius, Rameau, Sietaud, Santarelli, and Cassus used
straight catheters for men.  Gruithuisen recommended, in 1812, straight sounds in
his proposals for crushing stones; but of  late they have been more particularly ad-
vised by  Civiale  and Amussat.  It is  therefore remarkable that Fournikr  (b)
should have claimed the priority of discovery of straight sounds, because he has used
them since 1815.
  [(1) I  prefer  the catheter with a  very open curve, indeed with the point thrown
out rather beyond the quadrant of the circle, as recommended by Chelius, so as to
form with the stem, a curve represented by the long quadrant  of an oval, of which
the long diameter is double that of the short one.  Most surgeons have a peculiar
curve of their own, and those who  have  much practice in passing a catheter, soon
find out that with which they are most dexterous.
  (2) The thickness of the walls of the catheter is a matter of great importance, be-
cause unless sufficiently stout they are continually broken in the surgeon's altera-
tion of the curve to suit the particular case which is often requisite ; and because, in
passing the instrument, if it meet with much obstacle it is liable to be broken in
the  urethra, or even in the bladder.  Catheters, as commonly made, are far  too
slight.—j. f. s.]
  1815. The introduction of a catheter (Catheterismus, Lat.; Einhfuhrung
des Kathders,  Germ.  ;  Catheterisme, Fr.) is an operation requiring dex-
terity and practice, and is not unfrequently accompanied with very  great
difficulty.  It  is  best divided  into  three stages.   In  the first stage, the
catheter passes through that part of  the urethra contained in the spongy
body.    The surgeon  grasps the penis behind the glans, with  the thumb
and forefinger of the  left hand, without compressing the urethra.   With
the thumb, the fore and middle finger of the right hand he holds the up-
per end  of the  catheter smeared with oil or lard, and introduces its point,
whilst the handle is towards the navel, into the opening of the urethra,
and then drawing the penis up with  the left hand, he pushes the catheter
down  towards the perineum..   In the second stage, in which  the instru-
ment passes through the membranous part of the urethra, when the beak
of the catheter has got beneath the arch of the pubes, the penis is let go,
and the  handle of the  instrument being sunk slowly, and but a little, the
catheter is now again pushed somewhat forwards, and in the third stage,
when the beak of the instrument has reached the neck of the bladder, is
the inclination towards the thighs first increased, and the catheter pushed
slowly forwards into  the bladder.   When the beak has entered the ori-
fice  of the bladder, the handle of the catheter is at  last sunk  completely
between the thighs.   It is most convenient for the patient to lie on  his
back during the  introduction of the catheter, but  he  may either  sit or
stand; and, not unfrequently, it  is  more readily passed in one posture
than the other. The elastic catheter, properly curved, may be used either
with or without the iron stilette.
  In the so called  tour de mailre,  the handle of the catheter is held  towards  the
thighs, and with its convexity upwards, introduced into the urethra.  When the beak
lias reached the pubes, the handle is carried round towards the navel with a half turn,
and  then sunk.   This handling is objectionable.  In very stout persons the catheter
must, at first, be introduced somewhat on one side.
  [For other observations in regard to passing the catheter, refer back to par. 1807
and par. 1811, and their notes.—j. f. s.]
  1816.  The introduction of the straight catheter requires the same  three
  (a) Cassus, M^d. Opcrat.,  vol. i. pi. iii.    (b) De PEnaploi dc Lithotritie,  Sondes
f. !•                                  droiles, etc.  Paris, 1829_ 
OF THE CATHETER.
149
stages as have been just described.  The patient must kneel on the edge
of the bed, with his thighs widely separated, and with the upper part of
the body bent forwards, or he may stand or sit upon the edge of a stool
in the same posture.  The operator sits or kneels before him, and resting
his left elbow upon  the knee of the same side, grasps both sides of the
penis with his left hand supine, draws it towards him horizontally and
introduces with the right hand a straight catheter of proper size, carrying
it with a drilling motion directly horizontal till it reach the  arch of the
pubes ; he then draws the penis still more forwards,  and sinks it together
with  the catheter, till it has  made a right  angle without  inclining  it to-
wards the perineum.   The patient then bows himself considerably for-
wards, so that the urethra and neck of the bladder are brought into a line,
and the catheter instead of following the upper wall of the urethra slips
into the  bladder.—(Mohlin)  (a).
  According to Amussat's plan  (b), the surgeon, standing on the right side or
between the legs of the patient sitting On the edge of a bed, with his feet on two
chairs, draws the penis down with the left hand, till it be parallel with the-thighs,
introduces the straight catheter with the right hand into the urethra, and  readily up
to the pubic arch ; he then  draws the penis still more down, and holds the beak of
the catheter directed upwards, which  readily passes through the membranous part
to the prostate.  If the  prostate be healthy, the hand only is usually sunk a little
more, and the point of the instrument directed upwards to reach the bladder.  If on
the other hand the prostate be diseased, the  operation is  more  difficult, and no
positive rules can be  given.  It,  however, seems  in general to be more advisable
not to sink the hand till'the instrument reach about the middle  of the prostate;  the
point of the instrument also must be endeavoured  to be carried on upon the  upper
wall of the urethra.—(Civiale.)
   1817. The introduction of the catheter must always be performed with
the greatest  caution and tenderness;  violence may cause  severe  inflam-
mation, tearing the urethra,  false passages, and great  bleeding.
  The obstacles to the passage  of the instrument  are  very various.  If
the handle of the instrument  be sunk too quickly, its beak strikes  against
the pubic bones, and a firm  resistance is  felt:  it must then be drawn
back, and introduced rather deeper before the handle is again sunk.  In
difficult cases, it may be ascertained by the finger passed into the rectum,
whether the  catheter be beneath  the pubic  bones.   If the instrument be
introduced  too low,  or  its beak  be found in a wrong direction, when'it
either pushes the membranous part into a blind sac, or thrusts  against a
fold of the internal membrane of the urethra, it must  be drawn a little
back, the ring on the right side of the handle attentively observed, and
the catheter pushed forwards in the proper  direction.   The forefinger of
the left hand passed uptherectum can sustain the proper direction of the
instrument.   The entrance of the catheter is often opposed by spasm, or
by swelling of the prostate.   In the former case the catheter is to  be held
quietly, the perineum rubbed, and then the instrument pressed forward
in the proper direction.  In  swelling of the prostate, the method  to be
adopted  has been already described {par. 1807.)  Elastic catheters, when
stopped  by any obstacle, will often pass, if the iron stilette be withdrawn
about an inch, and the  catheter then  pushed forwards.  In strictures of
the urethra, a catheter may sometimes be passed, if a bougie have  been
  (a) Nouveau Traitement des Retentions d'Urine et  des Retrecissemens de 1'Uretre par
le Catheterisme rectilligne, &c.  Paris, 1834.
  (b) P. Ecot,  Dissert, du Catherine exerceavec la Sonde droite. Strasb., 1825. 4to. 
150
OF  PUNCTURING
previously introduced, and allowed to remain some hours.   In  difficult
cases catheters of different sizes must be used.
   1818. When the catheter has entered  the bladder  it is known by its
free  motion, by the  direction of its  handle,  which  sinks  between  the
thighs,  and  by the flow of the urine, when the stilette  is withdrawn.   If
the flow be prevented  by thick mucus or clots of blood, which  get into
the holes or into  the canal of the instrument, the obstacle must be re-
moved  by injecting lukewarm  water, or  by introducing the stilette, or
the water must be  drawn off by a syringe attached to the outer end of
the catheter.
   In  paralytic retention, pressure upon the lower part of the belly is often
necessary to empty the bladder completely.
   If  there be much difficulty in introducing the catheter, it is best to let
it remain;  its aperture maybe plugged, and  it  maybe fastened by a
double  bandage and circles of sticking plaster around the penis.   The
urine must  be allowed  to  escape every  three  or  four  hours ; and every
six or  seven days a fresh one  introduced, so that it may not  get  too
much softened and encrusted.   If the patient cannot bear the inlying of
the catheter, it must be introduced as often as needful.
   If a stiff elastic or silver catheter remain in very long, or if the urethra he shorter
than usual, its beak may gradually penetrate the hinder upper  wall  of the bladder,
and cause fatal peritonitis.  In this case the urine begins to escape after five or six
days, or it escapes between the  urethra and catheter,  and symptoms of peritonitis
arise.  To prevent this the catheter  must be carefully fastened, not too closely, so
that  it do not penetrate more deeply than that the  urine may escape by its  side
openings. This may be easily managed, if whilst the urine flows,  the catheter be
pushed  a few lines in, and carefully  fastened at the moment it cases to flow.—
(Lallemand) (a).
   1819.  The introduction of the catheter in  the female is much more
easy than in  the  male.   The patient being  laid  on her back,  and  her
thighs  somewhat separated, the forefinger of the right hand, with the
catheter upon its  volar surface, is  passed  between the labia towards the
orifice  of the urethra,  which is  distinctly felt with its tip as  an  aperture
surrounded with  a little  puffy edge,  and  into it the catheter is passed.
If it cannot be managed in  this way, the  parts must be exposed so  that
the orifice of the urethra may be brought  into view.

                  OF PUNCTURING THE BLADDER.
   1820. When  in  consequence of retention of urine, the bladder is so
greatly distended, that dangerous  results, as mortification,  tearing of the
bladder, or extravasation  of urine, are to be dreaded,  and  the voidance
of the urine cannot be effected by the natural passage, there  remains no
other means of safety for  the patient  than emptying the bladder by  arti-
ficial  means, or puncturing  the   bladder, (Paracentesis  Vesice, Lat.;
Blasenstich, Germ.; Ponction  de  la Vessie, Fr.,) as it is  called.   This
operation  is rarely  necessary,  if  the  introduction  of  wax or catgut
bougies, elastic catheters, and  a mode of treatment corresponding to the
character of the retention, have  been carefully pursued.  It is, however,
bad  practice to dispense  with  this operation, by trusting to the violent
introduction  of the catheter, in cases of insurmountable obstacles in the
   (a) Perforation de la Vessie  par les Sondes fixes: in Revue Medicale, vol.  ix., p. 299.
 1822, Nov. 
THE BLADDER.
151
urethra.   Puncturing the bladder is not so dangerous an operation as by
many supposed ; its danger is only much increased when it has been too
long delayed.
  1821.  Puncture of the bladder maybe performed in three ways: first,
above the pubes ;  second, through the rectum, and in women, through the
vagina;  third, through the perineum,
  1822.  In puncturing the bladder above the pubes, the patient must be
placed in a half sitting  posture in  bed.   The hair of the pubes having
been  removed, an assistant fixes the bladder with both hands, and holds
it in the  mesial line,  corresponding to the linea alba.   The surgeon puts
the nail  of the  forefinger of  his left hand upon  the  upper edge of the
pubic symphysis ; holds with the whole  right hand a somewhat curved
(Flurant's) trocar, lays  his forefinger on its Convex  surface, and. places
it with the concavity downwards, close above the  nail of the left hand
upon the white  line, and thrusts it through the walls of the  belly into
the bladder.   When the trocar has penetrated from two and a half to
four inches deep, according to the thickness of the  walls, the operator
grasps the tube with the fingers of the left hand, and draws the stilette
out  with the right.  The urine  now  escapes by the tube,  and  being
assisted  by pressure  on the belly, is gradually discharged.  In order to
prevent  the sharp edge of the instrument injuring or  irritating the walls
of the bladder as it contracts, another silver tube with  a blunt end is to be
introduced thr'ough it, through the side openings of which the  urine can
escape ;  its Other end is furnished with a stay. (a).   For fixing the inner
tube, a  cleft  compress is to be  so applied, that the  tube may lie in its
cleft.  The vertical  part of a T bandage  is to be  crossed  before  and
behind the tube and fastened to the girdle  part.  The outer  tube must
be fixed by bandages,  drawn through  the  openings  in its outer end, to
the girdle-piece  of  a T bandage.   To  prevent the  inner tube drawing
back, tapes must be introduced through  its rings, and attached to the
openings of the outer tubes.
  The direction to thrust in the trocar an inch to an inch and  a half above the pubic
symphysis rests on the notion that the bladder, in its ascent above the symphysis, is
separated from the hind  wall of the belly.  However, in puncturing high, the danger
of wounding the peritonaeum is greater, and the bladder may more easily slip away,
when it contracts, after the  urine has been voided.  In very stout persons, if the
bladder be not very full, it may be proper to make a previous cut of an inch and a
half long  through the coverings in the same place above the pubic symphysis, in the
white line, till the bladder can be distinctly felt with the finger.
  The curve of the trocar should be a segment of a circle of eight inches diameter
(Desault;) its length must vary according to the bulk of the body, but should not
be less than five inches.
  It is objectionable to  introduce a second  tube, with a rounded end, or a flexible
catheter, through the first, and to withdraw it, as the urine will escape  by the side
of the smaller tube.
   1823. After the operation, the urine must be discharged by the  tube
as often  as  is  necessary. If inflammatory symptoms arise or continue,
corresponding remedies  must be employed.  Towards the seventh  day,
the tubes must be removed to be cleaned.   The inner tube must be first
withdrawn, and then a  curved steel  cylinder having been introduced
  (a)  Zang, Op rationen, vol. iii.  pt. ii. pi. i.  The same mode of proceeding, though
with a different obj ct, is directed  by  D schamps, Traite historique et d.igmatique de la
Taiillc, vol. iv. pi. viii. 
152   PUNCTURING THE BLADDER, THROUGH THE RECTUM ;

into the  bladder, through the canula of the trocar, the canula  must be
drawn over it, and after having been cleansed, must be returned upon it.
  During the after-treatment, attempts must be made  in  every possible
way to restore  the  natural  passage for  the  urine.   When this can be
effected, and a  flexible  catheter have been introduced into  the  bladder,
the tube may be withdrawn; and then, whilst the surrounding coverings
are held back with one  hand, the opening is to be covered with sticking
plaster, and  if  it will not close, must be frequently touched with lunar
caustic.
  In changing the tubes care is always necessary for a long while, because the union
of the  bladder with the hind surface of the abdominal muscles is frequently not suffi-
ciently firm for a considerable time.  A previous cut through the covering prevents
this adhesion.  When, therefore, the reopening of the natural passage is impossible,
the trocar must be,thrust directly through the coverings, the tubes safely fastened,
and the urine discharged less frequently through the tube, which must not be changed
before the eighth, day, and  then only with the greatest care, the patient kept quiet,
and when union between tbe bladder and  abdominal muscles  has taken place, an
elastic catheter maybe introduced  into the bladder.  Schreger (a) proposes, by
means of loops introduced  into the walls of the bladder, by the sides of  the trocar
tube, to bring them into contact with the walls of the belly, and encourage their
union.
  Upon puncturing the bladder above the pubic symphysis, the following works may
be consulted:—
  Mery; in Histoire de l'Academie des Sciences.   1701, p. 378.
  Bonn, above cited.                               •
  Mursinna, Neue medic.-chirurg. Beobachtungen, p. 391.  Berlin, 1796.
  Palletta, Delia Punctura della Vesica orinaria; in Giorn. di Venezio, vol. ix.
p. 217.
  Desault, GSuvres Chirurgicales, vol. iii. p. 317.
  Meyer, Dissert, de Paracentesi Vesicae.  Urlang., 1798.   4to.
  Soemmering, above cited, p. 52.
  Schreger;  in his Chirurgischen Versuchen, vol. i. p. 211.
  Abernethy, Surgical Works, vol. ii. p. 189.
  Kothe, Wiirdigung der  Methoden des Harnblasenstiches; in Rust's  Magazin,
vol. xvii. p. 281.
  [Betton ; in American Journ. of the Med. Sciences, vol. xix. p. 389.
1836.—g. w. n.]
  1824.  In puncturing the bladder through  the rectum, after having
cleared  the  rectum with a clyster, the patient must be laid on the edge
of a bed, so that the depending thighs may  be bent and supported apart
by assistants.   The surgeon introduces  his  finger oiled into the rectum,
about six lines  above the prostate gland ; then carries the curved trocar,
with its  point retracted, upon it, to the  part where the finger determines
the puncture should -be  made.   The handle of the trocar is now sunk
against the buttock,  and at the same time the point thrust forwards out
of the canula, and the trocar pushed in the axis of the pelvis to the depth
of an inch to an inch and a half.   The stilette is then withdrawn, whilst
the left hand  steadies the tube.  The urine having flowed through the
first tube, a second, with  a rounded  end, is introduced, and both fixed
by  means of a cleft compress and T  bandage, and tapes drawn through
the rings.
  The works which may be consulted on puncture through  the rectum are
  Pouteau, Melanges de Chirurgie, p. 500.  Lyons, 1760.
(a) Above cited, p. 231. 
THROUGH THE PERINEUM.
153
  Hamilton; in Philosoph. Trans., vol. xvi.
  Reid, A., An Enquiry into the merits of the Operations used in Obstinate Sup-
pressions of Urine.  London,  1778.  8vo.
  Klosse,  Dissert, de Paracentesi Vesicae urina per intestinum  rectum. Jena,
1791.  8vo.
  Home, Everard; in Trans, of a Society for the Improvement of Medical and
Surgical Knowledge; and in Practical Observations on the treatment of Strictures
in the Urethra and the Oesophagus, vol. ii. p. 329.  Second Edition.
  Carpue, History of the High Operation for the Stone, p. 176. London, 1819. 8vo.
  1825. Puncturing the bladder through the perineum, is the most ancient
practice, but  at present almost entirely given up.   In this operation,
either the urethra and neck of the bladder are  opened directly by a cut
in the perineum or the cut is made  upon a staff,  (boutonniere,) into the
neck of the bladder, or the bladder  is pierced with  a trocar, which is
thrust in either  directly in  the  middle of a line supposed to be drawn
from the ischial tuberosities  to the raphe, two lines in front of the edge
of the anus, the point of the instrument being directed  first parallel to the
axis of the body, and then thrust somewhat inwards; or a  cut an inch
and a half long is made half an inch to  the left side of the raphe, begin-
ning beneath  the bulb of  the urethra,  and  ending by the verge of the
anus, through the cellular tissue and muscles; whilst an assistant presses
the bladder down,  the operator's forefinger of  the left hand introduced
into the wound, ascertained  its position, and then upon it he carries a
thick grooved trocar, directed somewhat upwards into  the bladder.  The
urine having been discharged, the outer wound is lightly filled with lint,
the tube plugged and  fastened as in puncture through the rectum.
  For a careful recital of the various methods of proceeding in puncturing the blad-
der through the perinaeum, see
  Poller,  Ueber den Harnblasenstich in Damme.  Erlang., 1813.  8vo.
  Upon the various modes of using the Sound, see
  Desault, above cited, vol. iii. p. 320.
   1826. Although opinions agree upon the undoubted  preference of
puncturing the bladder above the pubic symphysis, and through the rec-
tum, to that through the perineum, yet do they differ in regard to the first
two modes of operation.
  In regard to puncture above the  pubes, it is  considered as easily per-
formed and slightly painful; that by  it merely the  coverings of the belly
and one part of the bladder are injured, where it usually is not inflamed,
and where it  can  be  best treated ; that the  bladder cannot be missed,
that the after treatment is easier, extravasation of urine does not so rea-
dily occur, and  the tubes  if they accidentally fall  out, can be easily re-
placed, and may be changed  and cleaned with little trouble;  and that
the patient can go about whilst they remain in.   On the other hand, the
slipping off of the bladder from the tubes after the discharge of the urine,
by its falling together, and by the pressure on it, if it  descend very low,
inflammation and suppuration of the hind wall of the bladder, and thrust-
ing the tube into the rectum, are to be dreaded  ; also  if the urine be not
completely discharged, that a part of it  always  remains in the bottom of
the bladder.
  For the preference of puncturing through the rectum, it is alleged that
the walls of the bladder and rectum are in closer contact, that the trocar
has no thick parts to penetrate, and therefore the operation is not painful;
  Vol. hi.—14 
154   PUNCTURING THE BLADDER THROUGH THE PERINEUM.

that the swelling of the bladder is more perceptible, and failure in intro-
ducing the trocar less possible.   On the  contrary,  it is thought  that in
this operation the bladder may be missed, a blood vessel, or the seminal
vesicles, or the peritoneum wounded ;  that its effects are always greater,
the escape of the tubes, infiltration of the urine, collection of pus and con-
sequent urinary fistula, are to be feared.
   1827. The  objections to  the puncture above the pubes  are of little
value, as in  performing it with a  curved trocar,  and by the introduction
of a blunt tube,  no injury to  the hind wall of the bladder can ensue, and
the escape of the urine can be furthered  by the proper position of the
patient. This mode of operation, therefore, serves generally, but is espe-
cially preferable over that through the rectum in those cases where  the
bladder is inflamed or otherwise  diseased, in hardening of the  prostate,
in diseases of the rectum, specially in hemorrhoidal swellings, and if the
discharge  of the urine  through the operation-wound must be long sus-
tained, Or  throughout life.
   As to the objections made to puncturing through  the rectum, it may be
replied, that the injury of the seminal vesicles may  be easily avoided by
passing the  finger in deeply, and thrusting the  trocar directly into  the
middle of the swelling ;. that wounding the peritoneum is not easily pos-
sible, because in  the elevation of the bladder,  the space between  the
prostate and that membrane is  increased ;  and  the slipping out of  the
tubes, in many  cases, cannot produce any inconvenience,  as the  urine
either flows out through the  opening, or the bladder again fills. The
preference, however, of the  puncture above the  pubes always  continues
the greatest.   As peculiar indications for puncturing through the  rectum
may be held, a very deep-seated  bladder, effusion  of blood into it, and
an  overweening dread of the patient about an  operation, in which case it
can be done through the rectum,  without his knowledge.
  Poller (a), in cases where the operation above the  pubes cannot be performed,
prefers that through the perinaeum to the puncture through'the rectum, especially if
it be foreseen  that  the retention of urine may be continued a long time after the ope-
ration.   In  the puncture ihrough the perinaeum, there are also some special objects
attainable, as the emptying calcareous  concretions in permanent disposition  to form
stone, and the removal of the danger of ischury in consequence of large stones, which
cannot be removed.
   [But few surgeons in England, I believe, at the present time, ever perform either
of the operations for puncturing the bladder as above described, except in the single
case of enlarged prostate, in which the operation above the pubes should be performed;
and indeed as  regards that disease, the necessity for any artificial assistance, beyond
that of introducing a catheter, is  so rare, that it is scarcely thougbt of.  In all cases
the operation of opening the membranous part of the urethra, and introducing a cathe-
ter into the bladder, which is,, and has been for many  years past,  commonly prac-
tised in this country, is the most satisfactory and the most effectual.  If there be
stricture, it is the surgeon's fault if the stricture and  the  retention be not  cured at
one and the same time; and, to a certainty it prevents  the possibility of mischief
from extravasation, as the urine  speedily flows by the wound, and is never pent up.
There is neither difficulty nor danger in this  operation.  With common attention,
the urethra may, in most cases, be found, and a catheter at once passed into the blad-
der.  If it cannot be found, as occasionally happens with young operators,  who cut
light through the urethra before  they are aware of it, if the cut be continued more
deeply, the bladder must be opened, if the wound be carried up in the axis of the
pelois;  and if it be not opened, it is not matter of great  consequence, provided there
     (a) Above cited, p. 47.—Mondiere ; in Revue Medicalc, vol. ii. p.  319. 1841. 
THE CESAREAN OPERATION.
155
be a free external opening, as in the course of a few hours the urine will find its way
into the wound, and be readily discharged ;  and in cases of stricture, if the stricture
be so far forward that it be not involved in the wound in the perinaeum, made by the
knife, or by sloughing, if urine be extravasated, it generally relaxes so much that it
can be cured by the ordinary treatment with bougies, or sounds, during the  repara-
tion of the wound in the perinaeum.—j. v. s.]
               IV.—OF THE CESAREAN  OPERATION.
(Sectio Caesarea; Gastrohysterotomia, Leparo-Metrotomia, Lat.;  Kaiserschnitt, Germ;
                         Operation Cesarienne,  Fr.) s
  Rousset, Traite nouveau de l'Hysterotomokia, Paris, 1581.   Translated also into
Latin by Bauhinus.  Basil,  1582.
  Rulea, Traite de l'Operation Cesarienne.  Paris, 1704.
  Simon, Recherches  sur  l'Operation  Cesarienne; in Mem.  de l'Acad. de Chi-
rurg., vol. i. p. 623 ; vol. ii. p. 308.
  Kaltschmiot, De Partu Caesareo.  Jen., 1750.
  Stein, G. W., Praktische  Anleitung zur Kaisergeburt.   Cassel, 1775.
  Weissenborn, Observations duae de Partu Caesareo.  Erford., 1792.
  Frevmann, De Partu Caesareo.  Marb., 1797.
  Hull, John,  M. D., A  Defence of the Caesarean  Operation,  &c.   Manchester,
1798, 8vo.
  Gaillardot,  C, Sur l'Operation Cesarienne.  Strasb., 1799.
  Stein, G. W., Geburtshulfiiche  Abhandlungen.  Part I.   Marb., 1803.
  Ansiaux,  N., Dissert, sur l'Operation Cesarienne  et la Section de la Symphyse
des Pubis.   Paris, 1803.
  Nettmann, J. F.,  Speciem sistens Sectionis  Caesareas Historiam.  Hall, 1805.
  Graefe,  C. F., Ueber Minderung der Gefahr beim Kaiserschnitte nebst der Ge-
schichte eines Falles, in welchem Mutter und Kinderhalten  wurden; in Journal fur
Chirurgie und Augenheilk, vol. ix. p. 1.
  Michaelis, G. A., Vierter  Kaiserschnitt der Frau Adametz, mit gliicklichem Er-
folge fur Mutter und Kind; in Neue Zeitschr. fur Geburtskunde, vol. v. p. 1. Ber-
lin, 1837.
  Kavser,  C, De eventu Sectionis Caesareas.  Havniae, 1841.  8vo.
  Rigby, Edw., M. D., A System of Midwifery.  London, 1844.  12mo.
   [Gibson, W., On Hysterotomy or Caesarean  Section, in Institutes and
Practice of Surgery, vol.  ii.   Philadelphia,  1845.—g. w. n.]
   1828.  When the pelvis  is  so narrow that a child  cannot be brought
into the world at all by the natural  passages, or not  alive, the delivery
must be effected by some other than the natural way,  that is, by the arti-
ficial opening of the belly and womb.
   1829. The  circumstances demanding the Caesarean operation are first,
when the  antero-posterior diameter of the outlet of the pelvis is less than
two and a half inches, and the child is alive ; second, when  there  is  so
great narrowing of  the  pelvis, that the  dismemberment of the child is
impossible.
  When it is not quite certain the child is  alive, perforation should be preferred to
the Caesarean operation; as it should be also in misformed children.  If the mother be
against the operation, her voice must be attended to.  In doubtful cases, for instance,
when the signs which declare for and against the life of the child are of equal value,
the choice of the operation is not to be  left to her decision, if she resolve upon it
during the labour.
  [" The difficulty of deciding upon the operation, according to the indications of the
Continental practitioners, is," observes Rigby, "much more perplexing  than ac-
cording  to that  which is followed  in this country. The question here is, can the
child, under any circumstances, be  made to pass per vias naturales with safety to the
mother ?  The impossibility of effecting this object is the sole guide for our decision. 
156
THE CESAREAN OPERATION.
In using the operation as a means for preserving also the life of the child, we must
not only feel certain that the child is alive, but that it is also capable of supporting
life, before.we can conscientiously  undertake the operation  upon such indications.
This uncertainty as to the life or death  of the child  greatly increases the difficulty of
deciding. Under circumstances where there is  reason to  believe that, although the
child may be alive, it is, nevertheless,  unable to prolong its existence for any time,
and the pelvis so narrow that it can only be brought through  the natural passage
piecemeal, we are certainly not authorized in putting an adult and otherwise healthy
mother into such imminent danger  of her life, for the sake  of a child which is too
weak to support existence.   Circumstances may, nevertheless, occur, where the
pelvis is so narrow that the child cannot be brought even piecemeal through the na-
tural passage; in this case, even if the child be dead, the operation becomes unavoid-
able.  Under the above-mentioned  circumstances,  it is the duty of the surgeon to
perform the operation; and  he can do it with the more confidence, from the know-
ledge of many cases upon  record, where  it has succeeded, even  under very unfa-
vourable circumstances, and where it has been performed very awkwardly; more-
over, it seems highly probable, that the unfavourable results of this operation  can-
not often be attributed to  the operation  itself,  but to other circumstances.  Not,
unfrequently, the uterus has been so bruised, irritated  and injured, by  the violent and
repeated attempts to deliver, by turning or  the forceps, and the patient so exhausted,
and brought into such a spasmodic and  feverish state, by  the  fruitless pains and
vehement efforts, together with the anxiety and restlessness which must occur under
such circumstances, that it is impossible for the  operation to prove successful."
(pp. 154, 5?.)]
   1830. In a pregnant woman just dead,  the Cgesarean operation should
be  performed,  if pregnancy be  so  far advanced, that the child is capable
of living, if the delivery be not possible by the natural  passages, and the
mother actually,  not apparently,  dead (a);  in which case the operation
must be undertaken as quickly as  possible.
  [The importance  of the actual death of the mother being put, beyond all  doubt,
previous to  undertaking the  operation, under these  circumstances, cannot be too
strongly impressed.  A medical friend, on. whose veracity I can rely, told me of an
instance in which a practitioner in the country, presuming that a  pregnant woman
labouring under typhus fever was dead, began the performance of the Caesarean ope-
ration,  the pain of which arousing her from her dead-like state, she screamed out, and
soon died.  He lost his practice, and was  obliged to leave the place.—j. f. s.]
   1831. The  Cesarean' operation, partly on  account of the very large
wound it inflicts, partly  on account of the symptoms which  follow after,
is'a most exceedingly  dangerous operation.   The number of patients
saved  is very  few, in  comparison  with  those who  have died after it.
Cases, however, are mentioned, where the operation has been performed
two, five, six, and  seven  times,  upon the  same person  {b).   A more
favourable result is to be expected,  if the patient's health  be good; if
she have not  suffered  from  previous disease, fruitless labour-pains, or
artificial attempts at delivery, and if the  operation be  undertaken  at the
right time.
  [MIchaelis, who has very carefully inquired into the subject,  has considerable
doubts of the authenticity of many of the cases of repeated Caesarean operation on the
same,woman, which have been related by the writers of the seventeenth and eigh-
teenth  centuries; for, as he observes,  "it must be considered remarkable that no
writer, as it seems, relates*the circumstance at first hand, that is, from the surgeon
himself; for in  No. 3, (the woman who  stated she  had  been  operated on thrice,)
No. 7, (the ship's captain who declared himself the sixth son of whom his mother
  (a) Rigaudeaux ; in Journal des Scavans,  Sommer ; in Rnssischen  Sammlungen fur
1749.                                  Naturwissenschaft und Heilkunst, vol. i. pt.
  (6) Simon; above cited, p. 636.—Le Mai-  iv. Leipz., 1817.—Lochek, J. T., M. D.; in
stre ; in Journ. de Medec, vol. xliv. 1812.—  Med.-Chir.  Trans., vol. ix-xi. p. 182. 
THE CESAREAN  OPERATION.
157
 had been delivered by this operation, and that she died in her seventh pregnancy,
 because the surgeon who had previously operated on her was deceased,) No. 8, (the
 Minorite, the fifth son of another in this same way delivered of all her children,)
 and No. 9, (the woman mentioned by Count Tressan, who had been delivered by
 the Caesarean operation seven times,) the woman, or the sons who related it, are not
 of sufficient credit.  To this must be added, that some of these histories rest alone
 upon hearsay, or onsuspicious witnesses.   Thus  was it, for instance, with Count
 Tressan's case, at a time when, at least in France, literary intercourse was very ac^-
 tive, that it seems incomprehensible how BAUDEL0CQUE,in the  Recueilperiodique de
 la Soc. de Med., vol. v. p. 63 to 74, in which he gives a collection of sixty-six cases,
 from the year. 1752 to 1799, should never at all have  thought of this most remarka-
 ble case of all; and  it is almost beyond belief, that it should remain' for Count
 Tressan to discover such a case."  (p. 5.)   "This inquiry, therefore, leads to the
 single result, that the old cases of often-repeated Caesarean  operation must at least
 remain very doubtful.  If, however, we be disposed to give credit one way or other,
 yet there is little benefit to knowledge from the want of old precise data, as, on the
 whole, the case of Adametz alone  shows the possibility of an often repetition of
 the operation."  (p. 6.)
   The most satisfactory inquiry into the result of the Caesarean operation is that
 made by Kayser  (a), who  divides the history into two periods; the former termi-
 nating with Simon's Essay in 1749, and the latter from 1750 to the publication of his
 own paper.  Of the two hundred and fifty eight cases collected  in the first period by
 Michaelis, to some of which reference has  been already made, several rest on very
 slender authority.  Of the three hundred and thirty-eight cases in the second period,
 one hundred and twenty-eight had a fortunate  result, as regarded the life of the mo-
 ther;  whilst two  hundred and ten terminated  fatally;  or a mortality of 62 per cent.
 It appears, however, from the following table, that the fatality  of the operation has
 been diminishing  since 1750:—
          From 1750 to 1800 there  were  37 successful  80 fatal cases.
           „   1801 „  1832      „     54      „     94      „
           „   1833 „  1839      „     37      „     36     „

                                       128           210
 Or in a decreasing ratio of 68, 63, and 49 per cent.
   Where labour had lasted more  than seventy-two hours,  the mortality was 72  per
 cent.;  in those where it had continued a less time, only 61 per cent.
   According to  Kayser's inquiries, it appears, that " in one hundred and  twenty-
 three cases the cause of death was stated with  more or less accuracy ; and it appears
 that seventy-three  women died from inflammation, or its consequences, and twenty-
 nine from the shock to the nervous system.  Internal haemorrhage occurred in ten,
 in  whom coagula  of  blood were found  in the abdomen; two  died  from  external
 haemorrhage, two  from pneumonia, one from rupture of the uterus, and  consequent
 haemorrhage, on the seventh day after delivery; one died from osteomalacia, and one
 from the immediate effects of the operation, only twenty-four hours after its com-
 pletion."  (p. 129.)
   Michaelis's own case is the most remarkable and best authenticated of any that
 have been published.   The  woman  was delivered four times  by the  Caesarean
 operation.  The account of the first three is  given  by Feist  (b), and of the fourth
 by Michaelis himself (c).
   The woman was born at Wilster, in Holstein, in 1795,  and was so ricketty that
 she was only able  to walk a little when in her twelfth year.  She became pregnant,
 and  on the morning  of the 18th  June,  1826, all other  means of delivery being
 inefficient, the Caesarean operation was performed  by Dr. Zwanck, of Eddelack.
   (a) Cited at the head of the article.  lam list  as complete  as possible of all  well au-
very sorry that I have  been unable to lay thenticated cases) is by no means new, but
hand on  this Inaugural  Essay; and  am, it has  never been  executed so well as by
therefore, compelled to  refer to the very Kayser."  I hope, however, at a future oc ■
meagre  extracts from it in the British  and casion to be more successful.—j. f. s.
Foreign Medical  Review,  vol.  xiv.  p. 199,    (b) Neue  Zeitseh. fur Geburtskunde, vol.
1842, in which the reviewer observes :—" It iii.
is true  that this task (that of presenting a    (c) Cited at head of article.
                                     14* 
158
THE CESAREAN OPERATION.
The placenta was separated and removed immediately after the child, which appeared
to have been some time dead, had been extracted, the womb contracting strongly;
but this was followed by a severe bleeding, which was stopped by dropping cold
water from a sponge, at a height of some feet.  The edges of the external wound
fell so completely together that there was not need of sutures, and sticking plaster
was alone applied.   Shortly after  three weeks it had healed; before a month  she
left her bed, and two months from the operation  menstruated.  On the 21st Jan.,
1829, she was again in labour, at the Lying-in Hospital  at Kiel, where the Caesarean
operation was performed on her by Wiedemann : the child was born alive.  The
external wound was brought together with three stitehes and  sticking plaster, and
a small tent left in the lower angle of the wound. On the  21st Feb. she got up
from her bed for some  hours, and was very well.  In the  beginning of March the
wound was perfectly healed, except a few points  of skin and a small sinus, which
had not healed when she left the house at the latter end  of that month.  On the
28th March, 1832, she  was in Kiel Lying-in  Hospital, again subjected to the Caesa-
rean operation, which was performed by Michaelis, and the child born alive.  The
womb contracted imperfectly on the removal of the after-birth, and there was then
first a slight flow of blood from the womb, which was stopped in a few minutes by
a stream of water from  a sponge.  Four sutures were put into the skin-wound, with
a small portion of linen into its lower angle, and sticking plaster afterwards applied
with a circular roller.  The wound was healed, excepting a very small part of the
scar, by the 16th May; but on the 25th, a small  fistulous passage was discovered
running into the womb, which had become firmly adherent to the walls of the belly.
On the 10th June the fistula was healed (a)].
   1832. The favourable time for this  operation is that at which nature
would, under other circumstances, expel the foetus ;  when, for instance,
mucus, streaked with blood, flows from the generative  parts; when  the
mouth of the womb  is wide open, the waters have escaped, the head or
any  other  part of the child is perceptible, and the labouring woman has
suffered  already actual,  painful, quickly following labour-pains, nearly
approaching convulsions.  (Graefe.)
  ["Although it is  so important," says Rigby, "that we should lose no time, still,
nevertheless, it does not appear desirable to  operate before labour has commenced,
to any extent;  for, unless the os uteri has undergone a  certain degree of dilatation,
it will not afford a  sufficiently free exit for liquor amnii, blood, lochia, which, by
stagnating in the uterus, after the operation, would soon become irritating and putrid,
in which case they would be apt to drain through the wound, and create much mis-
chief." {n.  155.)]
   1833. The preparation for the  operation consists  in  emptying  the
rectum with clysters, and the bladder with  a catheter.   The instruments
required for  this  operation are  a convex-edged  and a button-ended
straight  bistoury, a director,  bandages,  and  several  needles.  The
position  of the patient should be  horizontal, upon her back, with  the
upper part of her back somewhat raised, on a narrow table, covered with
a  mattress; she should also be covered with a  cloth at those  parts  not
interfering with  the operation, and should  be held by assistants.   Her
face should  be turned from the operator, or covered with a thin cloth.
   1834.  To prevent the protrusion of  the  intestines through the wound
in the walls of  the  belly, moderate pressure with  the  hands is  usually
employed.  Auterieth proposes the previous  introduction of ligatures
before the womb is  opened, and Rietgen, a girdle of plaster.   Graefe
more properly makes well-regulated pressure with three sponges, each a
foot long, six inches wide, and three inches thick,  held by assistants, so
  (a) Michaelis, G. A.,  M. D., Abhandlungen aus dem Gebiete der Geburtshulfe.  Kiel,
1833, large 8vo.; with eight plates.  Extracts from the same in Neue Zeitsch, fur Geburt-
skunde» voL iii. p. 438.  By Feist of Mainz. 
THE CESAREAN OPERATION.
159
that a space about eight inches long, and from three to four wide, is left
clear.   If intestines be found between the womb and the wall of the belly,
which may be ascertained by the yielding elastic condition  of the latter,
they must be first thrust back by gentle pressure, till a convex, unyielding
firm hard bpdy be felt in  every  direction.   At the very moment when
the  last part of the child  escapes, the sponges must  be more firmly
pressed, by the  assistants.
   1835. The seat and  direction  of the cut has been variously proposed.
   First. The Lateral  Cut, on  the side where there  is  the  greatest
prominence of the belly, or, directly opposite it (a), by the side of the
white line,  more or less distant from it, in or near the  m. rectus abdo-
minis, between the navel and the pubic bones, and a little obliquely from
above downwards and  outwards (b).
   Second. The  Cut in the white line, beginning from above or below the
navel, to an inch and a half or two inches above the pubic symphysis (c).
   Third. The Transverse Cut, upon the side, where the womb is most
prominent between the m.  rectus and the spinal column, and between
the false ribs  and the crest of the hip-bone, above or below the navel {d).
   Fourth. The Oblique or Diagonal Cut, the direction of which is from
the extremity of the lowest false  rib to the horizontal branch of the pubic
bone of the  other side, obliquely across the white line, so that the middle
of the cut falls immediately upon it. (e).
   1836. The choice and direction  of the  cut, with  its accompanying
advantages, are not in  general determinate, but must  be guided by the
particular  circumstances of  the  case,  especially by  the position  and
direction of the womb, the  pretty well known seat of the  placenta, the
position of the child, the  size of the space between the navel and the
pubic symphysis, and the like.   As the placenta is most usually on the
right side, though it  may be also on the left, preference  has been given
to the cut on  the left side rather than to that on the white line.   In this
cut the outer  and inner walls are  parallel, all fluids escape  more readily
from the wound; the wall of the  belly is at this part thinnest; in open-
ing it no blood  vessel is wounded, and the healing of the wound in the
linea alba is as  quick as  in any other partnf the wall of the  belly.  In
the  diagonal  cut the womb, after the operation, contracts so  that the
wound in it does not gape.  The same also happens with the  oblique
cut; in it, however, the wall of the belly is cut through at its thickest
part, and vessels are wounded.   That part is to be specially considered
as the  best where the womb and  the child can be most distinctly felt.
   1837. The operation consists  of the following steps :—first, the open-
ing of  the  belly-wall; second, the  opening of the womb;  third, the

   (a) Millot, Observation sur l'Operation    (c) Guerin, Histoire de deux Operations
dite Cesarienne, faite aver  succes.  Pari?,  Cesariennes.  Paris,  1750.—Baudelocque,
1796.  Observations sur les Causes et les  L'Art des Accouchemens, vol.  ii.  Paris,
Accidens de plusieurs Accouchemens  la-  1807.—Deleurye, Observations sur l'Opera-
borieux.  Paris, 1750. 8vo. Second Edition,  tion Cesariennes a la ligne blanche.  Paris,
   (b) Rousset, above cited.—Levret, Ob-  178B.
eervations sur les Causes et les Accidens de    (d) Lauverjat, Nouvelle  Methode de
plusieurs  Accouchemens laborieux.  Nouv.  pratiquer l'Operation  Cesarienne.  Paris,
Edit. Paris, 1780.  8vo—Stein, Abhand-  1788.
lnnar von der Kaisergeburt.                (e) Stien, Geburtshulfliche Abhandlungen.
                                    vol. i. p. 125.                    s 
160
THE CESAREAN OPERATION.
drawing forth of the child and of  the  after-birth ; fourth, the closing of
the wound.
   1838. The skin and abdominal muscles are to be cut through to the
peritoneum in one of the directions  given, {par. 1835,) with a convex
bistoury.   Any vessel wounded  must be  tied;  a small opening  is then
made into the peritoneum to admit the forefinger of the left hand, and
upon it the button-ended bistoury is  introduced and divides the perito-
neum the whole length of the outer wound.  A cut is then made in the
white line, as no vessel can be there wounded, bearing in mind the thin-
ness of the  expanded wall  of the belly, with  one stroke  through the
coverings and peritoneum.  A length of  five inches  for the cut in the
wall of the belly is sufficient, and  of four and  a half inches for that in the
womb is generally to be considered sufficient.  The womb now present-
ing itself in the wound, of a bluish-red colour, its cavity is to be cut into
with the convex bistoury to  a small extent, and the wound enlarged in
the direction of the outer wound,  as quickly as possible with the button-
ended bistoury introduced on the forefinger.  The child, grasped accord-
ing to its position, by the  head or feet, is to  be drawn out, but not too
hastily, and  the navel-string tied and divided.  If the opening of the
womb fall upon the middle of the placenta the cut must be quickly en-
larged, the placenta cut through,  the child pulled out, and  the placenta
separated.  If the cut light  upon the edge  of  the placenta, it must be
separated.  If the separated placenta  present itself  in the wound of the
womb,  it must be separated by a  gentle pull  upon  the navel-string and
by a not very quick twist.  If this be  not sufficient, it must be separated
by introducing the hand into the womb.
  Wigand's (a) proposal of pushing the navel-string with a curved rod through the
mouth of the wound  into the vagina is objectionable.
  If the womb do not, by its own contraction, descend into the pelvis, it must be
cautiously thrust down (6).
  Various kinds of knives for the Caesarean operation have been recommended by
Stein (c), by Flammano, with a removeable sheath (d), by Zeller (e), and Mes-
nard's knife and scissors (/).
   1839.' After the blood,  which has escaped into the cavity of the womb,
has been sopped up" with fine  sponge dipped in warm water, the mem-
branes, which by  stopping up  the mouth of the  womb  prevent the flow-
ing  away of the blood, are  to be removed, the blood poured into the
belly gently pressed out, and any  of the intestines which have protruded
having  been replaced, the edges  of the wound  are brought  together by
the assistants, and closed with the sutures  {g), which are introduced with
needles of sufficient breadth, in such way, however, that the lower angle
of the wound, in which a  strip of oiled linen is to be placed, may remain
open for the escape of fluid.  To support the closed  wounds, some pieces
of sticking plaster, from  four to  five inches and  a half in width and
length, are to be put on,  and once and a half surround the belly, their
middle placed on the back, and the  ends brought  forwards crossing in

         (a) Drei Geburtshulfliche Abhandhingen, p.  96. Hamburg. 1812.
  (b) Geburtshulfliche Abhandlungen.        (e) Schnetter's Verzeichniss der chirurg.
  (c) Anleitung zur Geburtshillfe, pi. vi figs. Instrumente.
3, 4.  Fifth Edition.                     (/)  Krombholz's Akologie, pi. v. fig. 30,
  (d)  Dissert,  de l'Operation Cesarienne. pi. vi.  fig.  1844.
Paris, 1811.                            (g)  Graefe, above cited, p. 25* 
THE SjESAREAN OPERATION.
161
front upon the wound and fixed obliquely below.   The open part of the
wound below is to be covered with wadding spread with ointment, and
over it sticking plaster, and the whole belly supported with a linen girdle,
having strings in front.   The patient is then  so placed in bed that the
lower angle of the wound may, as far as possible, be the most depending
part.
  [In a case operated on by Godefroy of Mayence (a), after  the womb had con-
tracted  the  edges  of the wound did not come  together, but a considerable space
remained between them ; he therefore passed some sutures of waxed double threads,
with a needle, through the whole thickness of the womb.  The wound in the wall
of the belly was also brought together by passing the needle through its whole thick-
ness, and also through the peritonaeum.   On the eleventh day, the union of the wound
appearing firm, the sutures were removed.   On the twenty-ninth day no trace of
suppuration remained, and the patient left her bed.  She recovered, and her child
had been saved.   Objections have been made by Desormeaux to sewing up the
womb, but Godefroy thinks their danger is exaggerated.
  " The most dangerous circumstance  in this (Caesarean) operation is," observes
Michaelis, " the ijnpossibility of preventing completely the effusion of the secretion
from the wound into the belly.  The choice of the seat of the  operation, as nearly
as possible parallel to the white  line, seems to be always the most important point,
for there most rarely do  the two wounds separate from  each other.  I have already
mentioned, in another case (b), the remarkable circumstance  that the wound in the
womb lies transversely,  and  sinks to the lowest angle of the wound in the wall of
the belly;  and in other instances I have observed still more remarkable varieties in
the wound and its  fatal  consequences.   It may  be hoped that  this more frequent
separation would not be  so injurious, as the secretion of the wound discharges itself
through the mouth of the womb and  the vagina.  The form which the wound as-
sumes in consequence of the contraction of the womb is, however, unfavourable for
this escape; it gapes externally, and lies close together within.   Thus was it in my
case, in  which the whole wound  in the womb  remained long open, and was in
general supported by purely mechanical means.  But when the  after-pains  very
soon subside the womb may so close, in consequence of general turgescence, before
the oncoming of suppuration, that the cure is quick and without suppuration.  It is
therefore important that the after-pains should be  very early put a stop to, if possible,
by the moderate, or even the more active use of opium." (p. 24.)]
  1840. The after-treatment must  be  the same  as  that  generally laid
down for large  wounds of the  belly, the state of the patient in  regard to
her puerperal condition  being borne in mind (c).   The dressings must
be replaced when the secretion from the wound has penetrated through,
or if there be any strangulation  of the  intestines  or omentum.   The re-
moval of the sutures, if not previously required  on account of inflamma-
tion, should not be before the eighth or tenth day, first indeed, the upper,
and afterwards the lower ones.   The vagina  and mouth  of the womb
should be examined  every day,  and every thing removed which can in-
terfere with the lochial discharge.   When  scarring begins, a well-closing
belly-band must be employed to prevent abdominal rupture, and all ex-
ertion  avoided.
  [Michaelis observes, in regard to opium:—"The employment of opium, at first
in large, and afterwards  in  small doses, I consider the  most important remedy for
the purpose of guarding  the nervous system before it become affected by so great an
injury as the operation, for moderating the pain and for diminishing reaction."  And
as to the necessity of keeping the bowels freely open, he says, that "his own expe-
rience, and  his observation of other cases, have disposed him to it; that there is
scarcely a fully described successful  case in which the relief of the bowels has not

  (a) Gazette  Medicale, vol. viii. p. 444.   (b) Pfaff;  Mittheilungen, vol. ii. p. 119.
1840.                                   (c) Upon the after-treatment, see Graefe. 
162
THE CESAREAN OPERATION.
been frequent, indeed where there has not been severe diarrhoea.   Adametz had the
bowels moved on the last occasion, from the third to the twentieth day, almost daily
six times, and on the fourth day nineteen times; that this was excessive I will not
deny; the inconvenience, however, was trifling, and, indeed, had there not been on
the fourth day so great a discharge she would have been with difficulty saved.  It
is, however, difficult to effect the relief at the proper time with the usual means. I
believe, however, that we have in ice  the safest and, in other respects, the most pro-
per remedy;  it at once operates quickly as a purgative  if some doses of calomel be
given  with it." (pp. 25,  6.)]
  1841. The following special proposals to diminish the danger of  the
Caasarean operation may be here mentioned;—First. The head of  the
child should be pressed  up against the front of the womb and the belly
by the hand passed through the pelvis up  into  the womb, and upon it
and the white  line, the  cut  made as  far as  necessary in order to hasten
the expulsion of the child (a).   Second.  After the wound is made in  the
wall of the belly, immediately the womb, the vagina, and, if  necessary,
the*mouth of the womb should be opened at a single cut, and the child
drawn out of the  womb {b).   Third. According to Rietgen (c), a  semi-
lunar cut should be made from the crest of the hip-bone  to near the  pubic
symphysis, through the skin, whilst an  assistant, standing at the patient's
left breast, thrusts down the womb from the  right side, by which the skin
over the region of the  wound is stretched.  A cut of similar extent through
the muscles follows that through the skin, care being taken not to wound
the peritoneum.  The  cellular tissue  covering  the peritoneum is  to be
loosened  with  the fingers, with the handle of the knife, or with the knife
itself, and the  cavity of the belly undermined.   The  straight director is
now introduced into the vagina,  and so directed that its point pushes the
vagina above  the middle of the right linea innominata.  The operator
now thrusts the stem  of the director through the wall of the vagina, and
enlarges the opening  with a button-ended bistoury towards the bladder.
The director is removed and the cut continued  towards the rectum upon
the right  forefinger.   If the cut can be so made that  an edge of two or
three inches of the vagina be formed  on the right half of the neck  of the
womb, it must be divided obliquely with the scissors ; the wound is then
covered and the  passage of the child  watched.   If necessary, the womb
also may be cut into on the right side.
  Rietgen (d) considers that the wound in the walls  of the  belly, made as above
directed, gives but little  width, on account of the oblique direction of the descending
fibres of the external abdominal muscle, and that for  the extraction of the child a
second cut is necessary to divide those fibres transversely.  Cutting into the mouth
and neck of the womb seems in no case to be dispensed with, and after the first cut
has been made  through the cavity of the vagina, must be immediately proceeded
with.  By thus doing, the division of the hind part of the vagina is unnecessary,and
the considerable bleeding which accompanies it is thereby prevented, and what there
is may be easily and completely stanched with a sponge dipped  in cold water.  The
best chosen part for the cut into the womb is under that fold of the peritonaeum which
passes upon the round  ligament of  the womb, and partly lies upon  it.  Astley
Cooper's hernial knife answers best for opening the womb.

  (a)  Oslander ; in  Gott. gelehrt. Anzeig.,  fen bei Entbindungen, p. 441.   Giesseu,
1813.                                1820.
  (6) Jorg, Versuche und Beitrftge, p.  263.     (d) Geschicbte eines mit  unganstigem
Leipz., 1806.                          Erfolge verrichteten Bauchscheidenschnittes
  (c)  Die Anzeigen der mechanischen Hul-  und Folgerungen daraus;  in Heidelberger
                                     klinischen Annalen, vol. i. p. 263. 
THE CESAREAN OPERATION.
163
  Baudelocque's (a) method agrees almost completely with that of Rietgen.  He
makes in the right-sided obliquity of the womb a cut upon the left side  of the belly
along the outer edge of the  m. rectus, from the navel to an inch or two above the
symphysis.  The waters are discharged through the vagina, the legs and thighs bent,
and, with the finger introduced at the lower part of the wound, the peritonaeum  is
separated throughout the whole extent of the  iliac pit, and above  the  iliac artery.
One assistant then draws back  the peritonaeum and intestines, and another keeps the
womb in its place by his hand applied to the belly.  The operator introduces his
hand into the wound, seeks for the iliac artery, and ascertains whether any branches
pass from  it around the vagina, and  if there  be, they must be tied before he  cuts
through them.   The left hand smeared with oil is now carried into the vagina, which
is to be lifted into the wound, and then cut  into as low down as possible below its
insertion into the  neck of the  womb, and the cut lengthened to four inches and a
half.  In left-sided obliquity of the womb, the cut is to be made on the right side.
Baudglocque calls this operation Gastroelytrotomy.
   Physick (6) proposes making the cut horizontal above the pubic bones, and to dig
here beneath the peritonaeum.
   Experience has'not yet decided on the value of these several methods, especially
upon the various difficulties in  bringing the child  into the world.  The  advantage of
not opening the cavity of the  belly is  counterbalanced by the tearing away and
separating the peritonaeum, from which  dangerous  inflammation, effusion, and col-
lection of pus would necessarily ensue.
    [From the account which  Michaelis has given of the woman Adametz, it is evi-
dent that,  with good reason, he considers a repetition of the operation as more likely
to be successful than the first, on account of the adhesions  which the womb acquires
to the wall of the belly.  He observes, that "the growing together of the walls of
the belly with the womb had  the most favourable  influence upon the subsequent
operations.  This union  had already taken place,  at the second  operation, at one
part;  in the  third, three places had united; in the fourth, the union was complete
as far as the cut extended.. But I consider that even a partial union has an important
 influence,  by preventing the  wound of the womb  separating so far  from the wall of
 the belly, that the secretion from the former cannot find a free passage into the latter.
 It has also the advantage in this operation that  if it (the adhesion) be above, the
intestines  cannot protrude there, but if it be  complete, there can be no protrusion.
 This would  be a  very untoward condition, if Merrem^'s  opinion  (c) were correct,
 that  'in the adhesion the wall of the belly, in the  latter half of  pregnancy, there
 would be  tearing from  the little extensible belly-wall, and thus the flying open of
the whole imperfect scar of the womb would necessarily occur; and that  'in  such
 cases it was not to be  supposed  that the foetus would  be carried its full time.'
 MeIrrem, on the one hand, draws his conclusions from one single case; but  nature,
 on the other, has other means  than theory imagines. These are, that  the adherent
 wall of the belly, or the scar,  possesses the same extensibility as the  womb itself.
 The first wound of five inches had, in the second pregnancy, lengthened itself to ten
 inches, and was four inches broad.   In the third pregnancy it was  twelve long, and
 five inches broad; and in the fourth pregnancy still larger.  The contraction of the
 scar after the fourth pregnancy was most surprising,'for although the cut itself after
 some days had diminished to half its length, although it at last diminished from five
 inches to  one, yet was the wall of the belly, at the part where  the womb adhered,
 smooth and free from fold; but where it did not adhere, were two slight transverse
 folds." (pp. 22, 3.)]

   (a) These Inaugurate.  Paris, 1823 ;  and    (fc) Dewf.es, Compendious System of Mid-
 Nouveau Moyen pour delivrer les femmes  wifery.  Philadelphia, 1824.
 contrefaites a terme  et en  travail, substitue    (c) Gemeinde Zeitschr. fur Geburtsk., vol.
 a l'Operation Cesarienne, suivi de reflexions  iii. p. 338.
 sur ce sujct, par F. T. Duchateau.   Paris,
 1824.  &vo. 
164
GASTROTOMY.
                          V.—OF GASTROTOMY.

              (Gaslroiqmia, Laparotomia, Lat.; Bauchschnitt, Germ.)

    1842. If a foetus be developed in the Fallopian tube, in the ovary, or
 in the  cavity of  the  belly, or if by bursting of the womb or vagina, it
 escape  into the cavity of the  belly, and its  extraction  cannot be effected
 by the natural passages, dangerous symptoms in regard to the mother are
 to be feared whether  the  child be alive or dead, and there be  no signs
 that it can be discharged by the process of ulceration in one way or other
 by the  natural powers, then opening  the  cavity of the belly is required'
 The other diseases  which render this operation  necessary have been
 already mentioned.
   The symptoms of an extra-uterine pregnancy are never so  manifest, that before
 the usual period of delivery the operation can be decided on; although, if it can be
 performed between the second and fifth month, the hope of a successful result is by
 far greater than when it is undertaken at the ordinary termination of pregnancy; for
 in these cases the abdominal' bowels are always  considerably altered, the whole
 constitution of the patient is greatly disturbed ;  it is not certain that the placenta can
 be completely separated;  and in the separation of the membranes,  dangerous
 bleeding is always to be dreaded.   In what way also is the  lochial discharge to be
 got rid of?  It must also be remembered that the foetus, in extra-uterine pregnancy,
 very rarely reaches the full period, that on the contrary it not  unfrequently remains
 enclosed and crumpled up in  the  membranes, which are thickened and hardened;
 or that in consequence of the  irritation of the foetus, inflammation, adhesion of the
 neighbouring parts, and throwing off the foetus, piecemeal, by  suppuration, through
 the openings of the  abscess or by the rectum, may happen;  so that, in most cases,
 it may be best to assist nature in  the discharge of the foetus, in the way just men-
 tioned, by means which encourage suppuration, and the like.  According to Heim
 (a), most violent pains, and the most pitiable and deplorable  condition may exist,
 and in one case did for ten years.
   [It is an important question,  whether a womb can be ruptured completely,
 excepting its peritoneal coat, within which'the foetus may be still retained, and so
 found by the operation of gastrotomy.   Blundell  (b) thinks it can, and gives us an
 example Barlow's  (c)  case, in  which  it  is stated "the uterus  was very thin,
 scarcely exceeding that  of the peritonaeum, and equally so  throughout the whole
 extent of the incision." (p. 159.)  Hull (d), however, considered "that the child
 had escaped through a laceration of the uterus  into the abdomen, enveloped in the
 secundines, and that Barlow had merely divided the membranes, when he fancied
 he had divided the uterus." (p. 73.) But Blundell says :—"To me it appears to
 have been a case of rupture of the muscular substance of the uterus, without rupture
 of the uterine peritonaeum." (p. 552.) Under such  circumstances the operation per-
 formed would be merely gastrotomy, and not the Caesarean.]
   1843.  When in a  tabular  or ovarian pregnancy  the  membranes en-
 closing the foetus  are  torn, or by a rent of the womb,  the foetus escapes
 into the cavity of the belly, in which latter case the patient, after severe
 suffering and labour-pains, feels suddenly easy, and has  a sensation of
 warmth spreading over the belly, the pulse small and quick, and the like,
 death in general soon follows.
   1844.  No  definite rules can be  laid down for  the  place and direction
 of the  cut.   At the part  where  the foetus  is most  distinctly felt, and

  (a) Erfahrungen fiber Schwangerschaften    (c) Medical  Records  and   Researches.
 ausserhalb der Gebarmulter; in vermischten  London,  1798.  8vo.
 Med.-Schriften, p. 368.  Berlin, 1836.         (d) Defence above cited.
  (6) Lectures on the Theory and Practice
of Midwifery; in Lancet, 1837-38, vol. ii. 
CUTTING THROUGH THE PUBIC SYMPHYSIS.
165
towards which an assistant  should press it with his hands spread flat on
both sides, a cut of about  six  inches long should be made through the
skin and muscles down to the peritoneum, which must be then divided,
as in the  Cesarean operation.   If the foetus be uncovered by the mem-
branes, it  may be removed in any convenient way; if it be enclosed, the
membranes must be cautiously separated,  the foetus, and afterwards the
membranes, if not prevented by adhesion (a), and the placenta removed.
If the foetus be partly in a rent of the womb, it must be taken out cleverly,
if possible without enlarging the rent.  If separation of the placenta be
impossible, the navel-string, after having been tied, must be left hanging
out of the wound till the placenta come  away.   The dressing and after-
treatment are the same as in the  Ceesarean operation.
   1845. If an abscess or fistulous opening have already formed, it must
be cut into or enlarged for the purpose of removing the foetus whole or
piecemeal {b).
       VI.—OF  CUTTING THROUGH THE PUBIC SYMPHYSIS.

     (Synchondrotomia, Lat.; Schoosfugenschnitt, Germ.; Symphyseotomie, Fr.)

   Camper,  Epistola  de emolumentis  Sectionis  synchondroseos Ossium  Pubis.
 Groening, 1774.
   Sigault, Discours  sur les avantages de la Section de la Symphyse du Pubis.
 Paris, 1778.
   Leroy, A., Recherches historiques et pratiques sur la Section de la Symphyse du
 Pubis.  Paris, 1778.
   Leroy, Observations et reflexions sur l'Operation de la Symphyse et les Accouche-
 mens laborieux.  Paris, 1780.
   Piet, Pensees sur la Section de la Symphyse des Os Pubis.  Paris, 1778.
   von Krapf, K., Anatomische Versuche  und Anmerkungen iiber die angebliche
 Erweiterung der Beckenhohle, u. s. w.  Part I. Wien., 1780.  Part II., 1781.
   Siebold C.,etWeidmann, Comparatio inter SectionemCaesaream,etDissectionem
 Cartilaginum et Ligamentorum, Pubis in  partu, ob angustiam Pelvis, impossibili.
 Wirceb., 1779.
   Walter, von der Spaltung der Schaambeine in schweren Geburten.  Berl., 1782.
   Micheli, J. P., Dissert, inquirens Synchondrotomiae utilitatem  in Partu difficili.
 Lugd. Batav., 1781.   4to.
   JDesgranges, Remarques critiques et Observations sur la Section de la Symphyse
 des Os Pubis; in Journal de Medecine, p. 481. 1780.
   Lauverjat, Nouvelle Methode de pratiquer l'Operation Cesarienne et Parallele de
 cette operation et de la Section de la Symphyse des Os Pubis.  Paris, 1788.
   Baudelocque, An in Partu impossibili Symphysis secanda1?  Paris, 1776.
   Salomon, Verhandeling over de  Nettigheit der Schaambenschneede, etc.  Am-
 sterdam, 1813.
   1846. Cutting through the pubic symphysis is required  in a narrowing
 of the antero-posterior diameter of the outlet of the pelvis of from two and
 a half to three inches, and in a narrowing of the transverse diameter of
 the brim and outlet of from two to three inches.
  To lay down determinate  indications for cutting through the pubic symphysis is
 difficult, as  the experiments which have been made upon the  enlargement of the
pelvic dimensions, after division  of the symphysis in dead bodies, have presented

  (a)VEiEL; in Wurtemb. Med. Correspon-  novissimoque ejus exemplo.  Viteb., 1811.
denzbl.  1840.                    #   4to.
  (6) Fiedler, Dissert,  de  Laparotomia,
    Vol. iii.—15 
166         CUTTING THROUGH THE PUBIC SYMPHYSIS.
 different results, and it has happened with this operation, as with many others, that
 it has been, on the one hand, too much vaunted, as on the other it has been unhesi-
 tatingly discarded.  The indications here given, rest on the experiments and practice
 of Ansiaux (a), from which it appears that  the pubic bones, after the division of
 their symphysis, are capable of a separation of three inches, without the sacro-iliac
 symphysis being torn; that by this separation the outlet acquires an additional extent
 of ten lines, and that by the entrance of*a part of the child's head into the  space
 between  the separated  pubic bones, a still further space of five lines is obtained.
 This proportion may, however, vary in some subjects, which, however, can pre-
 viously be just as little decided, as can any ossification of the sacro-iliac synchon-
 drosis.  In deciding, however,  upon  the results of cutting  through the pubic sym-
 physis in  the dead subject, it appears to me an important circumstance, whether the
 experiments have been  made sooner or  later after  death.
   According to Vrolick's (b) experiments, in consequence of the intrusion of the
 rump-bone in the parting asunder of the separated pubic bones, the increase of the
 pelvic space  is little, and therefore a large restriction of the cut  through the pubic
 symphysis is necessary.
   Further experience is still requisite to determine how far this operation is appli-
 cable in the artificially produced premature labour (c).
    1847. The operation  is  to be performed in  the following way:—The
 patient having been placed  on her back  on a narrow couch covered with
 a mattress, the pudenda  cleared  of hair, and  the  rectum  and bladder, in
 the latter of which the catheter is to remain, emptied, a cut is to be made
 at  the part immediately corresponding to the pubic symphysis, beginning
 half an inch above the upper edge of the share-bone, and carried down
 to the clitoris, without wounding it.  In the direction of this wound every
 thing is  to  be cut through, down to the  cartilage.   An assistant now
 presses the  bladder aside with the catheter, and the operator  introduces
 a button-ended curved strong bistoury at the lower  edge of the pubic
 symphysis, and thrusting it  along the hind surface, divides the symphysis
 from within outwards.  Any bleeding must be stanched by pressure or
 ligature.
  If the symphysis be ossified, a little straight button-ended thin saw is  to be ap-
 plied on its upper edge, and division made with some short strokes, during which
 the assistant draws the soft parts as much aside as possible.
   1848.  The share-bones now in general separate from each other, which
 the assistants holding the thighs, allow to take place but very slowly, and
 the labour proceeds by the  natural powers, or  is completed  by artificial
 aid.   If the bones do not part from each other,  the thighs must be slowly
 separated, till the space between  the divided bones has acquired two,
 two and  a half, to three inches extent.
   1849.  After delivery, the bones are to be brought together, as closely
 as possible, in doing which special caution must be had that no soft parts
 be  between them.  The wound  is united with sticking plaster, covered
 with lint  and a compress, and the pelvis supported by a close-fitting girdle
 applied around it.
   1850.  The  after-treatment is specially directed by the ensuing symp-

  (a) Clinique Chirurgicnle, p. 79.          Experiments to determine  the applicability
  (6) Versnche iiber das Zurvickweichen des  of the Sectio Ossis pubis; in Med. Commun.
heiligen Beines  sowohl   im  unverletzten  of the Massachusi tts Med. Soc, vol. i.  Bos-
Becken, als nach der Schaambeintrennung;  ton,  1808.—Coujou, C, Essai sur la Syn.
in von Siebold's Journal fur Geburtshulfe,  chondrotomie pubienne.  Paris, lb25.  4to.
vol.  i. p. 542.—von Wy, Ueber die  Ausfuhr-    (c) Reisinger, Die kiinstliche Fruhgeburt,
barkeit und den  Nutzen des Schaamfugen-  als ein wichtiges Mittel in der Entbindung-
schnittes;  in same vol. i. p.  502.—Orne;  skunst.  Augsburg, 1820. 
          BLOOD SWELLINGS ON THE HEADS OF INFANTS.      167

toms  of inflammation.  If the bladder or urethra be wounded in this
Operation, a catheter must be introduced.   If suppuration, fistulous sores,
caries, or necrosis occur, their treatment must be  according to  the usual
rules.   Inflammation of the sacro-iliac synchondrosis, consequent on the
extension and tearing  it has  suffered, requires antiphlogistic treatment.
If collections of pus form, they should  be opened early.  An  imperfect
union of the share-bones, by which lameness or halting is produced, ren-
ders the continued application of a firmly-enclosing girdle, perfect rest
and the use of strengthening baths necessary.
B.—COLLECTION OF NATURAL FLUIDS EXTERNAL  TO  THEIR
             PROPER CAVITIES  AND RECEPTACLES.
  I.—OF THE BLOOD SWELLINGS ON THE HEADS OF NEWLY-
                          BORN  CHILDREN.
  Levret, in Journal de Medecine, vol. xxxvii. p. 410.  1772.
  Michaelis; in Loders' Journal fur die Chirurgie, vol. ii. p. 657.
  Naegele, Erfahrungen und Abhandlungen, u. s. w. p. 245.
  Klein, Bemerkungen fiber die  bisher angenOmmenen Folgen  des Sturzes  der
Kinder auf den Boden bei  schnellen Geburten, p. 20.  Stuttgart, 1817.
  Palletta, J. S., Exercitationes pathologicae, cap. x. art. 1, De  Abscessu capitis
sanguine, p. 123.  Mediol., 1820.
  Zeller, C, Praesid. Naegele,  Comment, de Cephalaematomate seu sanguineo
cranii tumore recens natorum.   Heide, 1822.  .
  Hoere, C. F., De Tumore Cranii recens-natorum sanguineo et externo et interno,
annexis observationibus de cranii impressionibus et fissures.  Berol., 1824. 4to^;
with two plates; in von  Siebold's Journal fur Geburtshulfe, Frauenzimmer  und
Kinderkrankheiten, vol. v. p. 219.
  [Bushe, G. On Hsematoma of  the Head in New-born Children, in N.
Y. Med. Chirurg. Bulletin, vol. i., 1831.—g. w.  n.]
  Schcemann, J. F., Dissert, de Tumore Cranii  recens-natorum sanguineo. Jena?.,
1832.
  Pigne, Memoire sur  les Cephalaematomes; in Journ. Hebdom., vol, xii. p. 46.
1833.
  Rautenberg, Dissert, de Cephalaematomate seu Tumore Cranii recens-natorum.
Gotting., 1833.  8vo.
  Bartsch, Dissert, de Cephalaematomate recens-natorum.   Rostochii, 1833.
  Geddings, E., Observations on  Sanguineous Tumours of the Head, which form
spontaneously, sometimes denominated  " Cephalaematoma," and  " Abscessus  Ca-
pitis Sanguineus Neonatorum;" in North American Archives.  July, 1835.   [This
very interesting and elaborate monograph has since appeared in  the Amer. Journ.
of Med.  Sciences, vol. 23. 1839.—g. w. n.]
  Unger, von  der blutigen  Kopfgeschwulst der Neugebornen; in Beitrage  zur
Klinik.   Leipz., 1833.
  Burchard, J. A., De Tumore Cranii recens-natorum sanguineo symbolae.  Vra-
tislav, 1837.  4to.
  Feist, F. L., Ueber die Kopfgeschwulst der Neugebornen.  Mainz, 1839.
  Chelius;  in Heidelb. Med. Annalen, vol. vi.
  1851. Upon  the heads of  newly-born  children  there  are  not unfre-
quently observed soft, fluctuating, generally painless, circumscribed swell-
ings,  upon  which neither  the  hair nor the  skin is at first affected, and in
the interior of which, bet-veen the pericranium and the skull  blood is
collected.   It is usually seated on  the  parietal bones, more frequently
than  on the right side;  it has, however, been  observed sometimes on
the back of the head,  and on the  forehead.   It varies in size from that 
168
BLOOD SWELLINGS
of a hazel nut to that of a hen's egg, and even more.   Sometimes, though
rarely, however, it spreads  over the  whole  parietal  bone, sometimes,
though rarely, it spreads  over both parietal bones at once; several of
these tumours of different size may also exist on different parts of the
skull.   Immediately after  delivery, they are in general little raised and
stretched, but they grow more quickly or slowly in the  first few days,
when  the swelling  is less distended  and pappy, and fluctuates.  The
skin covering it, which was at first natural, afterwards assumes a shining,
grayish,  reddish-blue or violet colour, according  to  its tension and ex-
pansion.   Some practitioners (Lf/vret, Naegele, Hoere) have observed,
by the application of the hand, whilst  the swelling is on the increase, a
pulsation, or a peculiar hardness (Hf.y, Felder) in them, which, how-
ever, neither others nor  myself could  perceive.  When the base of the
swelling is pressed with  the finger,  a firm, somewhat  raised  edge is felt,
so that it seems as if a part of the bone were lost.
  Naegele's opinion (a) that the blood swelling occurs only on the parietal bone
is  in opposition to the earlier statements (b) and  to the observations of others,
(Mombert, Schneeman, Dieffenbach,  Burchard,)  who have noticed these blood
swellings on the occipital and frontal bones.
  1852.  In  its further course,  the tumour, if left alone and not immode-
rately handled, either diminishes  gradually of itself, the blood becoming
absorbed, and the pericranium re-applying itself, or, what  is more usually
the case, if the swelling be of large size, it undergoes a  peculiar sort of
metamorphosis, which consists in a  thickening  of the pericranium, and its
conversion into bone.   The  tumour has  a peculiar elasticity and parch-
ment-like condition, so that when pressed, it is like a thin plate of metal,
which after being pressed down, rises again, and has a peculiar crack-
ling.  The swelling  gradually becomes harder, and  at  last  as hard as
bone, so  that like an exostosis, it becomes firmly attached to the other
bones; and  then by degrees, in a space of time, between four and  twelve
months, it shrinks, and at last entirely disappears, so that not the slightest
trace of it can be discovered.
  This important metamorphosis, which the blood swelling undergoes, I  first (c)
described, and pointed out its influence  upon  the treatment.   Although Feist has
ascribed this observation to  Schmitt (d), and has been followed by Naegele, who
has confirmed it, and though  Naegele (e) has made  no reference to  my name on
this subject, those, however, who compare my essay of 1828, with those before and
since that time, will at least not misplace the plagiarism.
  I  first mentioned (d) that  Schmitt  had pointed  out this metamorphosis ;  and
nothing more could be said  of Schmitt's observation.  For according to Goelis,
during the treatment of a blood-swelling with caustic, when the tumour becomes as
hard as bone,  and immoveable, and is not dispersed by the maintenance of suppura-
tion  and  the use of resolvent applications, it  must   be left alone, and gradually
subsides.  But Schmitt has  asserted the  directly contrary  and decidedly  inap-
plicable explanation of this  process,  " that  the portion of bone lying beneath the
swelling, which is at first pressed by the weight of the blood is, after the absorption
of the blood, again raised up  by an oscillation depending on  its own elasticity, to
which the increased thinning of the bone, perhaps induced by its maceration in the
blood, or  the more  influential act of absorption, seems to give some probability."
  (n) Feist, above cited, p. 5-7.              (d) Salzburgh Med.-Chir. Zeitung., vol. i.
  (b) Erfabrungen und  Abhandlungen, p. p. 32-1.  1819.
247, note.—Zeller, above cited,  p. 1.          (e) Vklpeau, Traite complet <!e l'Art des
  (c) Heidelb.  klinisch. Annalen, vol.  iv. Accouchemens, vol. ii. p.  596.  Paris, 1834.
1828.                                 2d Edit.
                                       (/j Handbuch, 1829.  Third Edition. 
ON THE HEADS OF INFANTS.
169
 It may be further remarked, that this observation of Schmitt has been noticed by
 no subsequent writer, and is not even hinted at in Zeller's Dissertation.
   1853.  Any other termination of this disease, when left to itself, cannot
 well happen.   It is  indeed stated, that if the blood  can find no escape,
 it  putrifies,  is  converted  into  a  bluish, brownish,  or  soot-coloured
 substance, which is  either thinly or thickly fluid, and has either a stale
 or putrid  smell;  and as the thickening of the pericranium is prevented
 by the external discharge of the ichor, the surface of the bone is attacked,
 its whole thickness destroyed,  actual perforation of the skull takes place,
 and death  follows.  The blood-swelling may also sometimes run on to
 suppuration {a).   From my own  observation, however, as well as that
 of others,  I  hold it decided that  this result, although it may actually
. take place, is not to be ascribed directly to the blood-swelling itself,
 since, as Dieffenbach has  correctly remarked, the excess of blood, and
 the great  nutritive condition of children, strongly withstands this mis-
 chievous  effect of the  pressure of the outpoured blood.  Some other
 influences  must,  therefore,  be  added,  as improper  treatment with de-
 structive remedies, either after opening the swelling, or  disease in the
 child, by which absorption is  set  up,  and the  destruction of the bone
 produced.
   The cases in which actual perforation of the skull has been observed, confirm the
 above stated opinion, inasmuch as in all there was an opening of the tumour.  Thus
 in the case related by Naegele  (A), in which, after opening the swelling, the treat-
 ment was  unavailing;  Kraus's (c) case, Burchard's cases (d), show also this
 perforation ; but a precise statement of all the  previous conditions is wanting, and
 in one case it is even stated that there was previous catching cold of the child, and
 disease of the mother, and the treatment was  the midwife's.
   1854.  The causes  and modes of origin of blood-swellings are as nume-
 rous as the various opinions which have  been put forward in reference
 to them, so that,  many have considered their generic relations as com-
 pletely in the dark.  Experience shows  that they occur especially after
 easy and, more particularly, after quick labours ; they have  even been
 met  with after breech  deliveries,  and also after difficult delivery and
 delivery with the forceps.  That the blood-swelling is always accom-
 panied  with a diseased condition of the bone, and destruction  of its
 outer table, so that the blood oozes out of the rotten bone as  out of sponge,
 is contradicted by experience.   The roughness  of the bone,  as well as
 the destruction of the outer table, which  is^ observed,  not in all cases,
 after opening the swelling, but particularly when the opening is  made
 late, is  the consequence, not  the  cause,  and depends on  absorption.
 The opinion that the blood, by extensive  bursting, is poured out under
 the pericranium, is not proved  by observation ; and in opposition to this,
 as well  as to the  notion  of an original disease of the bone, it especially
 applies  that when such  are the actual causes the cure of the disease
 cannot so  easily  follow.  The  assumption of a mere mechanical influ-
 ence has  therefore been attempted to  be denied, in that this swelling
 arises more frequently and  immediately  after difficult delivery,  but  of
 which  experience proves   the  direct contrary.   Notwithstanding  this
 objection, the origin of these  swellings  from mechanical influence is,
   (a) Busch; Handbuch  der  Entbindungs-    (c) Gemeinsame  deutsche  Zeitschr fur
 kunst, p. 442.                         Geburtskunde, vol. vi. p. 336.
   (b) Erfahr. und Abhandl., p. 252.          (d) Above cited.
                                 15* 
170
BLOOD-SWELLINGS
 however, the most probable,  and  is  especially confirmed by their, in
 general, easy and quick cure.   We do not, therefore, trouble  ourselves
 about a considerable degree of pressure, but especially about an unequal
 pressure, and  enduring but for a  short time,  against  a  projecting or
 angular part, by which the  vessels between the skull  and pericranium
 are either torn  or so  injured, that they afterwards pour  out the blood by
 transudation, in consequence of which, the origin of the swelling is first
 apparent a few days after birth.
   The various opinions brought forward upon the  nature of the blood-swellings of
 the head, may be referred to the three following causes:—first, primitive disease of
 the bone ; second, diseased condition of the vessels; and third, mechanical violence,
 Michaelis  holds the first, that in all these swellings, the  external table of the
 bone is wanting, and  the diploe bared ; that the affection of the  bone is primary,
 and the pouring out of the blood secondary.  Palletta also speaks in a similar way.
 This opinion, however, is contradicted by many cases, in which, on opening these
 swellings, the bone has been found smooth, and the change which it, at a later
 period, somewhat suffers, is considered as the consequence of absorption, depending
 on the pressure of the blood.  This entirely groundless opinion has, however, been
 recently  again put forward by Langenbeck (a), so that the disease appears, in so
 far a vitium primae formationis as the tabula externa ossium calvariae at one part (!)
 is deficient, so that the venae diploeiicae are covered only by the pericranium, galea
 aponeurotica, and skin.   As the venae diploeiicae have very thin walls, so the blood
 either escapes from them by rhexis or by transudation, and distends the pericranium
 into a fluctuating swelling to that point, where the external  table is not deficient.
 The raised edge of bone surrounding .the swelling thus points out the place where
 the two: bones lie upon each other, at the boundary of the  hollow.   If the external
 table be not wanting, it must according to Langenbeck, be very porous, and many
 vessels penetrate it which serve as emissaria  Santorini, and are the sources of the
 blood found in it and beneath the pericranium.
   A diseased  condition of the blood vessels has been, in different ways, assumed
 as the cause of these swellings.   According to  Naegele, perhaps the varicosity of
 the blood vessels penetrating the skull, which  commence  with  the growth of the
 bones of the skull,  and are torn  previously to, or during birth, may  cause the out-
 pouring of the blood, the increase of which  after birth may depend  on  respiration
 and the new  circulation.   Stein assumes an unnatural structure  of the vessels;
 von Siebold,  a similar  condition to naevus  maternus  (teleangiectasy"!); Brandau
 and Hueter, an original weakness of the vessels, as he has found  these swellings
 only in weakly children ; Schneeman, a loose connexion of the periostewm with the
 bone is but little in well-grown children, and the rush of  blood in the  ensuing re-
 spiration ; and Lang attributed, the cause to the encircling of the neck with the navel-
 string in weakly  children,  von  Ammon  (b)  imagines,  that  according  to  the
 pathological observation  of Hcere,  Osiander, Burcharo, and others, the vascular
 system of the bones, the dura mater, as well as the pericranium, are changed by
 disease.   He  Jiimself has sometimes found the veins enlarged upon, and in the
 bones of the  head.  The  disease,  indeed,  scarcely depends upon  a deficient
 development,  but is to  be considered as consequent on  a pathological formative
 process.
   Osiander  (c)  asserts, that a small artery, mostly a vasculum emissarium tears,
 either by the blood  collecting or from pressure,  if the head  be squeezed against the
 one side of the pelvis, or by the forceps if unequally applied, and that the swelling
 therefore takes place, especially on  the parietal bones, where the emissaria Santo-
 rini are found.  Wendt, Klein, Capuron, and  Carus attribute it to the pressure on
 the head during its passage through, the pelvis; Becker (d), on  the skull-bones
 being thrust in;  Neumann (e), on the great  overlapping of the  parietal bones
 during delivery ;  Wokurba (/), on a distention of the soft parts of the headaccom-
  (a)  von Ahmon's Monatsschrift fur Medi-    (d) Hufelaxd's Journal,  vol. viii. pt. iii-
cin, Augenheilkunde und Chirurgie, vol. i.  p. 80.  18^3-
P-  '6.                                     (e) Ri sr's Magazin, vol. xxi. p. 371.
  (6)  Die Chirurgische Fathologie in  Ab-    (/) Ocstreich,  Med. Jahrbucher, vol.iv.
bildungen, vol. i. p. 20.                     p. 421.
  (c)  Handbuch der  Entbidunsrskunde, vol.
ii.  p. 308. 
ON THE HEADS OF INFANTS.
171
panied with greater or  less pressure, and depending rather on one, than on the
coincidence of several causes, in which the vessels, in consequence of the peculiar
condition of the infant organism, permit a trickling through of"the blood.   Bartsch
assumes a mechanical violence, which presses on a projecting part of the bone, (as,
for instance, the crest of the hip-bone,) for a short time, and unequally, or a violent
though short enduring irritation with which the vessels are affected, and which,
together with the influx of the blood from the commencing respiration, they cannot
withstand, and transude the blood through .the weakened walls of the vessels.
Paul Dubois (a) seeks for the  cause in the peculiar structure  of the bones of the
head.  In their still imperfect ossification, they present fibres lying near each other,
which from the elevation of the parietal bone, diverge,  as from a  common focus,
towards the periphery.  Between these bony fibres there remain small fine clefts,
which have not either the length or whole thickness of the bone.  They exhibit a
correspondently spongy structure, appear to  be penetrated with a large quantity of
blood, so that after  the removal  of the pericranium and dura mater, the blood may
be squeezed out of these pores and interspaces.  The blood appears therefore during
life to be enclosed in the interspaces of the bony fibres by the dura mater and  peri-
cranium,  and to stand in close  relation with  them.   If now one or other of these
membranes be deficient at one small part, an outpouring of blood takes place, and
this may  happen from any violence operating on the head of the foetus in its passage
through a narrow pelvis, in its passage over hard, unyielding walls, or by the appli-
cation of the forceps.  In the same way, on account of an original disposition, the
natural connexion  of the pericranium at a certain point may be so weak, that the
impulse even  of the circulation may  raise  it up.   In a similar manner, even a
disease of the bone, as it increases the influx of  blood, can produce  outpouring of
blood by its destroying the natural  connexion  of  the pericranium.  Busch (b)
observed  on the hind-head of a  child,  probably many days dead, and delivered  by
the violent use of the forceps, a  bluish, blood-sac, on opening which, there appeared
a communication with the sinus.  The opinion founded on this  circumstance  as to
the origin of the blood-swellings of the head is less to be received, as the case was
not that  blood-swelling of the  head  which we  are now considering.   Flint (c)
describes a similar case of an  outpouring of blood in  the hind-head of  a child
several days after birth, which,  as dissection  proved, was connected by an opening
in the diseased bone with the sinus of the brain; on which account, the child died
after a cut had been made into it.
   1855. The result of the  examination of the cavities of these  blood-
swellings after their previous opening during life, or on examination after
death, varies according to the different period of the course of the dis-
ease.   In the beginning, the blood  is found more pale-red, and fluid;
afterwards, a thicker, clotted, and blackish  blood, even a  tough jelly,
(Palletta,) sticking to the  bone, is  collected between the  skull and the
pericranium.  The external surface of  the  bone  is  sometimes  rather
wasted  but smooth,  sometimes rough  and eaten  away, and, under the
already  mentioned circumstances, the destruction  of the  bone  is more
considerable, and penetrating even to the  dura  mater.   At the com-
mencement of the swelling, the pericranium is firmly attached to the bone,
but afterwards, when ossification  begins from the pericranium, a delicate
bony layer is observed on its internal  surface, and, as it were, attached
to it (Krauss); and if this ossificating process extend further, a cartilagi-
nous layer with some,points of bone, or a firm bony plate appears, which
imperceptibly passes into the outer surface of the  bone at the base of the
swelling, and from which the  pericranium can be separated as easily as
from every other part of the bone.   The  cavity beneath this bony plate
is filled with a  grumous, bloody, gelatinous  mass. (Burchard.)   The
  (a) Above cited.
  (b) Edin Beitrag zur Aufklarung des Wesens der Schadel.BIutgesehwiilste neugeborener
Kinder; in Heidelberger klinischen Annalen, vol. ii. p. 245.
  (c) New England  Journal of Medicine, vol. ix. p. 112- 
172
BLOOD-SWELLINGS
upper surface of the skull  bones is rough, porous, and  intimately con-
nected with the gelatinous  mass; in some cases even perforated. (Bur-
chard.)  If when the dura mater have gradually wasted, that part of the
bone be examined, in children who  have afterwards died, where it has
been eaten away, upon  removing the skin not the slightest alteration is
found, the pericranium  is  in its natural condition, and  may be just as
well separated as at other  parts';  on the bone itself there is  observed
only  to the extent which  the  earlier blood-swelling had occupied, a
greater  thickening which especially affects the  outer table, and  on saw-
ing through the bone a greater  development of diploe; otherwise there
is no change of texture in  the  bone.  These slight variations  even are
probably entirely lost (a).
  Bukhhard, from the existence of this bony layer beneath the pericranium, has led
himself into a mistake, by supposing it ihe raised and expanded  outer table of the
bone; and hence has arisen the opinion of a blood-swelling, in which the blood is
collected between the two plates of bone.   The  falsity of this opinion is  proved by
what I have above stated as to the course of the ossifying process in blood-swellings.
It is farther completely irreconcilable with the anatomical  character of  the skull-
bones of a newly-born child, in which nothing can be said of a diploe, in its pecu-
liar sense, perhaps even only at certain parts of an external and internal plate.
  1856. The distinguishing characters of blood-swellings from  other tu-
mours on  the heads of  newly-born  children, for instance, the  common
head swelling,  (caput succedaneum,) the congenital hernia cerebri, the
so-called water-bags, and the blood-sacs, which are connected  with one
of the sinuses (Bush, Flint) are, their circumscribed, elastic, fluctuating
nature ; their usual seat on  the parietal bones, and the impossibility of
diminishing them by pressure, in which no symptoms of pressure on the
brain arise.   It must, however, be observed in reference to congenital
hernia cerebri, that when, as usual,  it happens in the sutures and fonta-
nels, its existence is proved by anatomical examination at other than at
the seat of the sutures (b).  The pulsation which is  also given as a cha-
racteristic sign in hernia cerebri, is not always distinctly perceptible, and
even in blood-swellings maybe observed;  the pulsation, however, in
hernia cerebri is always more decidedly manifest than in blood-swellings.
In hernia cerebri an actual opening in the bone can  be  felt; in  the head
blood-swelling,  when the tumour is not very tense, the bone may be felt
by pressing strongly upon  it, inasmuch as  in  these swellings  the hard
edge at its base is not formed by loss of substance of  the bone, but by
the swelling of th& soft  parts, as in common boils.  In  the blood-sacs
connected  with a sinus, the  diagnosis is founded on the perceptible edge
of the pieces of bone, and the possibility of  diminishing the swelling by
pressure.   A  blood-swelling cannot be  confused  with oedema capitis;
from  the so-called partial external hydrocephalus, in which the water is
collected under the galea aponeurotica or the pericranium itself, is a dis-
tinction scarcely possible ;  the existence of such kind of watery head is
rightly doubted.  External  violence which produces bumps, always more
or less  injures the skin, which is  tinged with blood  and discoloured.
The diagnosis of blood-swelling may be very difficult when the  ossifying
process has already proceeded far, and the tumour has  not been pre-

  (a) My observations in Heidelb. klinisch. Annalen, vol. vi. p. 541.  1830.
  (b) Hoflihg, Zwei Falle von Hirnbruch;  in Casper's Wochenschrifl. 1835.  No. 23. 
ON THE HEADS OF INFANTS.
173
viously seen.   Osiander [{a) manifestly fell  into this mistake, against
which only the  observation of its peculiar elasticity, and careful inquiry
of its earlier condition can guard us.
  Osianoer believes the common blood-swellings cannot be confused with the con-
genital diseased bone swellings, which certainly belong to those very great rarities, in
which the bone is swollen in the diploe (?), in which swelling however  the upper
table is never wanting, but  only spongy and raised.   With such swellings of the
bone nothing can be done; and cutting into them would certainly always be followed
by death.  That Osiander here has mistaken blood-swellings which had already
gone on to ossification, and has given of them, as has Burchard, a false description,
there can be no doubt.  In a case, where two swellings on the right parietal bone,
the one more than the other presented the above-mentioned conditions, and in which
several practitioners asserted a.suspicious degeneration of the bone,  I made known
the true nature of  the disease and advised its being opened;  and its fortunate result
verified my opinion, coagulated blood escaping after  the opening.  In another case
which I showed Naegele, he admitted that he should not have known it for a blood-
swelling (b).
   1857. The prognosis,  if the  disease be properly treated, is generally
not unfavourable,  if it be unconnected with syphilis or atrophy.  All
blood-swellings on the heads of newly-born children either disperse in
the space of fourteen or twenty-one days  by absorption  of the blood
poured out  beneath the pericranium,  or they subside after a  longer time,
after  the  swelling has become  as hard as bone, very gradually.  From
the fear of the bone becoming atfected from  the continuance of the blood
under the pericranium, from  the opening of  the tumour being omitted or
delayed, which  is not supported by experience, and from not knowing
what happens to these swellings if left  alone, persons have been led to
the proposal of  the most  different reasons for  their treatment.   At least
I have seen, up  to the present time, in many  cases where the pericranium
has been ossified, very large swellings subside  without a single accident,
in the course of a year.
   1858. The treatment of blood-swellings aims either at their dispersion
by increasing the activity  of the  absorbents and thus removing the blood,
or emptying the blood by opening the swelling.
   1859. The dispersion of these tumours is usually attempted by vinous,
aromatic applications, by applying a solution of hydrochlorate of ammo-
nia, lead wash diluted, arquebusade,  decoction of oak bark,  and  the like.
It appears, however,  that with the  application  of these  remedies, the
necessarily  accompanying slight compression  perhaps contributes more
to the dispersion than the mere operation  of the remedies.   I know
instances in which  the dispersion of these swellings followed simply from
compression with a pad and a close-fitting hood; and it must  also not
be forgotten that many of these swellings,  especially if they be small,
entirely subside without  any treatment.  Henschel and Schneemann
have  recommended as the most efficient remedy, compression by means
of a hood, lined opposite the seat of the swelling with several folds of
tinfoil.   In  no  case should very irritating or cold applications, or much
compression be  employed; by which  in manifold respects injurious influ-
ence might be excited.  I doubt whether there be a single case of blood-
swelling of  the  head of newly-born children, where the tumour  was left

  (a) Hnndbuch der Entbindungskunst, vol.    (b) My observations; in Heidelberg, kli-
ii.jpar. 205.  Tubing., 1821.             niscb. Annalen, vol. iv. 
 174      BLOOD-SWELLINGS ON THE HEADS OF INFANTS.


 to itself, which ever had any bad result; or in which- the opening would
 have been considered necessary: and as I formerly asserted on this point
 that  if in a  space of from ten to fourteen days, the  swelling under the
 above-named treatment had not diminished, but remained equally large,
 and was of unusually large size, it was most advisable to open it, so can
 I now from  repeated  experience  assert that this  practice  is  to  be  con-
 sidered  safe  and  free from danger.   It  must, however,  apply only to
 those cases  which occur very rarely; so that the opening is  only the
 exception, and not as most writers on this disease  have laid down, to be
 taken as the  rule.  If the process of ossification have already begun,
 nothing  must be  done  except  leaving the  swelling  entirely to itself,
 because after opening,  the upper wall cannot,  on  account  of  its firm
 nature, apply  itself, and a tedious  suppuration ensues, as I have in one
 case  witnessed.
  An early opening  is equally objectionable, because in  consequence of it there is
 often  a considerable escape of pale-red  blood, whilst in a later made cut black blood
 is discharged in no great quantity.
  The application of lunar caustic upon the swelling, and the keeping up  suppura-
 tion after the separation of the slough for the purpose of favouring the dispersion of
 the tumour, as recommended by Goelis (a), is on  many grounds objectionable (4).
   1860. Opening the swelling is  best done  with a lancet to such extent
 as to allow the blood to flow out freely.   Some threads of fine lint must
 be  placed between the edges of the  wound, and fixed with  sticking
 plaster;  and  over all a  compress and close-fitting hood.   For the first
 few days ordinarily a  somewhat  bloody, afterwards a yellowish  serous,
 and at last a somewhat purulent fluid is discharged; but on renewing the
 dressings after a few days the  integuments have generally become in
 some degree united to the skull, and the cure  soon follows.  If, after the
 opening of the swelling, the surface of the bone appear rough, the dressing
 in this simple  way must be employed.
  Opening the swelling by a crucial cut or throughout its whole length, is unneces-
 sary and improper; the introduction of a seton (Palletta) is objectionable.   The
 simple puncture of the swelling with the lancet, and closing the opening, may, if at
 the  same time dispersing remedies and a compress be used, effect a cure.  Should
 the fluid collect again, the united edges of the wound  may be  easily separated with
 a probe, and the fluid having  been discharged, the cure follows.   When Dieffen-
 bach  observed, after  small incisions, a  secretion  of ichor for several weeks, without
 the  skin adhering in  the least, and after a free opening that a speedy cure ensued,
 and when von Ammon supposes the blood-swellings more frequently heal artificially
 than by the natural powers, the cut for assisting  the discharge of the blood, the pro-
 duction of an adhesive inflammation, or of a fresh natural activity, must be carried
 deep down to the pericranium, even into the diploe, and not merely through the
 whole extent of the swelling, but into the sound  parts of the neighbouring coverings
 of the head, inasmuch as small cuts, which are rather punctures than cuts, produce
venous bleeding from the varicose vessels, difficult to be stanched, and which can
only be stopped by a proper long and deep cut.  My own experience and that of
others so completely  contradicts this, that these bad consequences must certainly be
ascribed more to some other circumstances in the treatment, the time of the opera-
tion,  and  the like, rather than to the kind  of opening.   Further,  as  regards von
Ammon's opinion, it  may be observed that what I have already sought to employ
against Burchard, applies to it also.

  (a) Salzb. Med.-Chir. Zeitung, 1822.  No.  in Salzb. Med.-Chir. Zeit., 1819. No. 21, p.
81, p.  47.—Praktische Abhandlungen iiber  327.
die vorzuglichsten Krankheiten des kind-    (b) Zeller, above cited.
lichen Alters, vol. ii. Wien, 1818.—Schmitt; 
HEMATOCELE.
175
  Hoere (a) describes a case of a simultaneous collection of blood between the
pericranium and the skull, and the dura mater and the skull, with which there was
at the same spot a penetrating cleft of the bone.  The internal swelling was as large
as a pigeon's egg, and had formed a pit  in the brain of corresponding depth.  The
outer  table of the skull was unchanged, but the inner was eaten away, and at one
place  entirely wanting; at one spot also production of bone seemed to have again
begun.  If Hoere suppose that the internal swelling had arisen first, and that by the
changes of the bone the fissure  had been dependent on the birth, when the blood
collected beneath the pericranium had sunk down during birth, for which the destruc-
tion of the inner table spoke ; yet is this a merely voluntary assumption, and incor-
rectly has  been founded upon it a division of blood-swellings  of the skull into
internal and external, a division which Burchard assumed, and added the collection
of blood between the plates of the skull as a third form of these  swellings,against
the admission of which I have already given reasons.
                        II.—OF  HEMATOCELE.

             (Hxmalocele, Lat.; Blutbruch, Germ.; Hematocele, Fr.)

 . Pott Percival, The Chirurgical  Works of, vol. ii. p. 382.  London, 1783.
  Follett, Journal de Medecine continue, vol. xiii. p. 422.
  Cooper, Sir Astley, Observations on the Structure and Diseases of the Testicle,
p. 209.   London, 1830.   4to.
  Brodie, B. C, A Clinical Lecture on Hydrocele and Hsematocele in London
Medical Gazette, vol. ix. p. 926.  1832.
  Curling, Thomas B., A  Practical Treatise on the Diseases of the Testicle and
of the Spermatic Cord and Scrotum,  p. 236.  London, 1843.  8vo.
   1861.  Hematocele is  a large outpouring of blood  into the  various
coverings of the testicle.  The extravasation  may be seated in the cel-
lular tissue of the scrotum, in the vaginal tunic, or in the  testicle  itself.
  [This division of hematocele is similar to that made by Pott; but among most
modern British surgeons the term is restricted to a collection  of blood within the
vaginal tunic alone.  Herbert Mayo, (b) however, observes :—"This term is given
to  two affections, one effusion of blood, the other of  sanguinolent serum into the
tunica vaginalis.  The latter, I believe,  may alternate with hydrocele, the secretion
being from an accidental cause dark  and turbid at one time, clear and serous at ano-
ther. It may likewise arise from blood being mixed with the serum of the hydrocele,
in consequence of a bruise on the testes, or from a vessel having been punctured in
tapping a pre-existing hydrocele."]
   1862.  The yielding nature of the  cellular tissue in the  scrotum,  the
size of its cells, and the absence of fat render the production of this out-
pouring of the  blood easy, and permits a very considerable enlargement.
The usual cause is external violence, a blow on the scrotum and the like;
also a  wound in which the bleeding vessel cannot be tied may give rise
to  it.  That severe compression of the abdominal walls whilst the breath
is held should cause hsematocele  is unlikely.    According to the size of
the injured vessel is the hsematocele more quickly or slowly formed. The
colour of the swollen  scrotum  is  more  or less violet or dark, and  the
swelling, although  tense, is usually not painful.  Similar outpourings of
blood, in women,  occur  in the labia.
  [This form  of  the disease, Pott says, "consists in a rupture of and  effusion of
blood from a branch of the spermatic vein in its  passage from the groin to the tes-
ticle.  In which case, the extravasation is made into the tunica communis, or cellular

          (a) Above cited.
          (6) Outlines of Human Pathology, p. 561.  London, 1836.   8vo. 
176                        HEMATOCELE.
 membrane investing the spermatic  vessels."  (p. 385.)  Upon this  point Brodie
 justly observes:—"The tissue here (the cellular tissue of the scrotum) is exceed-
 ingly loose as in  the eyelids, and slight  injury will rupture vessels and  produce
 ecchymosis; but the name of haematocele is here improperly applied." (p.  927.)]
   1863. This outpouring of blood,  although it  may be  consfderable,
 generally disperses by antiphlogistic treatment,  cold applications,  the
 testicle being at the same time supported with a bag truss, and rest being
 enjoined.   If this do not happen, and the  swelling become more con-
 siderable, the collected blood must be discharged by several deep cuts,
 the bleeding vessels sought for and tied; or if this be not possible,  the
 bleeding must be stanched by inserting lint moistened in some astringent
 wash, and by applying a  close fitting bag truss.
   1864. The hsematocele which arises from  a collection of blood in the
 vaginal tunic of the testicle is either  consequent on a wound of a vessel
 of that tunic in  puncturing a hydrocele, or of the tearing of swollen ves-
 sels which, in the quick drawing off the water, are suddenly deprived of
 their accustomed pressure, or it may arise from a bruising of the scrotum.
 In the former case the swelling in general arises soon after the puncture,
 in the second it is more tedious.   The diagnosis is in other respects easy.
 In the third case the swelling has a resemblance to hydrocele; it, how-
 ever, generally arises more quickly, and is not transparent.  If the blood
 be partially coagulated, the  swelling may, on account of its finer and
 irregular character, be mistaken for  a sarcocele.   Not unfrequently a
 hsematocele of distinct portions occurs without violence, but from transu-
 dation of  blood, especially in gravel, and cannot  be distinguished from
 a  hydrocele;  or there may be a bloody exudation with varicosity of the
 vessels in old and very large hydroceles, in degeneration of the vaginal
 tunic and so on, which is  only discovered in the operation for hydrocele.
 Sometimes in old persons  mortification and death quickly follow {a).
   [Brodie  says:—" Haematocele most frequently occurs in  combination with hy-
 drocele, the blood being mixed with the fluid contained in the tunica vaginalis, and
 partially dissolved  in it.   If the quantity of blood be small, which is most frequently
 the case, the solution is complete; but when otherwise, coagula are formed, which
 remain undissolved." (p. 927.)  Upon this point Imust observe that I do not recol-
 lect to have seen a single instance in which haematocele followed the operation for
 hydrocele, though I am well aware that the disease is occasionally so produced,  in
 consequence of the trocar wounding the testicle, if the vaginal tunic be thick and
 rather more than ordinary effort be used for its introduction; but I have never seen
 such a case, though I have seen many of heematocele produced by a blow.—j. v. s.
   Brodie mentions a remarkable  " case, where  the extravasation was so great that
 the tunica vaginalis was ruptured, and the  blood escaped in large quantity into the
cellular membrane of the scrotum." (p. 927.)
   Astley Cooper mentions the case of "a gentleman who had a large pyriform
swelling in the left tunica vaginalis, which  had  never been painful, and which had
an obscure fluctuation, but was not transparent.  He made an incision into it, and
discharged near a pint of fluid  blood.  This swelling had not succeeded a blow, but
was imputed to excessive exertions which this gentleman had been in the habit  of
making." (p. 214.)]
   1865. Outpouring of blood into the vaginal tunic is rarely dispersed.
Cold resolving applications and the treatment above advised (par. 1863)
may be  attempted, but if  of no advantage, the  vaginal tunic must be
opened, the blood discharged, any wounded vessel tied, and in a decided
hydrocele the  necessary treatment may lead to a radical cure (1).
(a) Exercitationes Pathologicte, p. 201. 
HEMATOCELE.
177
  [(1) Upon this  point Chelius is in error, so far as I have had opportunity of
observing these cases, as the blood  is generally absorbed without difficulty in  the
course of two or three weeks.  The contrary is the exception.—j. f. s.]
  Of the  length of time which  a haematocele may exist without causing trouble
Astley Cooper relates a remarkable instance, in which a haematocele "as large as
the double fist had existed seventeen years, had not been attended with any pain,
and its size and weight were the only inconveniences it produced.   Its cause  the
patient attributed to a  blow, in hunting, from the pummel of the saddle, which gave
him great pain for a short time.   The testes and epidymis could be-felt at the lower
part of the swelling, and above it to  the ring, a solid substance united with a fluid
could be perceived.  It was not in the least  transparent, and  he had never suffered
pain in it.  The swelling was opened, a coffee-coloured fluid, blood and solid sub-
stance of a brownish-yellow colour was discharged,  the tunica vaginalis was exces-
sively thickened, looking like the densest  parchment."  In the course of the same
day, after riding home in a coach, "he was seized with a profuse  haemorrhage from
the tunica vaginalis, andfainted.   Much constitutional excitement followed, clots of
blood and  profuse purulent discharge  ensued, and  after six weeks he  got well."
(p. 210-12.)
  More commonly, however, if the outpoured blood be not absorbed in a few weeks,
it becomes an irritant, suppuration is set up within the vaginal tunic to get rid of it;
the scrotum oh that side becomes of a dusky-red colour, and more or less tender,
and, if left alone, will sometimes point, and then clots of blood with bloody pus
are discharged, and continue till  the  whole sac is emptied, when  healthy suppura-
tion follows, and the cavity of the tunic is obliterated.  I have seen two or  three
instances  of this kind.  When its existence is suspected  it is best to make a free
cut  from top to bottom of the vaginal tunic so as to empty its contents at once,
healthy suppuration soon comes on, and the patient is cured.—j.  f. s.]
  1866.  As to the  outpouring of blood into the substance of the testicle,
it is probable that it may be  confused with some organic  changes  of that
organ', and if, in consequence  of  a violent bruising,  blood be extrava-
sated within the tunica, albuginea, and  the above-recommended treatment,
castration must be considered necessary.
  [As the formation of hydrocele has been already shown (par. 1199, note) to take
place occasionally in  the spermatic  cord, so does haematocele, as was noticed  by
Pott, who says:—" The  last species of this disease (haematocele) arises from a
bursting of a branch of the spermatic vein, between the groin and the scrotum, in
what is generally  known  by the name of  the spermatic process.   This, which is
generally  produced by great or sudden  exertions of  strength, feats of agility, &c,
may happen to  persons in the best health.  * *  * The effusion or extravasation is
made into the cellular  membrane which invests and envelopes the spermatic vessels,
and has something the appearance of a true hernia."  (pp. 391, 92.)   If discutient
remedies  be unavailing, Pott recommends the  swelling should  be cut into, and
either the bleeding stanched with styptics,  or, if the  vessel be large, that it should
be tied singly, and if that be insufficient, that even the testicle should be removed,
and the whole end tied.
  Curling says :—" An encysted hydrocele of the spermatic cord may  be converted
into a.haematocele.  In the Pathological Museum of St. Bartholomew's Hospital
there  is a preparation  of encysted haematocele of the spermatic cord.  The cyst is
empty, but it is described to have contained blood, and its walls are deeply stained
with  the colour of partially decomposed blood.   Its lining membrane is wrinkled
and coarsely granular, and the tissues around it are thickened, tawny, and adherent
together.  I lately examined  a preparation in the Hunteria'n Collection, which I
have  no doubt  is a specimen of old encysted haematocele of the spermatic cord.
There is a good sized cyst, lined by a membrane, polished, and a little wrinkled, filled
with  a  soft tawny-looking granular matter,  resembling the  altered coagulum  of
blood which I have observed in ordinary haematocele  after long maceration in spirit.
The tissues around the cyst are thickened and indurated, just like those around  an
old haematocele of the testicle."  (pp. 249, 50.)]
  Vol. hi.—16 
178
DROPSY OF THE MUCOUS SACS.
III.—OF OUTPOURING OF BLOOD INTO THE CAVITIES OF JOINTS.

   1867. A collection of blood in the cavity of a joint occurs rarely, and
is only  the consequence of a violent bruise or wrench  of a joint, or of a
wound, if the blood cannot  escape through the outer opening.   The
quick occurrence of the swelling after one of the above-mentioned causes,
distinguishes it from other swellings.
   [Hey (a) mentions an instance of blood getting within the capsular ligament of
the knee-joint in consequence of a wound, but no  harm followed, and it was ab-
sorbed without having caused any inconvenience.]
   1768. The  treatment consists in the use of cold applications, general
and local antiphlogistic  remedies, by which dispersion is effected.  In
other respects  the rules laid down {par. 557 and onwards) must be borne
in mind.
Third Section.—COLLECTIONS OF DISEASED PRODUCTS.
              I.—OF DROPSY OF THE MUCOUS SACS.

(Hydrops bursarum mucosarum,  Lat.;  Wassersucht der Schleimbeutel, Germ.;
                   Hydropisie des Bourse muqueuses, Fr.)

  Kock, C. M., Untersuchung des naturlichen Baues und  der Krankheiten der
Schleimbeutel.  Niirnberg, 1795.  8vo.
  Monro, Alexander, M. D. (secundus.)  A Description of all the Bursae Mucosae
of the Human Body, &c.  Edinburgh, 1788.  fol.
  Brodie, Sir  Benjamin, Pathological and  Surgical Observations on the Diseases
of the Joints.  London, 1834.  8vo.  Third Edition.
  Schreger, B. G., De Bursis mucosis subcutaneis ; cum ix. tab.   Erlang., 1825,
fol.
  Mayo, Herbert, Outlines of Human Pathology, p. 110.  London, 1836.  8vd.
   1869. Dropsy of a mucous sac produces a swelling, fluctuating, pecu-
liarly elastic,  in general not, but sometimes very painful; most generally
occurring  on the hip-knee-ankle-wrist-elbow-and  shoulder joints, and
having the skin oyer it of its natural colour.  At first it is circumscribed,
and does not extend over the whole joint; its extent, however, may be
very  considerable.
   [Mayo says :—" The bursa situated between  the latissimus dorsi and the inferior
angle of the scapula, is liable to become distended with a very considerable quantity
of fluid."   (p.  111.) He also observes, that " pressure will cause the development
of subcutaneous bursae in thecellular tissue, where they previously had no existence."
(ib.)  This is the common opinion, but it must  be taken with some caution, as the
number of mucous bags just beneath the skin is much greater than commonly sup-
posed, so that one  of them originally existing may only have become dropsical, and
then first only have attracted  notice.  There seems, however, little doubt that they
are actually produced sometimes, when a part is subject to great pressure.—j. f. s.]
   1870.  This disease may be produced by external violence, by sprain-
ing the joint, or by pressure ; or by cold,  rheumatic,  gouty or scrofulous
disease, and  after the  frequent use of mercury.   The cause of the un-
natural collection appears to be always  an inflammatory condition  of the
inner membrane of the mucous sac, which corresponds in  its physiologi-
(a) Practical Observations on Surgery, p. 354. 
DROPSY OF THE MUCOUS SACS.
179
cal and pathological nature to synovial membrane.  This inflammation
is at first  often very great, and  appears to be  related to the  cause on
which it depends.  The fluid is  mostly thin, sometimes more consistent,
jelly-like,  and often contains  a great number  of cartilaginous concre-
ments, of whitish colour, smooth surface, and  different size, often felt
distinctly on examination of the  joint, and made up  of coagulated albu-
men.  The membrane of the mucous sac is often very much thickened,
and nearly cartilaginous.   If the swelling be highly inflamed, it may run
on to suppuration, the pus  may be  poured out beneath the  skin, and
considerable destruction and  fistulous  passages  may ensue.  This  is
very frequently the case upon the front of the knee-joint.
   Undoubtedly  here belongs a peculiar kind  of encysted swelling, described by
Cruvelhier (a), which is most frequent on the front of the  wrist, less so upon its
back,and more rarely at the ankle-joint, but always occurring in the neighbourhood
of synovial capsules and tendons, most commonly divided  into two halves con-
nected with, but beneath each other, by an opening in the tracks of two neighbouring
ligaments, and containing besides a quantity of serous or synovial fluid, a larger or
smaller number, even up to a hundred, of oblong, smooth bodies,  composed of
numerous layers, from the size of an oat, to that of a bean.
   The mucous  sheaths of tendons are similar to mucous sacs, and the swellings
developed in  them, which contain a thin or more consistent fluid, (ganglia, Lat.;
Ueberbeine Germ.; ganglions, Fr.,) must, at least the  greater number of them, be
classed with dropsy of the mucous sacs.
   [Partial enlargements of the sheaths of tendons by the collection of  a fluid  like
synovia within them, forming what are commonly called ganglions, sometimes occur
in very uncommon situations; I have in one or two instances seen a ganglion as big
as a pigeon's egg, and very hard, from its fulness, in the inner harpstring, just above
the  knee-joint.  I have at present under my care, a young  man, who after a little
more than ordinary  exertion, had a swelling come almost suddenly just where the
tendon of the  m. sartorius turns round the upper part of the shin-bone, and extending
up into the ham, so as to have somewhat the appearance, at first sight, of a popliteal
aneurysm, and nearly as  large as a  goose egg, tense  and free from pain.  In the
 course of a fortnight it subsided under the use of cold evaporating lotions.—j. f. s.]
    1871. Among the dropsies of the mucous sacs, those are most frequent
 which are seated on the knee-cap ;  they are painless, without any altera-
 tion of colour in the  skin, soft, elastic,  compressible, of a  spongy feel,
 mostly oval,  and always  distinctly defined,  or they are  bean-shaped,
 puffy, hanging down from the knee, or more elevated in breadth.   How-
 ever variously their extent  may  exceed that of  the knee-cap, yet is their
 base, however,  always alone  confined  to  it, and has  no other  attach-
 ment; and  although the mass itself be moveable  in  every direction, yet
 the base can never be moved  from this  one spot.  The fluid it contains
 is serum, in which are  frequently similar little bodies, to those found in
 the  mucous  bags  (I).  Schreger  (b) calls  this  swelling,  which is
 usually known by the  name of Knee-fungus  (Fungus genu,  Lat.;  Knie-
 schwamm, Germ.) or as dropsy of the mucous sac  on  the head of the shin-
 bone, an encysted dropsical  swelling on the knee-cap,  (Hygroma cysticum
patellare, Lat.;   Wasserbalggeschioulst auf der Kniescheibe,  Germ.,) in
 which the serous fluid is contained in a space naturally existing upon the
 upper surface of the knee-cap,  (bursa subcutanea patellaris,) but  not in
 the mucous bag  on the head of the shin-bone (c), or in the fine plates of
   (a) Essaies sur l'Anatomie Pathologique   (c) Cooper,  Samuel, on the Diseases of
 en general, vol. i. p. 306.  Paris, 1816.       Joints, p. 74. London, 1807.
   (I)) Chinirgische Versuche, vol. ii. p. 245.
 —Above cited, p. 38, pi. ii., iii. 
180        DROPSY OF THE MUCOUS SACS, TREATMENT.

the cellular substance (a), or in a  newly formed sac like a true encysted
swelling (b).   This swelling upon  the knee-cap is to be classed with
that seated on the olechranon, in  the bursa anconea,  appears mostly in
old people, and in wrhich the above-mentioned little bodies are observed
in quantities.   These two swellings, especially that on the knee-cap are
often accompanied at first with violent inflammation.
  The mucous sacs are capable  of a degeneration in which an homogeneous, tough,
moderately  fibrous mass, connected with  their walls, is formed, and  gradually
enlarges to an enormous size.  I have  noticed swellings of this kind on-the knee-
cap and at the elbow-joint, and have removed them  successfully.  All other treat-
ment is useless.
  [(1) This enlargement of the mucous bag upon the knee-cap is so  very frequent
among women  servants, that it has acquired,  and  usually goes by the name of
" House-maid's knee."  It is also extremely common to observe the  same kind of
enlarged bag upon the back of the olechranon, but without the person's  elbow having
been subject to any frequent pressure.—j. f. s.]
   1872. The  treatment  must  be  guided  by  the  circumstances  of the
swelling, and  according to  the causes with which it  is related.  Their
dispersion  is always the object, and  if this  cannot be effected, the dis-
charge  of the  collected fluid and  the  growing together of the cavity of
the mucous sac.
   1873. If the swelling  be inflamed and painful, cold applications of
lead  wash, leeches, and rubbing in  mercurial ointment  must be  em-
ployed; afterwards when the inflammation  has ceased, or the fluid still
remains, blisters kept up for some time, or rubbing in volatile ointments.
If  the  inflammation of  the mucous  sac  be  very  severe, arising from
mechanical influence on a previously painless  swelling of the sac, and if
the swelling he very great, then usually all dispersive  remedies are use-
less,  and it must be cut into to prevent the spreading of the suppuration.
Serous fluid and floccy pus  escape,  and the trea'ment is to be the same
as after opening abscesses.   If the swelling be, as usual, painless, vola-
tile rubbings, long continued blisterings, warm douche baths, dispersing
plasters, and the like are employed,  together with  which those remedies
are made use of which counteract the general ill condition of the consti-
tution; among which  I  have found vinum  seminum colchici  of  the
greatest service, especially in gouty and rheumatic complaints (c).
   1874. If by this treatment the dispersion be not effected,  and the still
increasing tumour  cause inconvenience, it must be emptied by a punc-
ture Or a  cut, and by the introduction of tents, by irritating the inner
surface of the swelling with the  blunt end of a  probe,  by injections
especially  of solution of iodine, by the insertion of a.-seton, or by a sub-
cutaneous  cut to produce such a  degree  of inflammation  as will put a
stop  to  all  secretion (d).   It must not, however,  be  forgotten  that
inflammation  and  suppuration of  a  large  mucous sac may  produce
  (a) Russf.ll, James, A  Treatise on the
Morbid Affections of the Knee Joint.  Edin.,
1802.  8vo.
  (6) von  Walther :  in  his Journal fur
Chirurgie  und Augenlieilkunde, vol.  iv. p.
390.            K          •       F
  (c) Gieri, J. M, Medicinisch-Chirurgis-
che Beobachtungen.  Loudon, 1807.
  (d) Upon  cutting into  these swellings
beneath the skin and into ganglia especially-
see Bartholemy, Chadmat, Marechal; in
Gazette Mddicale de Paris, vol. ii.  p. 773,
1 S3!).—Malgaigne; in Bullet, de Therapeut.
1840, p. 2<J.—Thierry ; in Gaz. Med. de
Paris, ,vol. ix. p. 537,  1841.—Hennemann,
Ueber eine neue Reihe subcutaner Opera-
tionen.  Rostock und Schwerin, 1843. 
DROPSY OF THE JOINTS.
181
dangerous symptoms.   If the walls of the sac be very much thickened,
this mode  oftreatment can be of no  service, and it may be necessary, if
the situation of the swelling permit, to remove the sac either entirely or
so that its  hinder walls alone remain and be thrown  off by suppuration.
  The treatment of encysted dropsical swellings on the knee-cap agrees precisely
with what has been just laid down, except that Heister's prescription (a), consisting
of litharge ^vj., Armenian bole 3j'., mastic and myrrh  of each g;iv., and vinegar a
pint, boiled  together for a quarter of an hour, and applied to the swelling on a folded
cloth, four or six times a day, and keeping the  patient quiet, with a moderately
tightly applied bandage, will in most cases produce either the cure at once, or after
the swelling has been punctured.
  In the/ encysted swellings, (par. 1870,) described by Cruvelhier (b), it is not,
according to Dupuytren, sufficient merely to open them with one puncture, but two
should be made, and a seton introduced.   It may, however, be sufficient in most
cases, to open the swelling  on both sides, and to use  irritating  injections, as the
irritation of the seton may produce very violent inflammation and fatal symptoms.
  According to Lenoir (c), three mucous  sacs are found on the sole of the foot, one
under the heel-bone, an inch in length, the second on the under surface of the joint
of the great toe, between the skin and sesamoid bones, and the third on the little toe
at the same part, with a lengthening on the outer edge  of the foot.   The dropsy of
these mucous sacs or their inflammation, with the serous exudation, may be easily
taken for abscesses.  If opened, they  readily become fistulous, produce ill-con-
ditioned pus, and  are covered with a thickened epidermis. In inflammation, a cor-
responding antiphlogistic treatment, poultices, cuts, cauterization, or excision must
be employed,
   [I  recollect seeing a case of the elder  Travers's in St. Thomas's Hospital, in
which suppuration of the mucous sac upon the knee-cap came on very rapidly, and
extended around the front and sides of the joint.  The patient suffered severe symp-
toms of constitutional excitement, and I must confess I thought the suppuration was
within the joint itself; he however thought otherwise, and directed the swelling to
be freely opened ; a large quantity of pus escaped, and the symptoms of irritation
soon subsided.  Union of the  skin with the parts beneath did not, however, take
place very quickly, and when all was quiet, the introduction  of a probe, which ran
along freely immediately beneath the skin, showed that  Travers's opinion was cor-
rect.  She recovered perfectly, and with  full use of the joint in a comparatively
short time.
  Irritation of the inside of these dropsical sacs by poking with a probe, setons or
injections, are on no account to  be resorted to, as the very probable consequence will
be severe inflammation, terminating in gangrerte of the sac and neighbouring parts,
and high constitutional disturbance.
  Occasionally it happens after the mucous sac on the knee-cap has suppurated, and
either burst or been opened,  that it takes on a fistulous  character, and two or three
or more little wounds ulcerate through the skin, which are very plaguing to the pa-
tient, and  very troublesome to  heal.   Under these circumstances it will be found
very advantageous to stuff in a little red precipitate powder,  and apply ointment of
the same with a bandage, keeping the patient at rest at  the same time.—j. f.  s.]
                   II.—OF DROPSY OF THE JOINTS.
     (Hydrops Articularurn Hydrathrosis,  Lat.;  Gelenkwassersucht, Germ.;
                             Hydrarthrose, Fr.)
   1875.  Dropsy of a joint is a collection of serous fluid within the capsu-
lar.ligament, by which  it is distended into  a  swelling, soft, bounded by
the attachments of the ligament yielding to the pressure of the finger, but
  (a) Institutiones Chirurgicse,  vol.  i. p. souscutanees de la  Plante du Pied, et sur
344.—Schreger, above cited.              leur inflammation ;  in Presse Medicale, vol.
  (b) Above cited, p. 323.                i. p. 48.   1837.
  (c) Recherches sur les Bourses muqueuses
                                    16* 
182           DROPSY OF THE JOTNTS ; PROGNOSIS
without  retaining any impress, distinctly fluctuating, little or  not at all
painful, and upon which the skin is unchanged.  The swelling does not
entirely correspond with  the whole extent of the joint, but is greatest
where the capsular ligament is most yielding and little covered.  Thus,
for instance, a swelling at the wrist-joint is especially distinct on its fore
and hind surface, but  is scarcely perceptible on its sides; at the ankle-
joint it is most remarkable on the front; at the shoulder it confines itself
to the  front, and projects most distinctly between  the deltoid  and great
pectoral  muscle.  At the knee-joint, where  the disease most commonly
occurs the swelling appears in front and  at the sides, when very large
projects  most on the  inside, is divided  into  two parts by the knee-cap
and tendon attached to it,  and extends upwards beneath  the muscles of
the thigh.  The knee-cap  is  thrust forward, is very moveable, and after
being  pressed down, again rises when  the pressure is removed.   When
the leg is bent, the swelling on the sides is larger and more tense; when
the leg is extended, the fluctuation is more distinct.   The movements of
the limb are little interfered with in dropsy of the joint.
   1876.  The  disease in  general  is slowly developed.   Its causes may
be external  violence, bruisings, sprains, catching cold, rheumatic or ar-
thritic attacks, cartilage-like bodies in  the joint, and metastasis, whereby
a  slow inflammatory condition and disproportion between the secretion
and absoption of synovia is produced.   The collected fluid does not dif-
fer from common synovia,  except that in long continuance of the disease
it  becomes more consistent, viscid, and of a tawny colour.
   In most cases where the parts  of the joint are organically altered, swelled up,
thickened, ulcerated, or affected with caries, collections of mucus, or pus, are formed
in its cavity.  This condition, which has been by some described as complicated
dropsy of the joint, requires only particular attention, if the disease which had pro-
duced it diminish, in which case, if the absorption of the collected fluid have not
taken place under the above-mentioned treatment, (par. 213 snd onwards,) it may re-
quire to be discharged, which I have several times done successfully at the knee-joint.
   [Brodie (a) observes:—" Cases occasionally (but not often) occur, in which a joint
is swollen from a preternatural quantity  of fluid collected in  its cavity without pain
or inflammation.  This may be supposed to  arise, either from a diminished action
of the absorbents, or an increased action of the secreting vessels.   The disease may
be compared to the dropsy of the peritonaeum pleura; or more properly, to the hydro-
cele ; and it has been not improperly designated  by the terms Hydrarthrus and Hy-
drops Articuli." (p. 7.)]
   1877.  The prognosis in dropsy of a joint is usually not favourable,
unless when it  have arisen quickly, and have not been of long continu-
ance,  in which case its dispersion  may be  often easily effected.  But if
the disease have existed  any length of time, and be very considerable,
and if the  ligaments have thickened, the hope of a dispersion is very
slight, and puncturing the joint for the purpose of  discharging the col-
lected fluid, is an operation which may lead to the most dangerous con-
sequences.  Dropsy of a joint is also easily liable to a relapse, and when
long continued, can produce organic  changes of the joint,  which build
up new  structures.
   1878.  The treatment of incipient dropsy of a joint is the same as that
directed for inflammation of the synovial membrane.   If the disease have
existed some time, it must be the  object to encourage the absorption  of
(n) On the diseases of the joints. 
AND TREATMENT.
183
.he collected fluid ; frequent rubbing, rubbing in volatile ointments, mer-
curial ointment with camphor, repeated  blisters frequently and at  differ-
ent parts applied, and long persisted in, fumigations, warm  and cold
douche baths, wrapping up in oiled silk, the moxa, the actual cautery,
electricity,  and  moderate  compression.   The  internal treatment  must
correspond to the cause of the disease.  Gimelle (a) has recommended
large doses of tartarized antimonial wine especially efficient.
   1879. If the absorption  of the collected fluid be not brought about by
this treatment, if, on the other hand, the quantity increase, so that great
pain and inability of using the limb  be produced, or  if there  be also a
foreign body in the cavity  of the joint, the collected fluid must be so dis-
charged as to prevent the entrance of the air.  With this object the fluid
is to  be pressed  against that part of the  joint where  the coverings are
thinnest, on the knee  for instance, on the inside.  With the  fingers of
the one hand the skin  is to be drawn aside, and a thin trocar,  a lancet,
or a bistoury, thrust into the joint, without, however, wounding the joint
surfaces.  After the discharge of the fluid, and the removal of the canula,
if the trocar be used, in doing which the wound is to be closed with the
thumb of the right hand, and the  coverings held back  with the  fingers of
the left, the skin which has been  drawn aside  is  allowed to return to its
place, so that the parallelism between the  outer and the inner wound is
got rid of, and the wound well  closed with  sticking  plaster.
   Opening the swelling with a lancet,  or bistoury,  is preferable to that with the tro-
car, if the fluid be very thick,  or if there be any little bodies at the same time pre-
sent in the joint, of which the  removal is also requisite.
   [I can hardly think the operation of puncturing a dropsical joint is, under any cir-
cumstances, justifiable, as the inflammatory symptoms which follow a wound of the
synoval membrane, even when healthy, are generally so great, and the  consequences
so serious, and sometimes fatal, that  the patient's life ought not to be endangered by
such treatment.  And should this practice even succeed, it is only useful  for a time,
as the fluid  will re-collect. As to the use of injections, after emptying the joint of its
contents, as advised by Velpeau, and  presently to be mentioned, I think it cannot
be too much deprecated, and I doubt whether any  English Surgeon would  risk his
reputation, and the safety of his patient, by a practice which must be attended with
almost certain mischief.—j. f. s.]
    1880. After the  operation  the patient  must be kept quiet for ten or
twelve  days, and the part bathed with cold lead wash.  If pain and
inflammation arise, the rules recommended for  wounds of joints must  be
followed.   If these symptoms do  not occur, or when they have been put
aside,  all  those remedies  must  be employed, after the  healing  of the
wound, which are capable  of restoring  the  due relation between the
secretion and absorption of the synovial fluid.
    1881. The simple puncture of the dropsy of a joint  rarely ever  indeed
produces a radical cure, as the fluid re-collects more or less quickly, and
besides severe symptoms and suppurative inflammation may ensue.
   To effect  a radical cure,  Bonnet (b)  has employed  successfully in
dropsy of the knee-joint,  injections  of  iodine; and the  same  has been

   (a) Gazette Medicale de Paris, vol. viii. p.  p. 310,  Nov., Dec. 1842.—Martin, (These,)
445.  Paris, 1840.                      Do Traitement des Maladies Chroniques de's
   (6) Mcmoires sur les Injections iodees dans  Articuhtion  par des Injections irritantes.
les Hydropisies et les Abces des Articula-  Strasbourg, 1842.
tions; in Bulletin general de Thurapeutique, 
184                WATER IN THE HEAD, AND
also practised by Velpeau {a).  After the leg has been stretched out, an
assistant places his hand on  one side of the joint, for the purpose of
pressing the fluid towards  the other, at which the puncture is to be made.
The outer or inner side of the joint above the knee-cap may be chosen.
The skin is  then to be raised  in a fold, the  base of which  is punctured
with a trocar, which must be thrust in at least three-quarters of an inch,
and so deep  as that its point shall touch the front surface of  the  thigh-
bone.   A viscid transparent fluid escapes through the canula, of  which
only from five to seven drams is to be drawn away, that is, about a simi-
lar quantity to the quantity of fluid presently to be injected.  The canula
is always to be directed  upwards, so that  it  remain full of fluid, and
therefore in  the injection  the air  is more certainly excluded.   Various
solutions of iodine may be used as injections ; Bonnet, however,  espe-
cially prefers a solution of half a dram of iodine and one dram of iodide
of potash, in four drams  of water (1).   The quantity of fluid injected
must not exceed  that drawn off, and therefore, in dropsy of  the  knee-
joint, never more than from four to five drams of fluid should be thrown
in.   After  the  injection has been  made,  and  the canula carefully with-
drawn, the puncture must  be covered  with sticking plaster, the  limb laid
in a tray, and kept perfectly still.   The consequence of the injection is
an acute inflammation, the running on of  which to suppuration must be
carefully prevented.  In very great and  painful  swellings of the  joint,
from  the excessive collection of fluid, it may  be necessary  to discharge
part of the fluid by puncture, so as to  lessen the symptoms.
  [(1) If there be no  mistake  in the proportions given for this injection, which un-
fortunately I have not the opportunity of verifying, it must be highly caustic, and
such as  no English Surgeon, I  think, would dare to throw into a joint, though a
French Surgeon might.—j. f.  s.]
           III.—OF LYMPH SWELLINGS.

These have been considered in par. 15-18, par. 59-62.
       IV.—OF WATER IN THE  HEAD, AND CLEFT SPINE.

(Hydrocephalus, Lat.; Wasserkopf, Germ.;  Hydrocephale, Fr.;—Hydrorachitis, seu
  Spina bifida, Lat.;  Ruckgrathswassersucht oder  Gespaltene Riickgrathe, Germ.;
  Hydrorachis, Fr.)
   1882.  The term water in the head, or watery head, is usually applied
to a collection of serous fluid beneath the coverings of the skull, between
the skull and the brain, or in the cavities of the brain itself.  According
to these  circumstances, it  is distinguished  into  external  watery head,
{Hydrocephalus externus,) internal watery head, {H. internus,) and dropsy
of the ventricles {Hydrops ventriculorum cerebri.)
   1883.  In external watery head the fluid may be either in the cellular
tissue beneath the  skin, beneath the  galea  aponeurotica, or beneath the
(a) Gazette Medicale de Paris, vol. x. p. 651.1842, Oct. 
CLEFT SPINE.
185
pericranium.   In the first case,  the swelling spreads more or less over
the  whole  head, often  over the eyebrows, retains the impress of the
fingers,  and is specially characterized  as oedema.  In  the second and
third cases, be the swelling more or less spread, yet it never reaches to
the  eyelids.   It  is  incorrect  to apply the  term hydrocephalus to  this
disease.  It requires merely the ordinary  treatment  of oedema,  the use of
dispersive  applications in connexion with rubbing and moderate  com-
pression, and  if these be insufficient, the discharge of the fluid  by cutting
into the swelling.
  Whether a partial collection of water under the galea aponeurotica actually exist,
in which the swelling depending on it  may be confused with other diseased con-
ditions, has been already doubted.
   1884.  The  collection  of water within the  cavity  of the skull appears
alone to deserve the name hydrocephalus.   The  collection  of  water
between the membranes of the brain and  the skull,  is most properly dis-
tinguished  as  hydrocephalus  externus,  and that in the ventricles of the
brain  as hydrocephalus internus, or hydrops  ventriculorum.  Both  con-
ditions may agree together in being congenital vices of formation, the coh-
sequence of the staying  of the foetus at an earlier stage of development.
Hydrocephalus, however, is  frequently first  developed at a  longer or
shorter period after birth, and  mostly without any  very decided cause.
The watery head now to be  considered may be distinguished  as hydro-
cephalus chronicus, from hydrocephalus  acutus, which quickly ensues, in
consequence of inflammation.
  The primary existence of external hydrocephalus is indeed denied by many, and it
is asserted that  the  water only reaches the surface  of the brain by a tearing of the
cavities (a); it  is, however, possible, that the water may be originally secreted as
well on the outer as on the inner surface  of the brain (b); for according to Magen-
die's (c) observation, there is naturally a watery fluid between the arachnoid coat
and the vascular coat of the spinal marrow, which communicates with the ventricles
of the brain by an opening in the bottom  of the fourth ventricle.  The same applies
to the fluid between the membrana arachnoidea and pia mater upon the surface of the
brain.  External hydrocephalus is at all events a rare circumstance; it is not easily
distinguishable from internal hydrocephalus, and resembles it in its symptoms, and
the treatment it requires.
   1885. In the congenital internal hydrocephalus, which is developed at
no very determinate period of pregnancy, as  also in  that occurring after-
wards, the walls of the brain  are considerably distended by the  collection
of water in the ventricles, are thinned, and the convolutions unfolded;
the  partition of the  ventricles (septum  lucidum) is  destroyed, and  their
internal lining  generally thickened; yet, however, with  this great thin-
ning and as it were membranous  extension of the brain, its  gray and
medullary substances are still distinguishable.  In proportion as the col-
lection of water becomes greater, the still yielding and not yet firmly con-
nected skull-bones spread out, and  the  head acquires an enormous size.
It is uncommonly broad,  especially in the region of the ossifying points,
because the bones, specially  those on the sides, are thrust asunder by the
water.   The face has no longer  an  oval, but a triangular form, the fore-

  (a) Monro,  Observations on  the Eye, the    (c) Journal de Pliysiologie, vol. vii. p. 1.
Ear, and the Brain, p. 38.                1827, Jan.
  (b) Meckel; Handbuchder pathologischen
Anatomie, vol. i. p. 263. 
186
WATER IN THE HEAD ;
head projects considerably over the orbits, and there is a remarkable dis-
proportion between the size of the face and skull.  The skull-bones form
slowly, and are connected only by a number of intermediate bones.  The
membranes enclosing the water  are not unfrequently torn during labour,
the water discharged, and the coverings of the destroyed brain, for the
most part, fall together.
   1886. If in great distension of the skull some parts be more  yielding
than  others, or the water  sink  from  the fourth ventricle, between the
pia mater  and tunica arachnoidea, into the canal of  the  spine, by which
the cartilaginous plates forming, previous to  its perfect ossification, the
hind  portions of the  vertebre are outspread, there are produced elastic
fluctuating swellings covered with a thin, sometimes transparent, skin, of
various  size, and forming  the disease  called Cleft Spine {Spina bifida.)
These may be diminished by compression, upon which ensue coma, con-
vulsions, palsy, and the like.  Several such  swellings  may occur at the
same time, so that the fluid may be driven from one to  another. Their
base is sometimes broad, sometimes has a neck, and on examination with
the finger the edge of the  opening in the bone, by which the fluid escaped,
is felt distinctly, its shape round and regular on the skull, and oblong on
the spinal column, where it  is formed by a double  row of spinous pro-
cesses.  These swellings may be seated at any one part of the skull,
where the bones are separated by the sutures, especially on the forehead,
on the sides,  and on the  back  of  the  head ; sometimes  several  exist
together.  These  swellings are  noticed  in the  spine, most commonly in
the lumbar region, more rarely  in the  back  and  neck.  Very rarely do
several exist at the same  time in the spine.
   If a close connexion and co-existence be assumed between internal hydrocephalus,
watery bags on the head and cleft spine, (hydrorachitis, spina bifida,) which opinion
is confirmed on  numerous grounds, it cannot, however, be denied that a primary
collection of water in the membranes enveloping the spinal marrow, may exist with-
out water in the  head.  Although the seat of the water be not always the same, it
is, however, probable that it  most  commonly collects between the vascular and
arachnoid coats,  (par.  1884.)  Gall  noticed  an example in a child eighteen days
old with a cleft of the second, third  and fourth lumbar vertebrae, and a collection  of
water within the arachnoid coat;  and in the whole length of the spinal marrow, two
lateral, smooth, slightly distended canals, which were perfectly closed, and entirely
unconnected with the collection of water (a).
   [(1)  A very good case of the watery sac  here described, is given by Chesman,
of Sheffield (b),  in a child three years and a half old :—" Over the left frontal pro-
tuberance was a  tumour of the  size of a large orange, membranous, but having in its
centre a small portion of thin bone.   This membrane arose from a projecting portion
of bone, almost circular, whose diameter was three  inches and a half, and contained
about half a pound of serum ; when this was suppurated, it appeared as if there was
a shell of bone below, which was not complete, as the fluid run from this cell into
the cavity of the skull.  The roof of the orbit was nearly convex.  On puncturing the
right side of the  anterior fontanelle, about five pints of serum were drawn off.  The
body was of a rickety appearance and much emaciated, and there was a spina bifida
of the size of a  hen's egg in the lumbar region.   The child had possessed  all its
faculties until a day or two previous  to its death, but generally lay on a sofa with its
head raised.  Until  five months of age the head had been normal, but then increased."
 (p. 564.)]

   (a) Compare Acrel ; in schwed. Adhandl.  Annali Universali di Medicina, vol. xv. 1820.
vol. x. p. 291.—Delpech, Precis Elementaire,  Luuolio.
vol. iii. p. 166.—Trompei, B.; in Omodei's    (b) Prov. Med.  and Surg. Journ., vol. vii.
                                      1844. 
CLEFT SPINE.                        187
   1887. The mischiefs produced by hydrocephalus and spina bifida in the
functions of the  brain and  spinal marrow,  are not  always the  same.
Most commonly children born with water in the head die soon after birth,
either in consequence of the disease itself, or the damage which the head
suffers during delivery; in rare cases, however, they reach a more or less
advanced age, and the head acquire an enormous size.   Notwithstanding
the diminished size  of the brain, its functions are not,always proportion-
ally lost.  Although the functions of the intestinal canal be in general
natural, the nourishment of the body otherwise is affected, so that  it is
extremely thin and backward in its development.   In those cases  in
which hydrocephalus is accompanied with watery bags, the above-men-
tioned mischiefs  are usually slighter, and scarcely observable.   In spina
bifida, indeed, the condition of the  spinal marrow is, for the most part,
altered ;  it is thinner, is dissolved into a watery substance, studded with
watery bladders, and at the seat of the cleft entirely deficient; it is, how-
 ever, rarely altered further  than at the  seat  of the cleft, and not always
 in the same  degree.   Symptoms of hydrocephalus usually accompany
 spina bifida,  great  wasting, weakness  of the lower  limbs,  involuntary
 discharge of the  urine and stools, spasms, convulsions,  and so on.   The
 larger the swelling, and the  nearer it  is to the head,  the  more violent
 generally are the symptoms.  Mostly children so affected die soon ; they,
 however, in rare cases, live a shorter or longer time.   With hydrocephalus
 and with spina bifida other misformations are  frequently connected, for
 instance,  hare lip, cleft palate, club foot, and the like, whence it decidedly
 follows that they must be  consideried as the consequence of an  arrested
 development (a).
   Fisher's (o) observations on the origin of spina bifida  are very interesting; he
 found in two cases a union of two or more sacral ganglions,  the passage of their
 respective nerves through the sheath in one bundle, and the union of the end of the spinal
 marrow with the walls of the sac.  I have fully verified this statement, in a case in
 which death followed  some time after puncture.  Fisher hereon founded the follow-
 ing opinions '.—first, that the  union  of the  sacral ganglions depended on primary
 irregularity, from which  arose the anomalous division of the corresponding nerves
 between the ganglions and the spinal marrow; second, the growing together of the
  spinal marrow with the sheath prevented the ascent of the marrow in its natural
  position, and to it is to be ascribed the irregular way in which the nerves are inserted
  into  the spinal marrow; third, the union of the  ganglions may, in a degree, be
  ascribed to the development of a process, by which the  neighbouring ganglions, in
  many cases, themselves of natural form, unite with  each other; and the  general
  existence of this deformity at the lower part of the spinal column depends on the
  relative position of the sacral  ganglions which lie in the sacral canal, whilst those of
  the other spinal nerves are in the intervertebral holes; fourth,  the incomplete form
  of the hinder wall of the vertebral column is rather to be ascribed to the influence of
  the irregular development of the corresponding parts of the nervous system, than to
  a peculiar tardiness in the process of ossification.
     [Hewett (c) observes, in regard to spina bifida.-—"The connexion which  gene-
  rally exists between  the chord or the nerves  and the walls of  the sac, is a  point of
  the utmost importance.  Some cases are related by various authors, in which neither
  the chord nor the nerves had  any connexion with the sac;  these parts followed their

    (a) Murray, J. A., Prosres.  de Spinne bi.     (6) London  and Edin. Philosoph. Maga-
  fidos ex mala ossium  conformatione initio. zi"e and Journal of Science, vol. x. p. 316 p.
  Go:ting., 1779.                         886.  1837.
    Meckel, above  cited.—Fleischmann-, De    (c) Cases of Spina bifida, with Remarks;
  vitiis congenitis circa thoraccm et abdomen, in London Medical Gazette, vol, xxxiv. 1841.
  Erlangen, 1810. 
1S8
WATER IN THE HEAD \
 usual course down the spinal canal; but in by far the greater number of cases that
 have been placed upon record, the nerves  presented some kind of connexion with
 the sac.  Of twenty preparations of spina bifida, occupying the lumbo-sacral region,
 which I have examined  in various collections, I have found  but one in which  the
 nerves, were not connected with the sac."  (p. 461.)]
   1888. As to the treatment of these two complaints, it has been advised
 to employ mercury internally and externally, repeated purgations, long-
 continued blisters, issues, setons, and a due pressure of the whole  skull
 with bandages or sticking plaster {a).   The  unsuccessful  result,  after
 drawing off the water  by puncture,  or  after spontaneous  bursting, had
 discouraged this practice till more recent observations had shown, that
 by small stabs with a  needle or a fine trocar, the fluid might be repeatedly
 emptied.   In a few cases  only, however, was a  cure thereby produced,
 as with the often repeated  puncture and simultaneous use of moderate
 pressure,  at last fatal  inflammation ensued.   Besides, in the critical ex-
 amination of these cases, it is proper  to bear in mind that the operation
 is only performed  when  the distention of  the skull is very considerable.
 An earlier employment of the  puncture, by which the fluid can be gra-
 dually emptied, and the head at the same  time properly compressed with
 a bandage, may perhaps allow the hope of a favourable result;  but espe-
 cially when the water in the head has not been congenital (1). The place
 for the puncture may  be chosen at any rate between the separated bones
 where there is no sinus.   Astley Cooper has recommended a palliative
 treatment, which has had  good  results, by means of  a  bandage which
 completely keeps back the  swelling in spina bifida, and  which must be
 continued for some time (2).
  [(1) Dr. James Copeland (6) has very carefully analyzed and compared the cases
 in which the operation of puncturing the brain for chronic hydrocephalus has  been
 practised, and  his opinion  upon the subject is  entitled to  serious attention. He
 says:—"From much experience I conclude that inflammatory irritation of the  brain
 and its membranes does  follow the  operation  in some instances; that the state of
 these parts and  of the system favours its occurrence; and that the encephalic struc-
 tures are  in a very different condition in this disease, both mechanically and vitally,
 but especially as to proneness to inflammatory action and softening, from what they
 are in health.  Whilst, therefore, 1 so far agree with those who argue for the ope-
 ration as to advise it to be tried after the measures I have detailed have failed, yet I
 would not recommend its performance early in  the disease ; first, because medical
 treatment has then sometimes effected a cure, especially when the head has not been
 very greatly enlarged ; and secondly, because, when the fluid is in the ventricles, as
 it generally is in cases commencing after birth,  a greater depth of brain must  be
 penetrated to reach it at an early than at a later period.  When punctures are resorted
 to medical treatment must not be abandoned,  or even relaxed ; for we should still
 endeavour to remove  the disposition to effusion, as well  as  to promote absorption;
 and as a certain degree of pressure  is requisite  to the healthy performance of the
 cerebral functions, strips  of plaster should be applied around and  over the whole
 scalp, in order to prevent the collapse consequent upon the operation.   I believe that
the punctures ought not to be frequent, nor much fluid withdrawn at one  time; that
 gentle pressure should be made around the cranium during the discharge; that the
 discharge ought to be stopped, and the puncture accurately closed, so as to prevent
 the entrance of air, as soon as the pulse begins to sink ; and that restoratives should
 be exhibited in order  to prevent convulsions or other nervous symptoms.  The ope-

  (a) Blane, Gilbert, M.D., On the effect  380.  London, 1822.—Barnard; in London
of mechanical compression of the head as a  Med. Repository, vol. xx. p. 314.  1823.
 preventive and cure in  certain cases of Hy-    (b) Dictionary of Practical Medicine,—
drocephalus;  in his Select Dissertations, p.  Ait., Chronic Dropsy in the Head, vo'. i.
                                      Lond., 1^44. 8vo. 
                      CLEFT  SPINEJ  TREATMENT.                 189

ration seems to be best performed by a small trocar or grooved needle, but it is diffi-
cult to withdraw any fluid with the latter, as the surrounding pressure fills up the
groove.  The application of a cupping glass may, however, produce a discharge.  A
pointed thin trocar, with a two-edged lancet-shaped extremity, not a thick triangular
instrument, is preferable upon the whole." (p.  683.)]
   (2) This is not quite correct.   Abernethy first suggested the trial of slight pres-
sure on the swelling of spina bifida, even from the  first, so as to excite absorption
and to prevent the distention of the unsupported dura mater.  He also first punctured
a  case  of  this sort, which was  hopeless, and repeated  it every fourth day for six
weeks, during which  time the wounds healed  regularly, and the child's health re-
mained undisturbed.  But at last the plaster slipped off, the wound ulcerated, sup-
puration ensued, and  the child died.   Astley  Cooper first practised pressure, and
afterwards puncture with a fine needle and pressure.   In two of his cases the patients
were alive and healthy, the one twenty-eight and the other twenty-nine years after
this treatment.
   Hewett lays down two good  general rules in regard to puncturing spina bifida,
according  to Astley Cooper's  method.   "First. The  tumour ought never to be
punctured along the mesial line,  especially in the sacral region; for it is generally
at this part that the cord and its nerves are connected with the sac.  The puncture
is to be made at one  side of the sac, and  at its  lowest  part, so as to diminish the
risk of wounding any of the  nervous  branches.  Second. The instrument ought to
be a grooved needle or a small  trocar; for if a lancet be used, there will be great
risk of wounding some important part contained in the cavity of the tumour." (p.
463.)
   Compare, on the Surgical treatment of Hydrocephalus and Spina bifida—
   Abernethy, John,  An  Account of  Spina  bifida;  with remarks  on a method of
treatment.  London, 1810.
   Cooper, Astley ; in Med.-Chir. Trans., vol. ii. p. 324.  1813.
   Earle, Henry, Case of Hernia of the Dura Mater connected with Hydrocephalus
internus; in Med.-Chir. Trans.,  vol. vii. p. 427.  1816.
   Sherwood, H., in Medical  Repository of New York, vol. i. p. 1.   1812.
   Otto;  in his Seltenen Beobachtungen.   Breslau, pt. i. p. 66.  1816.
   Hayes, Pliny ;  in New England Journal, vol. i. p. 237.
   Newendorff, De Spina? bifidae Curatione radicali.  Lips.,  1820.
   Trompei, B., above cited.
   Freckleton, in Edinburgh Med. and Surg. Journal, vol. xvii. p. 240.  1821.
   Lizars, in same, p. 243.
   Vacca Berlinghieri, above quoted, p. 251.
   Probart, F. L.; in Lancet, vol. xi. p. 800.
   Skinner, in American Journal  of Medical Sciences, vol. xix. p. 139.   1837.  In
this case seventy  punctures were  made,  and above four pints of fluid were dis-
charged .
   Conquest; in Cyclopaedia  of Practical Medicine, vol. ii. p. 478, is stated to have
punctured hydrocephalus successfully in four cases out of nine.   The largest quan-
tity of fluid drawn at any one time  was  twenty ounces and  a-half; the greatest
number of operations in the same child five, at  intervals of from two  to six weeks.
The largest total quantity of water removed was fifty-seven ounces.
   Oppenheim, F. V. (a),  has collected all the hitherto known cases of puncture,
and one which he himself treated, and has determined the applicability of this
operation.
   1889. The nearly always unfavourable result of repeated punctures in
spina bifida has recently led  to various modes of treatment with a view
to effect,  by the removal  of the  sac, at the same time, a closure of the
opening  of communication with  the  spinal canal, as  Dubourg(6), Ta-
vignot(c) Beynard(cJ), have shown, with successful  result.

  (a) Ueber  die Punktion des chronischen   (b)  Journ. de Med. et. de Chirurg. de Tou-
inneren Wasserkopfes; in Rust's Magazin,  louse.  1839, Sept.
vol. xxiv. p. 34.—Lee,  A.;  in  New  York   (c)  Gazette Medicale de Paris, vol. ix; pp.
Medical  and  Physical  Journal,  1828.—  481, 700.  1841.                    vv
Marsden ;  in Lancet, 1830-31, vol. i. p. 648.   (d) Ibid., p. 573.
   Vol. hi.—17. 
 190         SEROUS AND PURULENT COLLECTIONS IN

   According to Dubotjrg, the tip of the swelling is to be taken hold of
 raised a little up, and a part of its base cut through with a straight knife
 in such way as to form two flaps, which are brought down upon the spinal
 column, and without at first cutting into a middle string, which is gene-
 rally felt, and is formed by the sheath of the spinal marrow.   Immedi-
 ately after the rest of the base is cut off, and now but little skin remains.
 The pressure of an assistant's finger should  prevent the escape  of the
 fluid and the entrance of the air.  The edges of the wound are then to be
 united with two, three, or four hare-lip pins and the twisted suture.  This
 operation is required when  the  swelling  and the opening are of small
 size and the child's health otherwise good.
   Tavignot seizes the swelling at its base with an instrument similar to
 a pair  of forceps, before, which he cuts off the projecting mass,  and then
 unites  the edges of the wound as in the former mode.
   Beynard  surrounds the  base of the tumour with a spring, into which
 a ligature is  introduced, and ties it up.  The tightening  of  the ligature
 is  gradually increased till the inner walls of the sac, brought into close
 contact,  unite,  after which it is cut off and the remaining  suppurating
 part brought together with sticking plaster.   If the tied swelling be very
 tense, a portion of fluid may  be allowed to escape by puncture.
   1890.  Of  these several modes of treatment that of Beynard  seems
 preferable, as by it the too quick emptying of the fluid, and entrance of
 the air are prevented, the union  of  the applied  surfaces more  certainly
 effected,  and the cutting off performed when union  is produced.  Du-
bourg's  method  is,  in reference  to these points, to  be considered  the
most severe and dangerous.
V.—OF THE COLLECTION OF SEROUS AND  PURULENT FLUIDS
                IN THE  CAVITIES  OF THE CHEST.

  Brandes, De Thoracis Paracentesi.  Gotting., 1791.
  Gumprecht, De pulmonum abscessu aperiendo.  Gotting., 1796.
  Andouard, De 1'Empyeme.  Paris, 1808.
  Pelletan, Memoire sur les Epanchemens dans la Poitrine et l'Operation de l'Era-
pyeme; in CHnique Chirurgicale, vol. iii.  p. 237.
  Lancy, Memoire sur les effets de l'Operation de 1'Empyeme;  in Mem. de Chi-
rurg. Milit., vol. iii. p. 442.
  Duncan, Andrew, Contributions  to Morbid Anatomy, No. IV.  Empyema and
Pneumato-thorax;  in Edinb. Med. and Surg. Journ. vol.  xvii. p. 322.  1821.
  Delpech, Memoire sur 1'Empyeme ou Pleuresie suppuree ; in Memorial des H6-
pitaux du Midi.  1829, June.
  Mohr, B., Beitrage zu einer kiinftigen Monographie des Empyems.  Kitzingin,
1839.
'  Sedillot, De l'Operation de 1'Empyeme.  These soutenue, &c. Paris, 1841.
  Krause, A., Das Empyem und seine Heilung auf medicinisch und operativem
Wege nach eigener Beobachtung. Danzig, 1843.
  Townsend, R., M.D., Article  Empyema; in Cyclopaedia of Practical Medicine,
vol. ii. p.  28.   London, 1833.  Large 8vo.
  1891.  If in the cavity of the chest serous fluid (hydrops pectoris, hydro-
thorax) or pus (empyema)  collect, symptoms of compression of the lungs
and heart are produced, similar to those already mentioned when treating
of extravasation  of blood and collection of air in the cavity of the chest.
{par. 486 and onwards.) 
THE CHEST.
191
 •  1892. If the collection be only in one cavity of the chest, the patient
can only lie on the diseased side,  and the breathing is exceedingly diffi-
cult if he lie on the sound side;  if the collection be on both sides  he  can
only lie on his back with the upper part of the body raised.   The ailing
side is more  distended, the  ribs  separated  from  each other, and their
movements prevented.  In consequence of the compression  of the lung,
and the immobility of the chest on one side, the healthy half of the chest
must  move more actively.   Although the intercostal muscles and the ex-
ternal muscles of the breast be not inflamed, yet an cedematous swelling
occurs at certain spots, at least these muscles feel thicker.  This swelling
often spreads itself further over the diseased side of the body.  If there
be much fluid collected, pulsation Ls  communicated  to it from the heart,
so that it can be perceived to a great extent, though often very slightly,
and sometimes not at all.   The heart itself  may, by  the pressure of the
fluid,  be thrust to the other  side, and even  upwards.   The diaphragm
may also in like manner be driven downwards, often to such extent  that
a  swelling is observed below the  short ribs  and  in  the upper region of
the belly; the patient has therefore specially in the sitting posture, a  sen-
sation of weight and pressure on the  diaphragm.   A fluctuation in the
chest is often  observed, on examining the body, either with the ear alone
or with the stethoscope, and especially absence of the  respiratory mur-
mur on that part, except at the root of the lung.  A bleating noise, ego-
phony, is  observed when the collection  is not very great, but it is  lost
when that side of the chest  is distended by the collection.   It is most
 distinct at the lower end of the blade-bone  opposite the nipple.   On
percussion the chest does  dot yield the usual hollow,  but a dull sound.
 The  symptoms of hectic fever, dry or moist cough, small pulse, puffiness
 of the countenance, cedematous swelling of the upper limbs, and the like,
in a  great or less degree, accompany these symptoms.
   In  measuring {mensuration) an unyielding band is to be applied in an exactly
 horizontal direction from the spinous processes of  the vertebrae to the middle of the
 breast-bone upon the sound and  on the diseased side.  Piorry (a) has proposed to
 perfect this horizontal measure with a vertical one, for which purpose, whilst the
 patient sits or stands, the one end of a band is to be placed on the top of the collar-
 bone, near the shoulder, and the  other on the last sternal rib near its tip.
   Tarral has  proposed feeling the fluctuation. The patient must  lie on the dis-
 eased side, one finger is then to be strongly pressed into the intercostal space, whilst
 another finger gives a short blow on the corresponding interspace, and at such dis-
 tance that the direction towards the impressing finger shall  be as much as possible
 perpendicular.
   If  the flat of the hand be laid  upon the walls of the chest, a vibratory motion is
 felt on speaking, Which, according  to Raynaud, will not be perceived if  there be
 effusion.  The  mobility of the healthy, and the immobility of the diseased side in
 breathing, can also be observed by the feel.
   Percussion affords us the most certain sign of effusion into the cavity of the chest,
 and discovers to.us most of the changes in reference to its origin and course, its
 alterations and diminution.  If effusion do not fill the cavity of the chest, it changes
 its place according to the varying position of the patient, and, in consequence  of its
 gravity, falls to the most depending part of  the chest.   In the sitting posture  it oc-
 cupies the space between the hind  part  of the diaphragm, the spine, and the ribs.
 As this space is very narrow, a small quantity of the fluid can afford a "dull  sound to
 a pretty large extent.  At the part corresponding to the surface of the fluid a  clear
 pulmonary sound is observed.  If the patient lie on his back, percussion gives a
(a) Traite du Diagnostic, &c, vol. i. p. 570.  Paris, 1831. 
192                 PERCUSSION, AUSCULTATION.
clear sound in front, but a dull one behind, and this also happens if the patient lie
on his belly,  or upon one or other side; the sound is always dull at that part to
which the fluid sinks.   If the whole cavity be filled  with fluid, it cannot alter its
situation,  and the dull sound is observed at every part.  In circumscribed effusion
also, where bounded by adhesions, the dull sound remains at the one spot, whatever
posture the patient may assume.  If the sound  become duller  or more sonorous
where previously it was not so, it may be presumed that the fluid has increased or
diminished.  If percussion at one spot constantly give sonorous sound, around which,
according to  the different posture  of  the patient,  a sonorous  and dull sound can be
produced, it may be concluded that there is an adhesion of the lung at this  spot.
Percussion is able to decide with accuracy the pressure which the surrounding parts
suffer by the  fluid.  Sometimes, after the fluid  has diminished, a dull sound is ob-
served opposite the lower part of the cavity of the  chest, which depends on the false
membrane that has formed there, or has been separated from the parts above.  It is
not ever easy to distinguish between an effusion  into  the pleura, from one into the
pericardium.   An effusion into the pleura cannot extend towards the front of the
heart without arising behind nearly to  the spine of the blade-bone; if, therefore,
there be dull  sound in the region of the  heart without a rising of the fluid up to the
point stated, it must be concluded that there is effusion into the pericardium.
  Auscultation affords different results according to the variety of the circumstances.
In slight effusion the respiratory murmur may be distinguished, but it is weaker,
and  seems at  a distance from  the walls  of the  chest;  if the  effusion increase, the
respiratory murmur ceases completely.  In collections of fluid at the depending part
of the chest, where the upper part is free, the respiratory murmur maybe felt below,
and is perceived above.   If the patient's position be so altered that the lower becomes
the  upper part, the respiratory murmur is  heard  on  the former,  where it was not
heard, and it is no longer perceived where it previously had been.  This  stetho-
scopic sign is of the greatest  importance.  Laennec  considers  aegophony as the
pathognomic  sign of pleuritic  effusion;  but this sign  is of no actual value,, and by
aegophony alone  the  operation of paracentesis must not be decided.  If aegophony
point this out, it can only be shown at one part of the  chest in a certain extent, and
in a sharp change in  the patient's  voice; in other respects it consists in a strong
resonance of the voice, which is trembling and  broken, but is not so distinctly trans-
mitted to the  ear as pectoriloquy.  JEgophony, like the respiratory murmur, ceases
in great collection, and  in changes of  its  seat, according to  the different posture
which the patient may be placed in.  The  height of the effusion bounds the space
above where  it can be heard, above which the voice has its natural  sound.   This
line of demarcation determines the addition to,  and diminution of, the effusion.
Coughing presents an analogous change in the voice : sometimes the voice is per-
ceived at a distance with a peculiar change, to  which has been given  the name vox
senilis, (egophonie a  distance);  but this sound may exist without effusion, it can
therefore afford only a conjecture.

   1893. Notwithstanding  all  these  aids which  can be brought  to the
close determination of the state of the cavity of the chest, it is not ever easy
to distinguish pleuritic effusion with certainty.    Inspection and mensura-
tion have no actual value.   In healthy persons, the one side of the chest,
especially the right, is frequently more strongly developed than the other.
Every circumstance by which the activity of the lung is restricted, favours
the  diminution of the size  of the chest;  the other cavity of the chest, in
proportion  as  the lung becomes  more  active  than the  other, acquires
greater  size.   According  to Store's  observation,  the  increase  of the
chest on the left side, as a  sign of  empyema, is of more value; upon the
right side it is only of consequence when it exceeds  half an  inch.   In
other respects, the quantity of  effusion cannot  be determined by inspec-
tion and mensuration, as with  a trifling distention of the ribs there maybe
considerable thrusting back of the diaphragm  and mediastinum.   The
audible dashing of the fluid, when the patient is held  and  shaken by the
shoulders, is only perceptible  when the  cavity of the chest  at the same 
            SEROUS AND PURULENT COLLECTIONS, &C.        193

time contains  air; it therefore often affords  no sign except being very
distressing to the patient, and the audible dashing must be  distinguished
from that resembling it, which can be produced by fluid in the stomach.
I have, in one instance, fully distinguished the two kinds of dashing from
each  other.   The  sensible  fluctuation  is, according to Tarrall, per-
ceptible only in a small number of cases, in very thin persons, and if the
pleura be distended by a large quantity of fluid.   The immobility of the
chest may depend on many other circumstances.   The vibratory move-
ment does not, according to Raynaud, always exist,  and all the diseases
which prevent the  entrance of  the  air  into  the lungs do  not admit  its
occurrence.   Percussion and auscultation usually give the  most decided
signs,  though even they in many instances are uncertain.    Thus a duller
sound, is observed in pneumonia; but it does not arise in this case  so
suddenly, or, so to speak, at once, as in effusion ; on the  contrary, it is
gradually developed; at first weak and scarcely perceptible, it gradually
becomes  stronger in proportion as the inflammation  more and more pre-
vents the entrance  of the air into the lung; but in the highest degree of
hepatization  of the  lung, the dull sound is as distinct and complete as in
effusion.   The dull sound is generally circumscribed, rarely correspond-
ing to the whole extent of the lung, as on the contrary it  is  not seldom
that effusion occupies the whole of one cavity of the chest.  In effusion
the dull sound suddenly ceases above the level of the effusion, and gives
place to a hollow sound: this is  not the case in pneumonia, some cases
of pneumonia lobularis perhaps excepted.  Hepatization alone produces
so dull a sound as  can be mistaken for extravasation; but about a hepa-
tized part of the lung there  are always others which are  inflamed in a
lesser degree, and which form a gradual transition from the diseased to
the sound part.   Percussion, therefore,  carefully used, may give  a dull
sound, which gradually diminishes till that spot which corresponds to the
healthy part of the lung be reached,  where it  is entirely lost.  A  further
distinction between  extravasation  and pneumonia is, that  in the  former
the seat of the dull sound varies according to  the different posture of the
patient, whilst in pneumonia it remains  the same  in  every  position.   In
extravasation the dull sound always first begins  at the most depending
part of the  chest,  whilst in pneumonia  it is  often first perceived at the
upper part, as it often is situated at a higher part.
   Hirtz (a),  presuming that the physical phenomena vary according to the relation
of the lungs to the outpoured fluid, determines these relations upon three conditions ;
first, when the effusion is small, some ounces up to a pound; second, if it be mode-
rately great, from one to three  pounds; and third, when it  is considerable, three
pounds and upwards.   If the effusion be moderate, it varies, accordingas it is recent
or of some time standing.  In the former case the effusion spreads around the lung,
which, as it were, is bathed in fluid ; the pulmonary and costal pleura are separated
from each other by a layer of fluid, the thickness of which  is  every where nearly
alike.  In from ten to fourteen days the fluid, however, sinks down, and thrusts  the
lung upwards, if it be not hepatized or adherent.  A recent outpouring may be dis-
tinguished by. the  following signs:—breathing, voice, cough  short, broken, faint,
bleating, and a dull sound to a great extent; in considerable  effusion, the latter,  but
never the former symptom is observed.  When the outpouring has existed for some
time, the dull sound is perceived only to a trifling height, as the fluid sinks down;
on the contrary, aegophony is deficient at the lower part, as for its production  not

                  (a) Archives generates de Med, vol. i. 1837.
                                  n* 
194                 OPENING OF CHEST CAVITY.
 merely is the fluid necessary, but that also a portion of the lungs should be surrounded
 by it.  Above the collection a clearer sound is heard, and the respiratory murmur
 on auscultation.   We are, therefore, led to suppose that the fluid has been absorbed,
 whereas, however, it has only changed its place, and sunk to the bottom.  It may,
 therefore, be concluded, if with diminution of the dull sound, and a return of the
 respiratory murmur at the  upper part of the  lung, aegophony be wanting  at the
 lower part, that the fluid has changed its place, and has not diminished.  The phe-
 nomenon of the descent of the dull percussion-sounds, without diminution  of the
 fluid, depends  often less on  the removal, than especially  on  the diminution of the
 size of the lung, in consequence of the pressure upon it (a).
   1894. The collection  of these  fluids  may arise in various ways; by
 an abscess in the lung opening into the chest, in consequence of an in-
 flammation of the lung and pleura, after penetrating wounds, extensive
 fracture of the ribs, and the like, from a perverse  secretion, from an in-
 sidious  inflammation of  the pleura from organic disease of the lungs, as
 well also from the slow occurrence of hydrothorax.
   Abscesses on the exterior of the chest between the pectoral muscles and the pleura
 rarely penetrate the cavity of the chest, because the pleura in general becomes much
 thickened.
   [Sometimes the empyematous matter is discharged either by bursting into the
 lung itself,  or through the walls of the chest.   Under these  circumstances, the
 effusion  is circumscribed by'adhesions, forming a distinct abscess, and separate
 from the general cavity of the pleura.  According  to Laennec, the matter of
 empyema is discharged more frequently by bursting into the bronchi than by ulcera-
 tion through the walls of the chest.  Townsend  (b),  however, thinks that their
 frequency is nearly equal.   Sometimes the  abscess bursts both outwardly and in-
 wardly, and thus a fistulous passage is formed for the escape of the pus. Instances
 of this kind are mentioned by Le  Dran (c) and by Andral (d).~\
   1895. When from these collections in the cavities of the chest, the
 functions  of  the  lungs  and  heart  are destroyed  to such extent  as to
 endanger life, when  the accumulation  cannot be got rid of either by the
 powers  of nature, or by suitable internal treatment, opening the cavity
 of the  chest  (Paracentesis thoracis,  Operatio  empyematis)  is  required.
 This operation  can, however, only have a  favourable  result when the
 purulent or watery accumulation is unaccompanied with other incurable
 disease  of the chest, or with symptoms of general dropsy and the patient
 have  not  been  already  greatly enfeebled by long continuance  of the
 disease, or by colliquative symptoms, and is not very much  advanced in
 age.  The accumulation of pus in consequence of external injuries is the
 most hopeful for a  favourable result to the  operation,  which, however,
 must always be considered a  very  serious one as regards the conse-
 quences that  may arise from it;  although, on the other hand, it must be
 remembered, that the efficiency of the operation is considerably under-
 valued on account of its too late and  rare performance.  In the above-
 mentioned  cases, it is the only means of preserving life.
  Opinions vary as to the period  at which  accumulations after inflammation take
 place in the cavities of the chest, as some are in favour of the  early performance
  (a) Laennec,  Traite  de  1'Auscultation  Oester.  Jahrbuchern, vol. xxxvi. p. 372.—
 mediate et des Maladies des Poumons et de  von Rotteck, J., Ueber einige Bru-tkrank.
 Coeur, vol. i.  p.  72, vol. ii.  p. 230.  Paris,  heiten, mit besonderer  Rncksiclit auf ihre
 1826. Second Edition.—Piorry, Traite de  Diagnose aus phvsikalischenZeichen.  Frei-
 Diagnostic et de Semeiologie, 3 vols. Paris,  burg, 1839.
 1837. 8vo.—Stokes, Will, M.D., A Treatise    (b) Above cited in Cyc. Prac. Med.
 on the Diagnosis and Treatment of the Dis-    (c) Observations de  Chirurgie, vol. i. p.
eases of the Chest.  Dublin,  1837.  8vo.—  255.
Schuh, Ueber den Einfluss der  Percussion    (d) Clinique Medicale, vol. ii. p. 489.
und Auscultation auf Chirurg. Praxis; in 
OPENING THE CHEST WITH A CUT.              195
of the  operation  (Philip, Skodes,  Laennec,  Gendrin,  and others);  it can
however, only be  considered permissible under the above-mentioned conditions,
(Krause.)  It has been already mentioned (par. 495) that and under what con-
ditions, opening the cavity of the chest is necessary in extravasation  of blood and
collection of air.
   1896. Opening the cavity of the chest is performed either by a cut or
by a puncture with the trocar.
   Opening  the chest has been practised  from the earliest times in very different
ways;  first, by boring through the  ribs (Hippocrates,  Pare, Severinus,)  or
through the breastbone (Galen, Roger, of Parma, Purmann, van der Wyl, and
others) ; second by division of the soft parts, «. with the actual cautery (Euniphon
of Cnidos, Paul of iEgina, Avicenna, Lanfranchi, Ravaton, and others,) /3. with
caustic, and thrusting a knife through the slough (Thevenin, Ruysch, Bromfield,
von Winter, and others);  y. by puncture with the knife, after making a eut through
the skin and laying bare the pleura (Hippocrates, Celsus, Solingen, Delpech,
and others,) or with the trocar, (Heister, Morand, Boyer, and others,) with blunt
instruments, as a sound (Dionis, Verduc, Belloste,) or with the finger (Freck);
<r. without previously cutting through  the skin, by thrusting in a knife, (Rhazes,
Diemerbroeck,  Purmann,)  or  the trocar  (Drouin,  Nuck,  Palfyn, Heister,
Sharp, Leblanc, Rullier, Charles Bell, Laennec, Wattmann, Schuh, Krause,
and others); s. by dividing the skin and  muscles by layers with a funnel shaped
cut and the division of the pleura to a great extent (especially Benjamin Bell,
Larrey, Zang, Kern, and others.)
   1897. Opening the chest with a cut is performed in the following way.
The patient  should be laid  near the edge of the bed,  bending over
towards the sound side, and his arm brought  forwards, so that the light
may fall upon the part  for operation.  A  cut of a full inch is to be made
through  the skin, in the middle between the  breast-bone and the spine,
on the right  side between the fifth and sixth or sixth and seventh ribs,
reckoning  from above,  but never lower, as otherwise the diaphragm may-
be easily wounded ;  upon the left side,  between  the fifth and sixth, to
the seventh and eighth  ribs.   The muscles  are then divided cautiously
down  to the pleura, by repeated  cuts lengthways, and properly away
from the lower edge of the upper  rib,  without completely exposing the
upper  edge of the lower rib, so that the cut is conical, and exposes about
an inch of the pleura.   If the finger be then introduced into the bottom
of the  wound, when the patient  holds his breath or  inclines a  little  to the
diseased side, and distinct fluctuation be  felt, the pleura may be  care-
fully penetrated  with the bistoury, and the opening  enlarged with the
button-ended  bistoury.  If  no  fluctuation  be  perceptible,  the pleura,
which is frequently thickened, must be  divided by cutting cautiously.
For the  discharge of the fluid the patient must be  inclined towards the
diseased side.   Deep  inspiration, coughing,  and the use  of pumps or
injections, to assist the discharge, are dangerous.
   The  place for opening the chest, when there is no protrusion of the pleura and
accumulation  beneath  the external coverings, (locus  necessitatis,)  has been very
variously recommended.  Many (Sabatier, Pelletan, Boyer, and others) advise
it  on the left side between the third and fourth  rib, counting from below, and on the
right between the  fourth  and  fifth ribs.  Others  (Chopart, Desault) on the left
side, between the second and third, and on the right, between the third and fourth
ribs.  According to Bell, the lowest and most fitting place for the puncture is the
interspace between the sixth and seventh rib, reckoning from above.  According to
Begin, the cut should be made at the junction of the two front with the hinder third
of the  space between the breast-bone and  the  spinous processes.   Cruvelhier 
196         PUNCTURING THE CHEST WITH THE TROCAR.

holds that the fluid should not on any account be completely emptied, and therefore
the opening may be made where you please.
  If in a very fat person the ribs cannot be counted, the place for the cut may be
determined at from four to five fingers' breadth above the last false rib.  Opening
the chest at its most depending part, at a little distance from the spine is objection-
able ; because, by the patient's posture, a higher part may be brought lower down,
because on . the  right side  the diaphragm" thrust up by the  liver  may be easily
wounded, and adhesions at the lower part of the lung are extremely common.  For
these reasons, the interspace between the fifth and  sixth ribs, upon either side, is
to be preferred as the best place for paracentesis, if on percussion  it yield a dull
sound, and there be no perceptible respiratory murmur (a).  Drawing up the  skin
before making the cut, so that it may drop down on the inner wound, may prevent
the entrance of the air, but it also interferes with the free escape of the pus.  If a
part be cut on, where the lung is adherent, it must be attempted, if the adhesion be
not firm, to separate it with the finger, or to divide it dexterously with a blunt-ended
probe; but if this be not possible, the wound must be enlarged towards the breast-
bone, in hopes of finding a part not adherent, or the operation must be performed at
some other part.   If after opening the  chest no accumulation be found in it, but
that there is an  abscess in the lung itself, which is  shown  by the finger feeling
fluctuation, a pointed bistoury must  be introduced on  the finger, and  the abscess
opened (1).
  If there be need to open the cavity of the chest on both sides, the operation must
be performed on  the other side, if not pressingly required at once, frpm fourteen to
eighteen  days  after,  and the opening in the pleura  made as small as the object of
the operation will permit (2).
  Cartwright (b) proposes, in order to prevent the admission of air in opening the
cavity of the chest, to introduce a double thread, shaped like the Greek n after having
made a small cut, and to apply sticking plaster over it.
   [(1) I cannot think the recommendation here given of thrusting a bistoury into a
presumed  abscess of the lung, admissible  under any circumstances.  I have great
doubt whether fluctuation could be certainly ascertained, and  even  if it were, I do
not think opening it would be more justifiable, as it would be impossible to be sure
of the thickness of the wall of the abscess ;  whilst, in either case, the patient would
be endangered by the bleeding which would follow wounding the lung; on which
aceount, therefore, I think it would be highly imprudent J to risk so serious a conse-
quence.
  (2) I should also be exceedingly loath to open the chest on the opposite side,  as
here recommended by Chelius.—j. f.  s.]
   1898.  The  dressing consists  in the introduction of  an oiled fold  of
half unravelled linen, between the  edges of the wounded pleura, without
dropping it into  the  cavity of the chest, its ends being  fastened with
sticking plaster, and  over it  laid  a plaster full  of  holes, soft lint and a
compress properly confined  with  a  bandage over the  chest and  one
shoulder.  The patient  should  be laid so as to  favour the discharge  of
the pus  as much as possible.
  If the accumulation be large, the dressing should be applied without discharging
all  of it.   Pelletan (c)  advises, in every case, the application of the above-described
dressing, so that the cavity of the pleura  is opened, and  the fluid can gradually
escape, and the air should not enter so that the lungs might expand.
   1899.  The after-treatment requires, according to the  condition of the
patient,  and the symptoms which  may arise, a cooling; antiphlogistic,  or
a restorative  treatment.   The patient must be kept quiet, and not talk;
and the surrounding air should be properly dry and warm.  The dressing
should be renewed as rarely as possible, at the utmost  never more fre-
quently  than every twelve  or fourteen  hours.   Injections  employed for

                     (a) Laennec, above cited, vol. ii. p. 219.
  (b)  London Medical Gazette, vol. viii. p. 105.  1831.        (p) Above cited, p. 295. 
          PUNCTURING THE  CHEST, AFTER-TREATMENT.       197

the purpose of  encouraging the discharge are indeed usually objection-
able.  I have,  however, in cases where subsequently the discharge was
very bad and stinking, used injections of mucilaginous decoctions, with
a slight addition of muriatic acid, and slightly astringent decoctions with
advantage.  The wound must be kept open by this dressing  as long as
there is any secretion.  Tubes of  elastic gum and the like, for this pur-
pose, are objectionable ; repeated experience, however, has shown that
the mere introduction of the fold of half unravelled linen is insufficient to
keep the wound properly open.   A fistulous aperture  often continues
for a long while, which only  closes when  the  patient's health  is fully
restored.
  To prevent the hectic fever which, after the operation for empyema, results from
the absorption of pus and its putrescence by the admission of air, RECAMiER(a) in-
jects warm water, 28-30° Reaumur, (95-99^° Fahr.,) immediately after the dis-
charge of the fluid from the chest, and  in corresponding quantity to the discharge.
The aperture should then be closed with sticking plaster, and the patient laid with
his pelvis  high, so that the water  may completely fill  the cavity of the chest.   In
proportion as  the lungs expand, which is ascertained  by auscultation, less water
should be injected.
   1900.  In puncturing the  chest with the  trocar,  between the fifth and
sixth ribs, if that part yield a  dull sound on percussion, and no respira-
tory murmer be perceived, the point of the  left forefinger is to be placed
upon the upper edge of the lower rib, and the  trocar, held in the right
hand, thrust above  the finger-nail through the intercostal space, with
sufficient but not too sudden  pressure, till  the opposition offered cease,
and shows it has entered the  cavity  of  the chest.   The canula  is then
taken hold of with the fingers of the left  hand, and thrust deeper into
the chest, whilst with the right hand  the trocar itself is  withdrawn, im-
mediately upon which  the  fluid streams out.   From time to time the
opening of the canula should be closed with the finger, so that the patient
may inspire rather more deeply, and it may be seen when the discharge
is completed ; the canula should then be removed,  and the finger placed
upon the  opening, which  is   to  be  covered  up  with sticking plaster.
"Whilst the discharge is going  on, to prevent the entrance of the  air into
the chest, and to assist the escape of the matter, various modes  of pro-
ceeding and practice have  been  recommended, as well also as different
reasons proposed for the quantity of matter  to be drawn off.
  For the purpose of preventing the entrance of the air, valvular canulas and stop-
cocks, with syringes and cupping instruments attached to them, have been employed.
Bouvier's canula with a bail valve; Reybard's canula with a bladder;  Recamier's
trocar, the front  aperture of which, by drawing back a stilette, is covered with  a
spring pad ; Schuh's trocar, its canula furnished with a  stop-cock, and a trough
screwed on it, in which  the fluid as it escapes from the canula is collected, and may
be raised higher than the opening of the canula, being guarded with a leather valve.
Krause (b) objects to Schuh's trocar that its canula is too narrow to allow the escape
of pus or thicker  fluid,  that the play of  the leather valve is  frequently out of order,
so that the fluid sticks to its edge;  if the narrow canula be stopped up, the apparatus
must be unscrewed, and a probe introduced.  The following method  has been re-
commended by Baum:  the operator holds above the plate of the canula, fixed by an
assistant, a piece of goldbeater's skin so stretched with both hands that there remains
only a small aperture,  through which  the fluid  escapes directly.  He must very
carefully watch the discharge, so as to immediately close the opening air-tight by
dropping down the goldbeater's skin as soon as the stream begins to stop.  Guerin,
      (a) Bullet de Therap., vol. xii.  1837.            (6) Above cited, p. 167. 
198              MODE  AND CONDITION  OF CURE.
Stansky, and von Wattmann fasten a sucking pump to the canula.   Compare on,
the contrary von Winter (a).   Laennec has proposed, in weakly patients, in whom
the complete discharge of the fluid may cause dangerous fainting, and in cases where
no cure can be hoped for, and the operation is undertaken only for relief, that merely
a part of the fluid should be discharged.  According to Schuh, in those cases where
the effusion is  ten or twelve days' old, the lungs and constitution healthy, and a
radical cure maybe expected,as much as.possible should be at once discharged,and
that then it should be allowed to flow by the trough without much talking and effort.
If, on the contrary, the pleurisy and its products  be already a month  old, and the
patient cachectic; if there  be  haemorrhagic exudation, accompanied with  tubercles
on the lungs, and no cure be expected, a small discharge will be sufficient, even
when the fluid readily empties itself with perfect  freedom.  Inattention to this cir-
cumstance produces a.peritonitis, quick reproduction of the exudation, and pneumonia.
Krause (b), on the other hand, remarks, that we  may be deceived in regard to the
existence of tubercles, as Skoda himself experienced in several instances;  and that,
therefore, even in the most doubtful  cases,  the patient's complete recovery should
never be given up, and that it is often not possible to retain the remaining fluid by
the ordinary dressings.
   1901.  The symptoms which occur after puncturing  the chest with the
trocar,  are, besides fainting, for which analeptics should be given, a vio-
lent cough, which depends on the entrance of the air and of Wood into
the lungs, for which opiates  must be given, pleuritis, especially if the
puncture be made whilst there is still  inflammatory excitement, pneumo-
nia, inflammation  of the  diaphragm, and speedy reaccumulation of the
fluid.   A corresponding antiphlogistic treatment must be employed for
the inflammatory  symptoms and  absorption of  the  recurring exudation,
by those  remedies which strengthen the powers  and excite the secretions,
such as diuretics.   Keause especially recommends  milk at regular pe-
riods,  and in gradually  increasing quantity, and iodide of iron.   If the
symptoms of  accumulating fluid be urgent, the  puncture  must be re-
peated.
   1902.  The preference of opening the chest by cutting, or by the trocar,
must be decided by the following circumstances.   In primary extravasa-
tion of blood, and in accumulations of pus, the opening  of the chest by
cutting into it  should be considered  preferable; as in extravasation of
blood its discharge by the  trocar cannot indeed be effected,  and in the
suppurative accumulation, a continued discharge must  be kept up, under
which circumstance the union of the pleural surfaces is not produced by
adhesion but  only by firm  exudation  and  granulations.  On the  other
hand, puncture with  the trocar  is more proper in  acute empyema and
watery accumulation, in very weak patients, and when-the operation is
undertaken rather with a view to the relief of the patient.
  In accumulations  of pus Schuh has proposed, after removing the trocar-canula, to
introduce  a gum elastic tube, and  fasten  it  securely;  Krause, however, objects to
this as producing greater pain.   If, together with the  puncture, a  cut be not made,
the wound, according to Krause, should  be covered with a poultice;  it closes, in
course of a few days, but, with the continued use of the poultice, sometimes opens
again, and discharges pus constantly.  If this be not done, a cut should be forthwith
resorted to.
   1903.  The mode  and  condition by which, after  the discharge  of
bloody, serous, or purulent extravasation from  the  cavity of the chest,
the cure  is effected, and  the satisfactory or unsatisfactory result of the

        (a) Jahrbiicher des arztlichen Vereines zu Milnchen, Jahrg. iv. p. 10.
        (b) Above cited, p. 174. 
MODE AND CONDITION OF CURE.              199
operation ensues, is shown by the following circumstances confirmed by
pathological anatomy.
  In every large accumulation of fluid in the cavity of the chest the lung
is compressed, the pulmonary vessels  no longer permit  the fluid to be
properly poured forth, which, under  natural  circumstances, fill  it, they
are gradually obliterated, the proper structure of the lungs wastes, and it
hangs  quite  shrivelled up,  as on  a stalk.   If under these circumstances
fluid be discharged from the cavity of the chest, the lung is never again
expanded and  developed, the  space  which had contained the fluid
remains empty, and nature must  effect  the cure in  some other way than
by the development of the lung.   Hence  it must be concluded that the
result of the operation is the more uncertain, the longer the accumulation
of fluid in the cavity of the chest has existed.   If,  after the discharge of
the fluid, air enter the cavity of the pleura, which cannot by any precau-
tion be prevented, the walls of the cavity may inflame, and if the inflam-
mation become violent, it may cause death.  If the patient get over this
period, a profuse suppuration takes place over the  whole surface of the
pleura, which runs through its  stages with greater or  less quickness,
according to  the  constitution  and age of the  patient.  A cure  can only
happen when, by this development of granulations, by the successive ex-
pansion of the lung, and by the dropping together of the chest, by which
the curve of  the ribs is  diminished and their form  rendered more cylin-
drical, the pleura unites with the surface of the lung.  On these  grounds
is explained why, in great  and long continued  accumulations, &c, in the
cavity of the chest, and in old persons no cure in general takes place,
though in younger persons, in whom the walls of the chest are yet yield-
ing, and if the accumulation have not existed long, the  cure very com-
monly, and  often  very  quickly follows.   The same changes  affect the
chest in the cure after puncturing with  the trocar  as  those which occur
where absorption of the empyema has taken place without the operation.
Krause points out a change of the chest in which the shoulder is drawn
upwards and the spine is inclined towards the  diseased side, which may
depend on the high position of the fistula in the chest.(a).
   Laennec (6) proposes, for the purpose of encouraging the expansion of the lung,
to apply a cupping glass and syringe upon the wound.
   The return of resonance over the whole surface of the chest and of the respiratory
murmur proves the subsidence of the effusion, but the continuance of the dull sound
does not prove its continuance; for very frequently pseudo-membranes form after
pleuritic effusion, which overspread the lung to various extent, and in some instances
completely envelope it.  As these pseudo-membranes produce a dull sound the con-
tinuance of the effusion may he presumed, although it have already ceased.  When
these pseudo-membranes have long existed, and the patient is attacked with bron-
chitis or rheumatic pain on the  aUing side, it  may be mistaken for an attack of
pleurisy.  But with pseudo-membranes the dull sound does not  change its place
according to the posture of the patient, and its height is not  so well defined as in
effusion.   It rises to the same height on the fore and hind part of the chest, apd this
distinction  is often so great  that the whole hind part of the chest gives the dull
sound, whilst the fore part is perfectly sonorous.  The dull sound may also exist at
the upper or middle part of the chest, whilst the lower remains sonorous.   A partial,
circumscribed outpouring may, in that case, present the same peculiarity;  but then*
according to Louis, a partial elevation of the chest has been noticed, as on the con-
trary, when the dull sound is  caused  by pseudo-membrane consequent on effusion

    (a) See Pelletan and Larrey, above cited.      (6) Above cited, vol. ii, p. 220. 
200               DROPSY OF THE PERICARDIUM J
which has compressed the lung, not unfrequently a slight sinking in of the diseased
side is  perceived by mensuration.   When the rasping sound is  also heard the
presence of pseudo-membrane is beyond doubt (a).
  [The operation for empyema has been of late years not unfrequently performed in
London, and an account has been given by the late and much regretted Dr. Thomas
Davies (b) of  the result of twenty-three cases, all of which,  excepting six, were
under his own Care.  Of these, eleven were operated on for empyema, eight recovered,
two died, and one was under treatment; nine for pneumothorax, all of whom died;
and three for hydrothorax,  who also died.   Davies observes, upon  these cases :—
"First.  The result of the operation in the cases of empyema  is very satisfactory,
eight of the patients out of ten have recovered.   Of these, five were under six years
of age,  one was between eighteen and nineteen, and two were above twenty-five.
Second.  All the cases of pneumothorax were complicated with tubercular diseases of
the lungs, a circumstance which, of itself, precluded a favourable result.  All the
patients were beyond twenty years of age.  Third. All the cases of hydrothorax
were the consequences of  disease of the  heart.  Although none of the  patients
recovered, they were all relieved by the operation for a considerable time."  (p. 43.)]
              VI.—OF DROPSY  OF THE  PERICARDIUM.

(Hydrops Pericardii, Lat.; Wassersucht des Herzbeutels, Germ.; Hydropericarde, Fr.)
   1904.  Dropsy of the pericardium generally accompanies  water in the
chest, and but rarely exists alone.  The following symptoms accompany
it; the sensation of weight and pressure in  the region of the heart, and
a feeling as if the  heart  were swimming in  water, great  shortness  of
breathing,  and anxiety, which increases on the  slightest movements of
the body, but especially in the horizontal  posture, frequently going on  to
faintness and danger of suffocation ; the beat of the heart is felt to a great
extent, and at different parts; also accompanied with violent palpitation,
or more frequently a fluttering tumultuous movement of the  heart, as if
there were something lying within it.   The  dashing of water is often dis-
tinctly felt, or even  seen between the third and fifth ribs.   The pulse  is
small, quick, hardish, often  irregular and intermittent; cough  occurs only
spasmodically, and  is dry  ;  the speech is difficult, and  the voice hoarse.
When the disease has existed long, the countenance is puffy, the  extremi-
ties usually cold, and the  patient feels a peculiar pain in the  stomach and
over  the whole belly.  Death follows either from suffocation or from
apoplexy.
  According to Laennec, slight effusions,  as,  under a pound, cause no decided
symptoms; but those  exceeding two  or three pounds, are shown by percussion,
auscultation, and inspection.
  In some cases of considerable pericardial  dropsy, the breast-bone  exhihits a re-
markable elevation.  Piorry believes that a careful measurement would show greater
distention of the left side from above downwards, or from the one side to  the other.
In one case (c) the liver was so thrust down,  that its lower edge  projected two inches
below the edge of the false ribs. If but little fluid be collected, it makes little pres-
sure towards the sides of the pericardium;  therefore percussion discovers a dull
sound, rather from  above downwards, than from  side to  side.  This dull  sound
varies according to the different posture of the patient, on his back, whilst  sitting, or
in lying on his side; the change of place of  the dull sound in the side posture is of
less value than when on the back, or sitting, because it depends on displacement of

         (a) Hirtz, Pigne.
         (b) Cyclopeedia of Practical Medicine, above cited.
         (c) Bouillaud ; in Diet, de Med. et de Chirurg. Prat^ vol. x. p. 158. 
DROPSY  OF THE  PERICARDIUM;  OPERATION.       201
the heart.  In large collections of water, the  stroke of the heart is, according to
Bouillaud, deeper, less to be felt, and the accompanying murmur  more obscure,
less perceptible at a distance than in the natural state ; and if to these symptoms be
added a duller sound, the existence of dropsy of the pericardium is exceedingly pro-
bable, even if it be not quite certain.
  According to Piorry, in large collections of water a perfectly dull sound is found
in a pyramidal space; the base of which is the region of the heart, and the psint at
the upper part of the breast-bone.
  Gendrin thinks that there is stabbing pain on the left side of the chest towards
the shoulder,  arm, and back, opposite the  base of the heart; or it may be confined
to the region of the stomach on the outer edge of the ensiform cartilage, and is rarely
wanting; the point of the heart is displaced inwards and upwards to the top of the
third rib, and  on account of the oblique position of the large vessels thus caused, at
the place of their opening, a rubbing noise is observed at the base of the  heart, in
the arch of  the aorta, and in the arteria innominata, which noise diminishes in pro-
portion as the fluid is absorbed.
  Hypertrophy and expansion of the heart may be distinguished by their slow origin,
by the various condition of the beating of  the heart, and by the dull sound, by the
various condition of the pericardium, and the dull sound in a round space. (Pigne.)
   1905. The quantity of water in the pericardium is various, and some-
times amounts to  many pounds;  it  is usually like albumen, yellowish,
whitish, reddish, and, when  arising merely from a perverse  secretion, is
unaccompanied with any diseased change of the heart, or of the pericar-
dium {a).   Frequently is the pericardium united  to  the neighbouring
parts, and thickened ; the  surface of the  heart is inflamed, excoriated,
sometimes covered with layers of purulent matter; sometimes the water
is found in sacs attached to the heart  or to the pericardium.  At the same
time, other organic diseases of the heart, of the large vessels,  and lungs
are found, which in  many cases are  the  cause, and in other the conse-
quence, of the pericardial dropsy, and therefore the fluid is of a different
nature-.  Chronic inflammation of the heart or its sac, wounds  and the
like may give rise to it: and predisposition thereto frequently  originates
in pregnancy and  childbed.
  [In very rare cases, inflammation of the pericardium runs onto suppuration: there
is an example of this  kind which has been in the Museum at  St. Thomas's many
years.  The swelling protruded at the pit  of the stomach, and, being supposed an
abscess of the liver, was punctured, and the pus discharged.  After death, the dis-
ease was found in the pericardium.  I do  not know  any further particulars of th«
case.—j. f. s.]
   1906. When, in dropsy of the pericardium, the diagnosis  be decided,
and it be  also ascertained that there is  not any accompanying  organic
disease of the heart, if the usual remedies be unavailing, the  emptying of
the water, or even of the blood in wounds (par. 505,) has been proposed,
an  operation which, in  reference to its practice and consequence, must
be  considered extremely  dangerous.
  This operation, first proposed by Senac, is rarely practised, and of all the cases
performed there are but  two which  had a  favourable result.   Karawajew (b) has
performed it twice on account of  exudation of blood into the pericardium, arising
from scurvy ;  one was fatal and the other successful, and in the latter case three and
a half pounds of bloody fluid were discharged.  Schuh (c) has also  operated suc-
cessfully.
  1907. The seat  and manner of making the  opening have been vari-
ously given.   A cut made  on the left side, two fingers,  and in a large

                    (a) Laennec ; above cited, vol. ii. p. 669.
      (b) Preuss. Vereinzeit.   1840.  No. 52.               (c) Above cited.
  Vol.  iii.—18 
202       DROPSY OF THE PERICARDIUM J OPERATION.
extravasation, at from four to five fingers' breadth from the breast-bone,
between the fourth and fifth, or fifth and sixth true rib, or at any other
place, if the heart have haply changed its position,  and there be distinct
corresponding fluctuation, carefully through the skin and muscles, down
to the pleura, which  must be  opened with  the greatest carefulness, and
the opening enlarged with the  button-ended  bistoury.  The exposed
pericardium is cautiously opened with the bistoury, and the fluid allowed
to escape gradually.   Senac fixes the place for the  opening between the
third  and eighth rib, and five or six inches from the breast-bone; Camper
between the fourth and fifth ; Romeiro and Larrey between the fifth and
sixth ; and Desault between the sixth and seventh rib.  More recently,
Larrey has proposed that in  the space  between the base of the sword-
like cartilage  and the united cartilages of the seventh and eighth ribs, an
oblique cut should be made along the lower edge of the cartilage of the
seventh rib, to the extremity of the  eighth, by which some fibres of the
m. rectus and obliquus externus abdominis are cut through, and then should
penetrate deeper through the cellular tissue, till that part of the pericar-
dium is reached which projects between the first two digitations of the
diaphragm, and  into which  the knife is to be carefully thrust from above
and to the  left side.   Hager's proposal  must also be mentioned, to draw
out the exposed pericardium with  a thread, into the wound of the pleura,
after the  discharge to bind  up the opening, and to fasten the thread ex-
ternally,  so that the  pericardium  may unite with the wound.  Skielde-
rup (a) advises perforating  the breast-bone  between  the fifth and sixth
ribs,  where the  cartilage  of the  fifth rib joins the breast-bone, with a
common trephine;  and when, after the bleeding is stanched, the fluc-
tuating pericardium protrudes into the aperture, to open it.  This practice
has the advantage of the pericardium being laid bare at the part where it
is directly in  contact with the breast-bone, the pleura not at once opened,
and  the water  not poured into  the cavity of the chest.  Karawajew
penetrates with a trocar, as advised by  Senac, but warned against it by
Desault, between ihe fifth and sixth rib, three fingers' breadth from the
breast-bone, into the pericardium;  Schuh  also uses  the  trocar in the
fourth intercostal space on the inner side of the internal mammary artery.
The  dressing and  after-treatment are  the  same as after  opening the
 chest {b).
   Richerand (c) proposes to  lay bare  the front of the pericardium by removinga
portion of the cartilage, and of the rib, and  so  to open it that not only the fluid
escapes, but such degree of adhesive inflammation is set up, that union of the
 secreting surfaces, and  a radical cure ensues.

   (a) De Trepanatione Sterni  et Apertura  Larrky, Memoires de Chirurgie Miliiaire,
 Pericardii; in Acta Nord. Soc. Med. Har-  vol. iii. p. 459.  Paris, 1812.  8w>.
 niensis, vol. i. p. 130.  Huun., 1818.         (c)  Histoire d'une Resection des Cotes et
   (6) Senac, De la Structure duCoeur, p. 3G5.  de  la Plevre, p. 10.  Paris, If 18.—Nicou,
 Paris, 1749.—van  Swieten, Comment,  in  Dissert, sur le Danger de la Resection des
 Aphorismos Bocrhaavii, vol. iv. p. 138.—De-  C6tcs, &c.  Paris, 181b.
 sault, CEuvres  Chirug., vol.  ii. p. 304.— 
[   203  ]
   VII.—OF THE ACCUMULATION OF  SEROUS  AND PURULENT
                   FLUID IN THE MEDIASTINA.

   1908. A collection of water  in  the  anterior mediastinum {Hydrops
Mediastini) occurs only in connexion with dropsy of other kinds.  More
frequently a collection of pus or blood takes place in the mediastinum, in
consequence of an external wound which  has penetrated the breast-bone,
or has  injured its surface only after inflammation of the mediastinum,
{Pleuritis Stemalis,) or it follows carious  destruction of the breast-bone.
   1909. The signs of such accumulation  are more  or less uncertain.  If
there be  symptoms of inflammation  of the mediastinum, fever, difficult
breathing, pain behind the breast-bone, which generally extends down-
wards towards the pit of the stomach, upwards towards the air-tube, and
backwards towards the  spine;  if  these symptoms  be consequent  on
external injury, the pain  subsides with frequent shiverings; if the patient
feel  a sensation of weight and pressure behind the breast-bone, if there
be oppression  and hectic fever, no doubt can remain of the presence of
pus  behind the breast-bone.  If there be carious destruction accompanied
with a fistulous opening,  the introduction of a probe and the more free
escape of  pus  in  particular positions of the patient, besides  the  above-
described  symptoms,  point out the nature of the disease.
  If,  soon  after  the breast-bone has been injured by  external violence, difficult
breathing, pressure  and weight behind the breast-bone, and  general  symptoms of
hidden haemorrhage occur, an extravasation of blood has taken place into the medi-
astinum.
   1910. When the existence of extravasation into the mediastinum is
ascertained, its removal is necessary, must not be long delayed, and is
effected by perforating the breast-bone (Perforatio  Trepannatio.)  This
operation   may be also necessary, in  addition to the above-mentioned
diseases, for the purpose of removing a dead piece of the breast-bone, or
in order to make  the  reduction of  a fracture possible {par. 624.)  The
part at which the perforation is to be made is directed according to the
different objects of the operation: thus, in extravasation, the aperture is
to be made opposite  it, and where possible  at the lowest part; if the
ends of a  fracture be driven in, upon the  still firm remaining part of the
bone near the edge  that is depressed; and in caries must be so made
upon it, that all the diseased part may be removed.
   1911. A cut is to be made about an inch and a half in length along
the  middle line  of the breast-bone  through  the skin,  its middle  cor-
responding with the part to be perforated.  The edges of this wound are
then drawn asunder by assistants, the periosteum cut through to the extent
of the trepan-crown, and then removed with a scraper.   The perforation is
best  made with a trephine, according to the  rules laid  down in trepan-
ning {par.  441.)   The perforated bone must  be  lifted out with an ele-
vator, and any connexions with the internal periosteum  divided with the
knife.
  But in children, whose breast-bone is  still cartilaginous, the perforation can be
made with a trocar without a canula.
  1912. After the collected fluid has been discharged by proper posture
and sopping up with a sponge, a simple dressing  must be applied, and a 
204
DROPSY OF THE BELLY \
piece of linen spread  with mild ointment introduced into the wound
fastened with sticking plaster, and bound on with  a  scapular  and chest
bandage.  The after-treatment  depends  on the  ensuing symptoms of
inflammation and suppuration, and  is much the  same  as that directed
after the operation of empyema.
  Upon Trepanning the Breast-bone, see
  De la Martiniere, Memoire sur l'Operation du Trepan au sternum;  in Mem. de
l'Acad. de Chirurg., vol. iv. p. 515.
  Clossius, De perforatione Ossis Pectoris.  Tubing., 1795.
  Fabrice, Diss, de Empyemate Mediastini ejusque  curatione, ope Trepani.  Al-
torf, 1796.
                VIII.—OF DROPSY IN THE BELLY.

(Hydrops Abdominis, Ascites, Lat.; Bauchwassersucht, Germ.; Hydropisie, Ascites, Fr.)
  Martini, F., Ueber die Art der Abzapfung des Wassers bei der Bauchwasser-
sucht; in his chirurgischen Streitschriften, vol. ii. p. 25.
  Monro, Donald, M. D., An Essay on the Dropsy and its different species.  Lon-
don, 1765.  8vo.  Third Edition.
  Ackermann, De Paracentesi Abdominis.  Jenae, 1787.
  Spiritus,  Dissert, variae rationes Paracentesis  Abdominis  instituends.  Jenae,
1794.
  Ehrlich's Beobachtungen von der Bauchwassersucht; in his chirurgischen
Beobachtungen, vol. i. chap. x.
  1913.  In dropsy of the belly, the water  collects  either in the whole
cavity of the peritoneum, {General Dropsy,) or in a proper sac, (Encysted
Dropsy,) which may be attached  either to  the peritoneum, or to one of
its folds, or it  may be formed on some one particular bowel, most com-
monly to the ovary {Ovarian Dropsy.)   In both cases, if  the accumula-
tion of water be so great as to produce distention and fluctuation of the
belly, and do not yield to the usual remedies, then its removal by tapping
{Paracentesis Abdominis, Lat.; Bauchstich, Germ.) is required.
   1914. This  treatment,  indeed, is usually only palliative, as the water
soon re-collects ; but  it may so far assist the cure as that, after its removal,
the remedies which had previously been useless, act efficiently, or if the
causes of the dropsy  be'got rid of.  This will happen so much sooner if
the operation be  undertaken early, and great  re-collection of the water
be permitted before it be again drawn off.    Although considered merely
as a palliative, yet the operation  has the advantage  over long-continued
internal  remedies  for the  purpose of discharging the fluid by the urinary
organs, or  by the  alimentary canal.
  In  encysted dropsy, the operation rarely assists  the  radical cure, but
is more likely to do  so if not too long delayed, if there be yet no organic
changes in the sac, thickening, scirrhous hardening, and the like.  When
with dropsy of  the belly there is considerable and  painful hardening of
the bowels, in encysted dropsy, if the collection be very considerable and
of longstanding, if the patient's powers have been much sunk thereby, the
operation may produce relief for a time, but soon afterwards the patient
becomes worse, and usually  the fatal  termination  is  hastened.   If in
encysted dropsy, the position of the sac be such that the operation is not
possible without injuring some important part, it is positively forbidden. 
TAPPING.
205
   1915. The spot where tapping is performed, is either the  middle of a
line, supposed to be  stretched from  the  navel to the upper front iliac
spine, especially on the left side, or the point where a line,  drawn from
the lower edge of the last false rib to the crest of the hip-bone, is crossed
by another carried horizontally from the navel to the back.   As, however,
in ascites, the front wall of the belly is in  general most considerably dis-
tended, and the strait muscles become much broader, there is not unfre-
quently danger in making the puncture at  the spot mentioned, of wound-
ing either a part of the belly where the muscles are thicker, or  the
epigastric artery, or one of its branches.  On this  account the puncture
on the white line, two or three inches below the  navel, where the walls
of the belly are generally thinnest, and no injury in any one artery is to
be feared, is preferable (a).
   [According to Astley Cooper (b) we, at least in  England, are indebted  to the
elder Cline for the adoption, if not the proposal,  of tapping in the white line.  " His
reason for this change was, that in the spreading of the abdominal muscles from the
pressure of the water, the epigastric artery is brought into a situation of risk of being
wounded by the trocar.  This happened to him  in tapping a person in St. Thomas's
Hospital;  florid  blood issued  through the canula, and the quantity gradually in-
creased as  the water flowed: as  the patient was becoming faint, he withdrew the
canula, and closed the wound, but the bleeding  continued into the abdomen, and the
man died ;  upon inspection the epigastric artery was found wounded." (p. 381.)]
   1916. When decided hardening  of the  bowels  is felt, another, and
indeed  the most distinctly fluctuating part is to be  chosen:  in encysted
dropsy  that, where the fluctuation  is the most strong, care,  however,
being always taken to avoid the  epigastric artery; the navel,  if its sur-
face be distended like a bladder ; the scrotum, if there be a rupture-sac
without gut or omentum; the vagina, when by the pressure of the water,
it is protruded.  In the latter two cases,  care  must, however, be  taken
that a pieee of gut or omentum have  not united  with the rupture-sac, and
that the protrusion of the vagina have not been caused by  the  bowels,
especially by the urinary bladder (c).
   1917. The patient is to be put into a half sitting posture,  but, if very
weak, he must be laid  more horizontally on  a bed,  with the part where
the operation  is to be performed towards its edge (1).  A  broad belly
bandage, having a four-cornered hole opposite  the part to  be punctured,
is then applied and  drawn  rather tightly upon the back  by assistants.
The o'perator holds a trocar of proper thickness, and furnished with a
silver canula in his right hand, so that the forefinger stretches along the
latter, to  about an inch and a half of the point of  the trocar, which he
pushes  in with a rotatory motion and rather obliquely through the  walls
of the belly, thq thumb of the left hand being placed below the point of
puncture.   A  diminution of the obstruction shows  that  the trocar has
entered sufficiently deep, and then  the operator, with  the finger of his
left hand,  fixes and holds fast the canula  at the edge of the perforated
skin, with the  other hand draws out the trocar and  allows the water  to
escape, the assistants generally tightening the  belly-bandage in propor-
tion, whilst another assistant, with both his hands spread upon the sides
of the belly, moderately compresses it.  If the quantity of water be large,
         (a) Cooper Samuel, Dictionary of Practical Surgery, p. 1061,
         (6) Lectures on Surgery, by Tyrrel, vol. ii.
         (c) Zang, Operationen, voL iii. p. 295.
                                18* 
206
DROPSY OF  THE BELLY  ;
the mouth of the canula should be  frequently closed with the finger, or
otherwise an overloading of the blood vessels of the belly and fainting
will  quickly occur.   If the flow of water should  be checked by the
clogging of the canula, or if any thing lie against its inner end, either a
probe must be introduced or a thinner canula, closed at its end but with
openings on its side, or the direction  of the canula already introduced
must be changed, or it must be withdrawn a little.   If the operation be
performed on an incurable patient, merely for the purpose of relief, and
the accumulation of water be very great,  only a third, or, at furthest, not
more than  half should be allowed to escape.   When the fluid is so thick
that it cannot escape through the canula,  it is recommended to  introduce
a longer trocar, or  to enlarge*fhe wound  with a knife, or  with a piece of
tent introduced into the wound (2).
  A round and tolerably thick trocar is undoubtedly the best instrument for tapping
(a).
   [ (I) Before the operation of tapping is performed it is always advisable to pass a
catheter so as to ensure the emptiness and safety of the bladder; and this may also
be useful in correcting any mistake in the diagnosis as to the cause of the swelling,
since great  distention of  the  bladder, from  retention of urine, may so  completely
stimulate dropsy  as to deceive the most  wary; at least, since  John Hunter was
deceived, and tapped a distended bladder for dropsy, if Everard Home tell truly,  it
well behooves others to be cautious.
  In women, also, it is especially necessary that no mistake should occur with re-
gard to the  condition^ of the womb.  I knew of an  instance in which  a pregnant
woman would most certainly have had  a trocar thrust into the  womb by a very
eminent surgeon had he not been providentially prevented by the  better knowledge
of an able  practitioner in midwifery.  Such dreadful errors have, however, been
perpetrated.
  (2) I do not think a trocar of any kind  is the best instrument for tapping.  If  it
were certain that  the walls of the  belly were always thin, and not tough, it might,
perhaps, be so, though I doubt it.  But the wall of the  belly is very often, nay,
very frequently thick, from effusion into  the cellular tissue between the skin and
muscles, and often tough also, and therefore the trocar requires  to be thrust in with
more force than is advisable or safe; and it is only surprising that, in the careless
way in which tapping is too frequently performed, so little mischief results from it,
as too frequently the  danger  of wounding an  intestine by driving a trocar with a
plunge into the belly  up to the hilt, does not seem to enter the mind of the operator.
1 much prefer the  Clines' practice of puncturing the wall of the belly with an abscess-
lancet, and then introducing a blunt-ended canula through the wound, notwithstand-
ing  Samuel Cooper's assertion  that " it is superfluous."   Immediately the lancet,
which should be  introduced with its edges vertical, has entered the cavity, the fluid
begins to escape, and  a blunt canula can be passed without difficulty through the
wound.   In this  way there is no  opportunity, or at  least as  little probability as
possible, of injuring an intestine; and the wound, instead of being a bruised one,
as it is from the trocar, is a simple clean  cut, most favourable for  union.
   I do not recollect to have seen any instance in which it was necessary to stop the
escape of the water from the  belly on account  of the overloading of the vessels  or
fainting.  It is very true that in tapping a dropsy faintness does often occur, but this
depends on  the want of support which the  diaphragm suffers from the  withdrawal
of the fluid, which had previously thrust it up into the chest and diminished the
capacity of  the lungs; but when,  by the escape of the  water from the belly, and
consequent  relief of the diaphragm from pressure, the lungs and  heart have increased
room, are capable of receiving, and do receive more blood at the expense of the brain,
then faintness ensues.  To prevent the diaphragm losing its acquired support, and

   (a) Upon  the different forms of trocar  vol.  v. p. 611.—Arnemanx, Uebersicht der
consult Gusovius, Dissert, qua novem  Para-  beruhmtesten und gebrSucblichsten  Instru-
cepteseos instrumentum ofFertnr, Regiomont,  mente, p. 132.—Krombholz, Akiologie.
1722; in Haller's  Collect. Dissert., Chirurg., 
TAPPING;  AFTER-TREATMENT.                  2Q7
to preclude its sudden descent and the consequent fainting, the common practice of
a sheet folded, passed round the belly, crossed on the baek, and the two ends con-
tinually but gently pulled by assistants, so as to keep the sheet tight and support
the remaining contents of the belly against the diaphragm, and not merely to hasten
the flow of the water, as generally supposed, should be always employed.
  If, whilst the water flow  off the  patient become faint, which is not at all unfre-
quent, the tightness of the  draw-sheet should be carefully attended to, and wine or
brandy given in such quantity as may seem fitting.—j. f. s.]
   1918.  When the water is emptied, the operator grasps the canula with
the fingers of his  right hand, closing its mouth  at the same time with one
finger, whilst with the fingers of the other hand the wall of the belly is
held  back,  and the canula slowly withdrawn  by turning it on its axis.
The  wound is then cleaned, covered with a  four-cornered piece of stick-
ing plaster, a compress  put upon it, and  the belly-bandage having been
moderately tightened, is made fast.
   Bleeding may occur after tapping in three ways:—first, by wounding a bowel in
pushing in the trocar, blood then escapes mingled with the water; second, by rent of
the blood-vessels from overfilling, after the quick removal of the pressure;  in  this
case,  towards the end of the operation, the water is tinged with blood;  and, third,
by wounding the epigastric artery, or one of its branches, the blood then appears
after the removal of the canula, or it may be poured into the belly and symptoms of
hidden bleeding ensue.
   In the first two cases proper compression of the belly with cold applications should
be employed; in the third attempts should be  made to stanch the  bleeding, by the
introduction of a stiff bougie or a piece of wax taper into the wound, or the wall of
the belly should be raised into a fold and compressed  for some hours (a).
   The external branch of the external epigastric artery, generally the largest, is some-
times scarcely observable, whilst on the contrary the vessel itself, with its principal
branches, passes upwards  and inwards, where on tapping, a dangerous bleeding
readily ensues if one or other of them be very large (b).
   [I once, very soon after  becoming Assistant Surgeon to St. Thomas's Hospital,
had the misfortune  to puncture the epigastric artery in tapping a dropsy of the belly.
I had tapped this patient on the first occasion in the usual place, on the white line,
midway between the pubes  and navel.   Some weeks after my friend Green tapped
him again, and about a month after, a  third tapping was performed by me.  Fancy-
ing that perhaps the scar woujd not readily heal if I tapped in the same place again,
I passed the  lancet  into the white line scarcely  half an inch below the old scar, and
afterwards the blunt canula.  As  the  water flowed he became very faint, but not
 more so than I have frequently seen without any ill consequence;  and indeed
 wounding  the epigastric  artery never  crossed my mind, for I felt assured I was far
 away from it; nor  was  there any blood with the  water, or from  the wound after-
 Wards, to lead to suspicion.  Wine and brandy were given, and he was put to bed
 quickly,   He gradually sunk, and died within twelve or fourteen hours.  On exami-
 nation, the belly was found full of blood, I should think four or five pints; and on
 carefully dissecting the  wound and its neighbourhood, the  epigastric  artery  was
 found to have inclined inwards, very soon after its origin from the iliac, and ran up
 behind the white line through a large part of its extent, between the pubes and navel,
 so that it was remarkable the vessel had escaped wound in the first twD operations.
 From this  untoward case I learnt a lesson I have never forgotten, and which I would
 anxiously  impress, to wit,  that if tapping be performed safely at' one spot, it should
 be again  and again performed  in the same place, if the patient required tapping
twenty times.   I have known another example very similar to my  case, which hap-
 pened in the private practice of a medical friend, and  with the same painful result.
   I also had another case in which there was  considerable difficulty in drawing off
the water at all, as I had tapped with a trocar and open canula, and the intestines fell
so upon the edge of the tube that I could only give escape to the fluid by introducing
a long elastic gum catheter through the canula into the belly.  In this case, the

   (a) Medical Communications, vol. ii. p.     (b) Edinburgh Med. and Surg. Journal,
482.                                   vol. iii. p 281. 1822. 
208
DROPSY OF THE OVARY |
 water was much tinged with blood, and, on the removal of the catheter and canula,
 there was a very free discharge of dark-coloured  blood from the wound, which
 alarmed me much, and was stayed with difficulty by pressure on the  sides of the
 wound.  No ill consequences, however, ensued, and some time after I tapped her
 again without recurrence of this annoyance.  Whether correctly or not, I presumed,
 from the dark colour of the blood, that I had wounded some large veins.—j. f. s.
   Watson (a) mentions an " instance which he witnessed: clear serum issued for
 some time through the canula, but at length pure blood, not less  than a pint.  The
 patient sunk, and no opportunity was given to investigate the cause of the bleeding.
 In another strange but well-authenticated case, the almost incredible quantity, twenty-
 six pints, of blood, flowed out at the orifice made by the trocar, and afterwards sepa-
 rated into clot and serum.   To the wonder of those who saw the incident, the patient
 recovered from the tapping; and the source of the  haemorrhage is still a matter of
 conjecture." (p. 399.)]
   1919.  For the first two days after the operation, the patient should be
 kept quiet,  and allowed only a little light food.   On the third day the
 dressings may be replaced, and at the same time rubbing in volatile oint-
 ments, spirituous fluids,  or diluted spirit of  ammonia.   If there be in-
 flammation of the diaphragm, or of the bowels, the patient must be treated
 antiphlogistically, with due attention to the state of the constitution.  The
 inflammation sometimes  runs on very speedily to gangrene or to suppu-
 ration.  Colicky pains, if not inflammatory, require aromatic waters, with
 the addition of some antispasmodic-.   If the water re-collect, the opera-
 tion must be repeated, when fluctuation is again distinct.
   1920.  The following  remarks must be  made in reference  to the dif-
 ferent parts at  which tapping must be,  under peculiar circumstances,
 {par. 1916,)  performed.   In  puncturing  through  the navel,  the trocar
 must be thrust through its bladder-like distention and the enlarged navel-
 ring.  Puncture through the  scrotum  must be performed in the same way
 as will be directed for hydrocele.  In_puncturing through the vagina {b),
 after having forced the water down still more  into the pelvis, by means
 of >a belly-band, the patient  must be laid upon the edge  of the bed,  her
 thighs separated, the trocar and canula introduced into the vagina on the
 forefinger of the left hand, and then thrust into the most fluctuating part.
In encysted dropsy, after the swelling  has  been made very  tense by
 placing a folded  towel upon  the  belly above  and below it, the trocar
 must be introduced  at the most fluctuating part.  If the water be con-
 tained in several sacs, it  should be attempted, after introducing the trocar
 into one of them,  withdrawing the stilette and drawing off the water, to
press the other sacs against the inlying canula, and with the trocar again
 introduced to open them;  or they  should be severally punctured.
   [Among the variety of schemes proposed for the cureNof dropsy in the belly, the
 ingenious one of Buchanan (c) is worth adverting to, though it was not successful.
 His object was to ascertain the effect of a communication between the cavity of the
peritonaeum and that of the bladder, for which purpose he employed a curved trocar,
 similar to that commonly used in retention of urine.   He first introduced the canula
 through the urethra, towards the upper and fore part of the bladder, pushing it as far
 as possible up, to  keep the  coats of the  bladder stretched;  and  then passing the
 trocar through it, without difficulty punctured the bladder, and withdrawing it, the
 water flowed freely.  The aperture closed within a fortnight, and the operation was

   (a) Lectures on the Principles and Prac-   the Vagina; in Medical Communications
 tiee of Physic, vol. ii.                     vol. i. p. 162.  London, 1784.
   (6) Watson, Henry, A Ca?e of Ascites, in    (c) Glasgow Medical Journal, vol. i. p. 195.
 which the water was  drawn off by tapping   1828. 
          diagnosis; puncturing in encysted dropsy.     209

 again resorted to, but with the same result.  About a fortnight after, the operation
 was repeated, but with no better success, and was therefore given up.]
   1921.  Of all dropsies, that of the ovary is the most common.  The
 fluid is of different nature, colour, and consistence, is contained either in
 one or several sacs, the walls of which are of different thickness.   In most
 cases, this dropsy is accompanied with other degenerations and diseased
 productions of  the  ovary, hydatids,  steatomatous,   and  sarcomatous
 changes, bony, stony, and other concretions.
 _ The diagnosis of dropsy of the ovary is often difficult vyhen the disten-
 tion is very great.  The following circumstances  may direct the prac-
 titioner:  the swelling begins at one particular spot, on one or other side,
 at which there is often  weight or  painful feeling for  a long time, often
 after the stoppage of the menses, often  after suppression of discharges
 from the generative organs.  With considerable distention,  there is also
 often observed an irregular  condition of one or other  side of the belly,
 and, at some parts, a resisting hardness.  The state of the general health
 is usually less disturbed  than  in  ascites.   The situation of the vaginal
 part of the womb is  mostly changed, and  dragged to one or other side.
 If the water be collected in  several sacs, or there be also other kinds of
 degeneration,  the swelling can be only partially emptied by the puncture,
 and is then more distinctly felt,  and may even be displaced.   But if,
 with ovarian dropsy, there  be  also ascites, the kind of disease and the
 contents  of the belly can only perhaps be determined after previous tap-
 ping.   Both ovaries  are rarely dropsical at once; and the left is more
 frequently so than the right.
  According to Blasius (a), ovarian dropsy appears  under three forms, as  hydrops
 hydatidosus, saccatus, or cellulosus.  In the first form, a number of hydatids are found
 beneath the serous membrane of the ovary;  in the second, the water is collected in a
 distinct sac beneath the serous membrane; in the third, it is contained in numerous
 cells within the substance of the ovary.  These cells are originally Graafean vesicles,
 have thick walls, but in which openings are often formed  by  the pressure of  the
 water, so that several cells communicate  together, or even tear  on the surface next
 the cavity of the belly, and discharge the water into it; or, in rare cases, when the
 Fallopian  tube has its open end applied to the ovary, the water escaping by the
 tearing of the corresponding cell is discharged through the tube into the womb, and
 escapes by the vagina; in which case,  the patient, from time to tinie, loses a pale
 or discoloured bloody stinking water, by which the  swelling of the ovary is at the
 same time remarkably diminished, and  the inconvenience, which it had at first
 caused, frequently subsides.  Any immediate external violence is not necessary to
 cause this. Blasius has collected examples of this  kind, and  has distinguished it
 as hydrops ovarii profiuens.
   1922.  As puncturing an  encysted  dropsy,  and especially that of the
 ovary,  is only a palliative, various modes of proceeding have been pro-
 posed for the radical cure.  After  making the puncture, the canula of the
 trocar should be  left  in, to diminish  the  size of the  sac, and then  by
 enlarging the wound to excite  adhesive inflammation, or by introducing
 a  flexible tube  to keep  up the  discharge.   Ollenroth (6), after first
 making the usual puncture, thrusts in a round-ended  tube  through the
 former, leaves it there some days, empties the fluid  several times a day,
 and applies moderate pressure on the belly.  Le Dran (c) made  an

  (a) Commentatio de Hydrope Ovariorura   (b) Richter, Anfangsgriide, vol, v. p. 165-
profluente.  Halce, 1834.                170.
               (c) Memoire de l'Acad. de Chirurg., vol. ii. p. 431. 
210                      OVARIAN DISEASE,
opening into the sac upon a director introduced through the trocar canula,
or immediately upon it, to the  extent of four or five inches, held the
wound open, and endeavoured  by injection or  by the introduction of
wadding to destroy the sac, or bring about its growing together.   Lit-
tre (a)  effected this  by injection.   Chopart and Desault (6) opened
the sac with caustic, by which it gradually flaked off.   Dzondi (c) opened
the sac with a cut, passed in  a bougie, and separated the loose sac with
forceps.  King (d), West (e), and  Jeaffreson (f), puncture the swell-
ing and enlarge  the wound, or make a cut on  a fold of the wall of the
belly, open the peritoneum, carry a ligature  through  the  exposed  cyst,
empty it'with a puncture, draw the swelling  gently forward, put a liga-
ture around its stalk,  cut off  the sac in front of  the  ligature, and then
unite the wound.   But when  there also exists degeneration  of the ovary,
or complete steatomatous alteration, in which the former modes oftreat-
ment can have no satisfactory result, for the purpose of effecting a radical
cure, De la Porte and MoRAND(g-) proposed the extirpation of the diseased
ovary; and L'Aumonier {h), Smith (i), Lizars (k), Chrysmar (/), and
Quittenbatjm (m), have  successfully  performed  it.    The  practicability
of this operation depends on the usually thin  stemmed attachment of the
dropsical and otherwise degenerated  ovary, which is  merely formed by
the broad ligament, and has usually no considerable adhesions.   The
W'all of the belly must be cut  into on one side or the  other of the while
line, according to the  seat of the swelling, and to a corresponding length,
in whtch the protrusion of the intestines must, as in the Caesarean opera-
tion, {par.  1844,) be prevented.  The swelling is now carefully separated
from  whatever attachment it has to  the  omentum, the peritoneum, and so
on, with the fingers or with  the knife, and drawn out through the wound;
the now apparent thin stem is pierced near the womb with a needle, and
tied by means of  a double thread, to prevent the ligature  slipping off.
The stem is then cut  through before the ligature, which is  brought out
at the bottom of the wound, which is  to be  united after the rules above
given for the Caesarean operation.
  (I) Here  also must be noticed Recamier's (n) mode of treatment; the swelling
is emptied with a flat trocar, the canula thrust into the blind end of the peritonaeum
till it is felt in  the vagina, into which it is thrust, and an elastic tube  introduced.
The result was fatal.
  [(2) Brown (o) advises a combined constitutional  treatment, with tapping and
very tight bandaging. He sums up the principal points in the successful treatment
of the four cases  he has given  in the following words:—"I  shall divide the  treat-
ment  into constitutional, local, and treatment after  tapping.   First, constitutional;
mercurials administered internally, as alteratives, and externally by friction over the
  (a) Mem. de l'Acad. des  Sciences.  1707,    (k) Observations on the Extraction of Dis-
p. 502.                                eased Ovaria, p. 9.   Edinburgh, 1825,  fol.
  (b) ffiuvres Chirurgicales, vol. ii. p. 238.     {I) In Hopfer, Ueber Exstirpation krank-
  (c) Beitrage zur Vervollkommung der Heil-  hafter Eierstcicke; in Graefe und Walther's
kunde, vol. i.  Halle, 1816.               Journal, vol. xii. p. 60.
  (d) Lancet, 1836-37, vol. i. p. 586.          (m) Quittenbaum, C. F., Solemnia Christi
  (e) Ibid., 1837-38, vol. i. p. 307.         nate precelebranda indicit.  Inest Conimen-
  (/)  Transactions of Provincial Medical  tatio de Ovarii h\pertrophia et Historia Ex-
Association, vol. v. p. 239.   1837.          tirpationis Ovarii hypertrophic! et hydropici
  (g) Mem. de l'Acad. de  Chirurgie, vol. ii.  prospero cum successu factse.  Rostochii, 1
pp. 452, 455.                           35.  4fo.
  (h) Hist, de la Soc. Roy. de Medecine, vol.    (n) Revue Medicale, vol. i. p. 19. 1839.
v. p. 296.  1782.                          (o) Cases  of Ovarian  Dropsy, &c.;  in
  (i) Edinburgh Med. and  Surg. Journal,  Lancet, 1843-44, vol. i.
vol. xviii. p. 532.  1822. 
OPERATIONS  FOR.
211
abdomen, and continued till the gums are slightly yet decidedly affected, and this
affection must be continued for some weeks.  I lay particular stress upon this point.
At the same time diuretics must be given, and after  the first week tonics should be
combined with them.  The food should consist of light animal diet, and should be
unstimulating, and the patient should take daily exercise in the air.  Second, local
treatment; the careful and constant application of tight flannel bandaging, so as to
procure considerable pressure over the tumour.  When it is proved that the abnormal
action has been checked by a positive decrease of the tumour, and  a continuation of
such decrease, or by a positive non-increase for some weeks, then the cyst should be
tapped, and its fluid  evacuated.  Third, after-treatment; accurate padding (napkins
folded in a square form and placed one over the other, so as to form a firm pad)  and
tight  bandaging over the cyst  and belly generally, for two  or three weeks after tap-
ping, and the medicine  and friction continued  for at least six weeks.  I would
particularly wish to enforce the importance of the after-treatment, as on that depends
very much the success or failure of the case." (p. 181.)
  Bonfils (a) and Camus (6) recommend, that after puncturing the cyst and with-
drawing the  water, the canula should be briskly moved  in different directions, to
bruise and even tear the wound in the walls  of the cyst, to prevent the  adhesion of
its  edges, and allow the continual escape of the  fluid  into the cavity of the perito-
naeum, wherexit will be absorbed.   Berard,  however, thinks that the movements of
the instrument rather excite adhesive inflammation and obliteration of the sac.
  (3) With  regard  to the advantage  derived  from  tapping an ovarian dropsy,
Southam (c) observes, from  the  analysis of twenty cases  which he recites, "that
paracentesis, which  is  generally considered  the  most effectual palliative, not  only
affords a very temporary relief, but is by no means unattended with danger.  Thus
fourteen died within nine months  after the first operation, four of whom survived it
only a few days.  Of the remaining six, two died in eighteen months, and four lived
for periods varying from four to nearly nine years.   It further appears that paracentesis
does  not prolong life on an average for  more than  eighteen months and nineteen
days; and that one  in five dies of the first operation.  Another fact  to be gathered
from  the  table is, that the peritonaeum being more prone to inflammatory action in
some persons than in others, repeated tappings, instead of  proving barriers to extir-
pation, show that (other circumstances favourable) there is  much less  risk of inflam-
mation following the operation (of removing  the ovary.")   (pp. 237, 38.)]
  The operations now generally performed for the extraction of dropsical or other-
wise diseased ovary, are distinguished by the names, the small and the large opera-
tion.
  The'small operation was evidently suggested by Dr. William Hunter (d), who
observes:—"If it be proposed, indeed, to make such a wound in the belly as will
admit only two fingers or so, and then to tap the bag and draw it out, so as to bring
its  root or peduncle  close to the wound of the belly, that the surgeon may cut it off
without introducing  his hand, surely in a case otherwise so desperate,  it might be
advisable to  do it, could we beforehand know, that the circumstances would admit
of  that treatment." (p. 45.)
   This  operation was performed  first and with success by  Jeaffreson (e) of Fram-
lingham, in Suffolk, in 1836, and consisted in  "an  incision of between ten  and
twelve lines in the course of the linea alba, midway between the navel  and the pubes,
and having thus carefully exposed the sac he evacuated by the trocar, about twelve
pints  of clear serum.  During the flow of the serum, a portion of the sac was secured
in  the gripe  of a forceps, to prevent its receding; and he  afterwards extracted  the
sac entire from the cavity of the abdomen, together with another sac containing  two
ounces of fluid ; indeed the entire ovary, having only to cut through a slight reflec-
tion of the peritonaeum and ovarian ligament, which, with  the exception of a small
portion of the fimbriated extremity of the Fallopian tube are the only natural attach-
ments of the ovary to the uterus. But as this  part was  the medium  of vascular
supply to the sac, and the vessels on the surface of the sac were unusually large,

  (a) Gazette Medicale, vol.  xi.                (d) Remarks on the Cellular Membrane
  (6) Ibid, vol. xiii.                       and some of its Diseases, in the History of
  (c) London Med. Gaz., vol. xxxii. p. 732. an Emphyoemc; in Med.  Ob. and Enq
 1834.                                  vol.ii.   1762.                        **
                                           (e) Above cited. 
212
LARGE AND SMALL OPERATIONS
but he thought right to include it in a ligature previous to returning it into the cavity
of the abdomen; the ends of the ligature were cut off close  to the knot." (p. 242.)
In  King's case (a) in which the same operation was performed, it was necessary,
'• towards the termination of the extraction, that the opening be enlarged to above
three inches; and the obstruction which rendered this requisite, consisted of a solid
tumour of about two and a half inches in  diameter."  (p. 589.)  West's was the
third case, and he made a cut of two inches long in the linea alba, an inch below
the  navel.
  The large operation, as practised by Macdowall of Kentucky, Lizars and Clay, is
described by the latter (b) as "a large incision of eighteen or  twenty inches in
length, or from the ensiform cartilage to the pubes, the ovarian tumour is fully ex-
posed, its pedicle and adhesions separated,  its vessels secured, and the  whole mass
removed entire."  Walne (c), who follows the same practice, after having made a
small opening of an inch and a half in  length below the  navel, for the purpose of
ascertaining  the existence of any adhesions which may prevent the propriety of pro-
ceeding with the operation, makes a cut of about thirteen inches, leaving a space of
three inches  from the pit of the stomach, and another  an  inch  and  a half from the
pubes undivided.   He advises, also, that  the skin should  be  marked  with lunar
caustic across the linea alba, previous to the operation, so as to ensure its proper re-
adjustment afterwards.
  The preliminary treatment consists in abstinence from animal food, and a general
antiphlogistic regimen a few days previous  to the operation,  and Bird  strongly re-
commends attention to the temperature of the room which was kept at 85° Fahr.,
and gradually lowered as the patient became convalescent.]
  1923. In the critical  examination  of these various modes of treating
encysted dropsy, especially that of the ovarium, the following circum-
stances must  be  borne in  mind :—that in all cases in which the  disease
does not  cause great  annoyance, any operation is  to be  considered un-
allowable, as frequently the tumour,  when it has reached a certain bulk
remains  stationary, and  the  patient  may live for a  long while ;  but by
the puncture there is only short relief, as the  fluid generally re-collects so
much the quicker  the  oftener it is  punctured.   Sometimes  life is much
prolonged  by  repeated  tapping, but  at other limes fatal  inflammation
soon  comes on.   Only  in  extremely rare instances does the puncture
produce  a radical cure (d).   Fortunate  results have indeed  been pub-
lished of cutting into, injecting the sac, and  the  like, but in the  greater
number of  cases  the result has been  unsuccessful (1).   The  same also
applies to extirpation,  which,  however, if the radical cure be undertaken
in degenerated,  hypertrophied ovary,  when the position and  attachments
of the swelling are well  made out (2), may be considered as  ihe opera-
tion most to be depended on, and its  frequent performance with success
does away  with Boyer's (e) doubt of the possibility of carrying it into
practice.  In like manner,  in dropsy of the ovary without  other  de-
generation, the  operation of opening  the wall of the belly with a small
cut, drawing out  the  cyst when  emptied,  and  carefully cutting  it  off,
after  putting a  ligature around its stem,  (King,  West,  Jeaffreson,)
appears  preferable to all the other methods proposed for a radical cure,
and is supported  by the  successful cases published, as  well as the fact,
  (a) Above cited.                      a tabular synopsis  of the operations which
  (b) Cases of Peritoneal  Section for the have been recorded, see a paper by Dr. VV.
Extirpation of Diseased Ovaria,by the large L. Atlee, in the Araer. Journ. of Med. Sci.
incision, &c; in Medical Times, vol. vii. pp.  veil. 9.  N. S. 1845.—g. w. n.]
43,59, 67, 83, 990, 139,153, 270.             (d) Boyer, Traite des Maladies Chirurgi-
  (c) Removal of a Dropsical Ovarium en-  calcs, vol. viii. p. 436.
tirely by the large operation.  Two pamph-   (e) Boybr, Traite des Maladies Chirurgi-
lets,  1834.                            cales, vol. viii. p. 438.
  [On the removal of Diseased Ovaria, with 
FOR OVARIAN DISEASE.
213
that such tumours, often even when of great  size, contract no adhesions
with the peritoneum.   On the  other  hand,  it has been objected  that
although this operation at  the first glance appears safest and easiest, as
only a small  cut is required, and the bowels are subjected to less serious
influences,  these advantages  may be  outweighed  by  the difficulty of
drawing the  large mass through a small wound so as to reach and tie its
stem;  whilst the large cut puts the patient in no greater danger of in-
flammation than the  small one,  and has the advantage of getting  at  the
stem with certainty, and of drawing  out the tumour without  danger.
This objection cannot be assented to, as in dropsy  of the ovary, unaccom-
panied with  other  degeneration  and  adhesions, the  smaller cut  presents
indisputable  advantages,  and  therefore the advice  is good,  always to
make  first a  small cut  between  the navel and the pubes, so as to ascer-
tain if there be any adhesions  (a) (3).
   (1) The puncture of an hydropic  ovary through the vagina, cutting into the  sac
and the various kinds of injection, are followed, according to Callisen, with a fatal
result (b).
   (2)  Martini, in one instance, found it impossible to draw out the tumour to its
base (c).
   [ (3) As to the preference of the small over the large  operation, or the contrary,
much must depend upon  the character and size  of  the diseased ovary, and which
can only be decided in  the course of the operation.   It would seem, however, only
reasonable, after making the exploratory cut for the purpose of ascertaining whether
the tumour be free from adhesions, first to attempt its removal by the small cut, and
afterwards to enlarge it., if necessary.
   The results  of the published cases of both the small  and large operation have
been, as far as possible, collected by Phillips, Jeaffreson, and up to the present
time (July, 1846) by T.  Safford Lee, who has recently received the Jacksonian
prize for a very able paper " On Tumours of the Uterus and its  Appendages," not yet
published, but from which he has kindly furnished me with the most perfect account
yet obtained ;  which, however, is only perfect comparatively, as one of the persons
who is believed to have operated on  the greatest number of cases in this town at
.present has not made known the results of his experience.
   It appears from Phillips's (d) table, that of the forty-five cases in which  the large
cut and the removal of the tumour entire was practised,  the number of successful
cases was only eighteen;  whilst of the twenty-five in  which as much of the contents
of the sac were withdrawn as  was possible, and the small cut only used, twelve
succeeded.
   Of the seventy-four cases of the operation for the removal of ovarian tumours which
had been published up to October, 1844, and have been collected by Jeaffreson (e),
it appears, according to his analysis, that " in  thirty-seven  cases the tumour was
removed, and  the patients recovered.  In twenty-four cases the operation was fol-
lowed  by the death of the patient;  of these twenty-four fatal cases, the tumour was
removed in fourteen, could not be removed on account of  adhesions in six, and was
found to be other than  ovarian  tumour in four  cases.  Thus again in seventy-four
cases in which the operation for extraction of ovarian tumour has been undertaken,
it has been completed in fifty-one instances, in fourteen, out of which fifty-one, it has
been followed  by death, and in thirty-seven, by the successful removal of the tumour
and the recovery of the  patient; whilst out of the seventy-four cases selected, it was
found impossible to  carry out the intentions  of the operator  in twenty-three; or in
other words the diagnosis was not sufficiently accurate to enable the surgeon to foresee
the impracticability  of  carrying out  his intentions.  Of  these twenty-three cases,

  (a) Systerna Chirurgia?, vol.  ii. p. 71.—  Second Series, vol. i. p. 473. 1843.  Southam,
Vermandois; in Journ.de Medec, par Se-  above cited.
dillot,  vol. xlvii. p, 150.  1813.             (d) Med.-Chir, Trans., vol. xxvii. p. 473.
  (b) Rust's Magazin, vol. xxviii. p. 436.    1844.
  (c) Key; in Guy's  Hospital Reports,    (e) London Med. Gazette, vol. xxw. 1814.

   Vol. hi.—19 
214               OPERATIONS FOR OVARIAN DISEASE.
thirteen recovered with  life to  remain in statu quo; and ten  died.  The cause of
failure was impossibility of removing the tumour on account of adhesions in fourteen
cases.  No tumour was  found in three cases; and  the tumour  proved to be other
than ovarian in six instances, (p. 648.)
   Lee states to me " the actual number of cases in which the peritonaeal cavity has
been  performed is one hundred and eight (commencing with  L'Aumonier's case.)
Of these  seventy-nine were operated upon by the large incision, twenty-three by the
short, and in six cases the length  of the  incision is unknown.   The  mortality  in
these patients is as one death to nearly three recoveries—namely, sixty-nine recovered
and thirty-nine died.   The operation  was  not completed  in twenty-four out of the
one hundred and eight cases, either  on account of adhesions  or no tumour being
found.  Of the eighty-four cases where  the operation  was performed with a fair
chance of benefit, fifty'-three recovered and thirty-one died, making as 1  death to 2|£
recoveries.  Of the seventy-nine patients  operated on by  the long incision forty-five
recovered and thirty-four died,  making the  mortality as 1 death to 2%± recoveries.
Of the twenty-three operated on by the small incision nineteen recovered and four
died, or"l death to 5$ recoveries.  From  these facts we learn that this operation
terminates frequently fatally;  that a correct diagnosis is very difficult, and in many
instances  defective; and that the short incision has  been used  more  successfully
than the large."
   Much difference of opinion still exists  as  to the propriety of subjecting a female
to such imminent danger, as, without doubt,  she must incur, in undergoing the ope-
ration of the removal of a diseased ovary.   In addition  to which, much has been
said in reference to the malignant character of the disease, which if it were really
so, would justly forbid it being meddled with.   Southam says, that  "having care-
fully examined several specimens of dropsical ovaria, he  is inclined  to believe thai
they never present a truly scirrhous character; on the contrary, that they generally
consist of simple  cysts, or partake of what is called  cystic  sarcoma (a), for the
development of which, the peculiar structure of the ovary appears highly favourable."
(p. 238.)   The proneness of both ovaries to be diseased has  alsO been brought as
an objection to the operation.  But Southam says :—" I have carefully examined
the records of twenty-nine cases of true dropsical-(warm, and found that there were
but two  in  which the opposite ovary presented  a  decidedly abnormal character.
Where, however, the disease was malignant, both were affected in three cases out of
four."  (p. 240.)
  It is also held by some, that the patient has a chance of recovery, without the risk
of an operation, by the cyst bursting of itself,  and, the discharged fluid being absorbed
from t;he  general  cavity  of the peritonaeum.   Such bursting of the dropsical ovary
does now and then occur, but favourable issue is very rare.  One case of  this kind, in
which, after several burstings, and the woman recovered, is related by Bonfils (b).
Another  occurred  recently to Camus  (c), in an old woman of  eighty-five, who  had
had an ovarian dropsy for two years and a  half.  She was then  attacked  with severe
pain in the swelling, attended with extreme lassitude, shivering, and slight fever;
on the following day, she had severe  pain in  the belly, with nausea, vomiting, great
restlessness, colic, quick small and hard pulse, and anxious countenance as in peri-
tonitis.  The shape of the  belly was completely  altered ; instead of projecting,  it
was flattened in the centre, but had  gained in size what it had lost  in prominence.
The fluctuation from one side to the other  had never been so distinct before.  A few
days after she began to void large quantities of urine, and in less than a fortnight
the existence of fluid in  the belly was no longer apparent. Reaccumulation, how-
ever, came, on, and the  belly became larger than before;  but at the end of six months
the cyst burst, and the water subsided as before.   The belly again filled, and at the
end of four months and a half the cyst burst the third time, with less severe symp-
toms, and the patient recovered.  Dr. Locock informs me, that  he  has at present
under, his care, with  Sir Benjamin  Brodie, a female  about fifty years of age, in
whom the ovarian cyst has burst several times.  About a year and a  half ago, long
before any  tumour was  discovered, she had about once  in six weeks  an attack  of
violent abdominal spasms, of the same nature as those which have since clearly been

   (a)HoDGKiN; in Med.-Chir. Trans.,  vol.     (c) Gazette  Medicale, vol.  xiii.  p.  158.
.-xv.-p. 265.   1829,                          1845, and Rankin's Half-yearly Abstract of
  Jjb) Gazette Ms-licdc, vol.xi.p. 746  18:3.   the Medical Sciences, vol. ii. p. 151.  1846. 
OPERATIONS  FOR OVARIAN DISEASE.             215
connected with the bursting of the cyst.   These attacks  became gradually more
frequent, latterly once in three weeks.   The first discovery of the tumour was about
six or seven months ago, a globular elastic tumour of the size of an orange; but pre-
vious to this being felt above the pubes, a very distinct elastic tumour was perceived
by examination by the vagina.  Suddenly spasms  came on as before, and the tumour
was gone, which led Locock to think it was not an ovarian cyst, as he had pre-
viously called it, but only a collection of flatus in the bowel, as great eructations
and general abdominal distention always followed the attacks.  After several repe-
titions of the rise of the tumour gradually, the spasms, and the dispersion, it was
noticed that the tumour became larger and larger each attack.   Then Brodie detected,
after the dispersion, slight fluctuation  in the abdominal cavity, which soon disap-
peared.  The next time it filled, being then the size of a shaddock, they punctured
it with a very fine trocar and drew off a few ounces of brown fluid, exactly the same
as usually found in ovarian cysts.   After this, firm pressure was tried, for a week or
two, over the tumour, but she could not bear the pain it produced.  Since this, the
same alternate filling, bursting, spasms, and disappearance have returned at still
shorter intervals, and recently her health has begun to fail.   The extreme rarity of
these favourable results, however, can scarcely be allowed as argument against the
operation.
  Camus, from the inquiries he was led to in reference to his own case, has obtained
some very  interesting conclusions: first, that in  the rather  great number of cases
which died immediately, or within a few days after the first bursting, the cyst had,
previous to its  rupture, contained a purulent fluid, more or less  altered, and not the
usual serum.  Second, that others, after one or more burstings, ascites remained, though
it was not proved that the ascites and the dropsy of the ovary had  not existed at the
same time.   Third, that most of the patients, who survived one or  two burstings,
were cured only for a time, and at last sank under the progressive effects  of the
encysted dropsy, (p. 158.)
  Astley Cooper mentions  two instances in which the ovarian cyst was burst by
accident; in the one, the patient was thrown out of a one-horse  chaise, and the dis-
ease seemed to have been  cured,  but  it returned seven years after, and sire was
obliged to be tapped ; the other patient fell  out of bed on the corner of a chair, she
afterwards passed large quantities of urine, but the disease returned, (p. 375.)  But
besides the very rare cure of ovarian dropsy by bursting into the general cavity of
the belly, the  cyst also very rarely bursts into  the fallopian tube, and  the water is
discharged through the womb.   Astley Cooper mentions a case of this kind; and
also another in which it burst  into the intestinal canal; and though the patient was
subject to  occasional returns of the disease, she ultimately recovered, (p. 385.)
Schmucker (a) also says, that  in one case, after the sixteenth tapping, the ovary
became suddenly extremely painful in one night, and was followed by the discharge
of a large quantity of very stinking ichorous  matter through the womb, which con-
tinued for some days, and then ceased, (p.  196.)
  Astley Cooper relates a remarkable instance,  in which the navel ulcerated, and
large quantities of water were discharged for a considerable time,  but ultimately
closed, and the disease did not return,  (p. 384.)  Similar to this, though the open-
ing was artificial, is the case of a female of forty-three years  of age, who was tapped
for ovarian dropsy by my friend Sutton, of Greenwich, in 1821, and three or four
times after; on each occasion some hair passed through the canula, and at the last
operation, he determined  to lengthen the cut downwards, so as to empty all the hair,
which he  effected.  A portion  of bougie was kept  in by  his direction for some
months, when the discharge ceased; but the lady fearing the fluid might re-collect,
continued the bougie in the wound till her death,  of apoplexy, in 1841.
   In concluding this important subject, it will not be improper  to give.the opinions
of two able practitioners against and in favour of this operation, about which there is
Still so much difficulty in deciding.
  Ashwell (6) observes:—" If the operation is to become established, of which I
have the strongest doubt, it must be confined to examples of the malady where tap-
ping has been already so often performed  as to preclude, from the experience of
similar cases, any idea that it can ever be  dispensed with; and where we are con-

         (a) Chirurg. Wahmehm., vol. ii.
         \b) Practical Treatise on the Diseases peculiar to Women, 1844.  8vo. 
216
DROPSY OF THE WOMB.
 fident that great  suffering must lead to early death.   Perhaps this may be regarded
 as too limited a view of the value of extirpation, but it is, I think, the correct  one.
 In such cases, if the diagnosis excludes the  belief that there are serious adhesions,
 or malignant and solid growths complicating the tumour, and, if the patient strongly
 desires it, the operation is defensible.   In all other examples, it can only rest on the
 patient's own views of her future prospects, and on  a calculation of chances.   She
 might live many years, and without much suffering; she may die in a few years, after
 great suffering; she determines, therefore, being courageous, and probably strongly
 urged by  her surgeon to run the risk of immediate death, for the hope of immediate
 and  radical cure.  Whether she has done wisely to submit to  such a hazard, a suc-
 cessful operation can  scarcely prove; that she has happily secured her safety,
 through eminent peril, such an operation does prove." -(p. 648.)
   On the other hand, Southam, (a) says :—" The operation is perfectly justifiable
 when the patient's sufferings are such  as to make her life a burden to her; when the
 symptoms of structural lesion of any important organs are absent; and when the con-
 stitution is suffering merely from functional derangement consequent upon pressure
 of the tumour on the neighbouring parts.  On the contrary, it ought not  to be at-
 tempted when the well-known characteristics of malignant action are present; when
 the tumour is  solid,  uneven, and has been of rapid growth; when the glands in the
 vicinity are enlarged, and hard  knots  can be felt in  different parts of the abdomen,
 or when there is distinct evidence of other organs being similarly implicated. Still
 less  should it be undertaken until the surgeon, by varied and repeated examinations,
 is convinced of the existence  of the disease.   Nor must the rules, which direct us
 as to the propriety  of operating in other diseases, respecting the condition of the
 sexual organs, and the fitness  of-the patient's constitution to undergo so severe an
 operation  be overlooked." (p. 211.)
   The number of times which a patient may bear tapping is almost incredible; three,
 four, and five times are by no means unfrequent.
  ' Schmucker (b) mentions a woman of forty-five, on whom he operated twenty-nine
 times in four years;  Ford (c) forty-one  times  in four-and-half years; Schmucker (d)
 on ano'ther woman, sixty years old, fifty-two times in four years.  Mead (e) sixty-
 five  times in sixty-seven months;  Callisen (/) one hundred times;  in Dartford
 churchyard "lies the body of Ann Mumford, &c.  Her death was occasioned by a
 dropsy, for which, in the  space  of three years  and ten months she was tapped one
 hundred and fifty-five times.  She died 14th May,  1778, in the 23d year of her age" (g).
 But  Bezard's  (h) case exceeds all, a woman  who, he says was tapped six hundred
 and  sixty-five  times in  the course of thirteen years.   Whether these cases were
 ascites or encysted generally, is not mentioned.   The  quantity of water drawn off,
 varies of course according to the size of accumulation ; and whether the tapping be
 repeated frequently, and before the belly has  recovered  its former size.  In  the se-
 cond case, recited above  from Schmucker, the quantity had  been reduced  to five
 pints;  and in the greater number of these operations, three or four quarts only was
 the quantity withdrawn.  Astley Cooper says:—"The smallest quantity he had
removed was eight quarts, and the largest twelve gallons and a pint, from an ovarian
 dropsy, the cyst of which  is now  in  St.  Thomas's Museum."   Stoerck took
away twelve gallons and a half.  " The proportion averages," says Astley Cooper,
 " from twenty-five to thirty-two pints," (p. 374,) and this upon the whole, I believe,
a fair estimate.
  Besides the  writers already mentioned, the following may also be consulted in re-
ference to  puncture and removal  of the  ovary :—
  Sacchi, Memoria sull' Idrope delle Ovarie e sulla  loco estirpaaione;  in Omodei,
Annali universali di Medicina, vol. lxiii. p, 257.  1832.
  Chelius ; in Heidelberg. Annalen, vol. i.
  Hevin.; in same.
   [Dohlhoff  (i) operated successfully by the  large  ineision on a large  tumour,
  (a) Above cited.   ,                       (/) Syst. Chirursr. Hodiern, vol. ii. p. 55.
  (b) Above cited, vol. ii. p. 202.               (g) A. Cooper's Leciures, vol. ii. p. 374.
  (c) Medical Communications, vol. ii.  p.    (h) Bullet de la Soc. Med. d'Emulation,
 123.                                    vol. ii. p. 495.  1815.
  (d) Above cited, p. 187.                    (i)  Caspar's Wochenscbrift, vol. i. p. 513.
  (e) Medical   Works,  p.  394.  Dublin, 1833.
1767. 
DROPSY OF THE WOMB; OPERATION.           217
which turned out to be a cyst, containing nine and a half pints of purulent fluid, so
closely connected with the under surface and thin edge of the liver and the intestines,
that its removal could not be attempted.  Having discharged the pus, he filled  it
with charpie, and subsequently stimulated it with ung. elemi and injections of liq.
hydr. mtr., and added Peruvian balsam and tincture of myrrh to the ointment. At
the end of two months the discharge had nearly ceased, and she shortly after re-
turned to her occupation of midwife.]
   1924.  If dropsy of the belly accompany pregnancy, either at the onset
or during the middle of its course, very considerable uneasiness is pro-
duced by the great distention of the  belly, by  the great swelling of the
lower limbs, and  by the pressure which the bowels  suffer ; breathing is
much interfered with, and at last death-like agony, and danger of  suffo-
cation ensue.
   1925.  If pregnancy be connected with acute ascites, the regular form
of the fundus and body of the womb cannot be distinguished by the touch,
specially on account of the  enormous distention and projection of the
hypochondria caused by the  quantity  of fluid  driven  up towards the
diaphragm  between the fundus and back of the womb  and the  bowels.
The urine is scanty, and the perspiration ceases.   In examining the dropsy
of the belly, a fluctuation of  water is felt, indistinct in the hypogastrion
and on the sides, but perceptible and distinct enough in the hypochondria,
decidedly so and  vibrating in the left  hypochondrion between the upper
and outer edge of the m.  rectus abdominis, and the edge  of the  false
ribs.
   1926.  This place  appears  to be most  fitting for  the performance of
paracentesis, without running the danger of wounding the womb or the
intestines (a).  It is less proper to make the puncture at the usual place,
whilst an assistant with both hands presses the  womb towards the spine,
thus forming a thick fold of skin, which is either perforated with  the
trocar {b)t or previously opened with  a cut made through the wall of the
belly (c).
   1927.  A collection of Water in the cavity of the Womb (Hydrops  Uteri,
Hydrometra) may exist in that organ when it is either unimpregnated or
impregnated.  In the former case it comes on with painful feelings  about
the pudenda, numbness of the feet, irregular menstruation  and whites,  a
cold swelling in the region of the womb,  spreading  also  over the lower
part of the belly,  in which, on careful examination, a fluctuating move-
ment can be perceived.   The patient has a feeling of cold over the whole
extent of the womb, of its dropping to one side, and  when she lies down.
If the swelling be in itself  very large, there is  pain, indigestion, qualm-
ishness,   vomiting, frequent flatulence, colic,  costiveness,. difficulty in
making water, retention of urine, at last great  wasting and hectic fever.
Sometimes the water is discharged by the vagina from time  to time, ac-
companied with agony and labour-like pains.   This discharge is  not un-
frequently periodical.
  The signs of distinction between this; kind of dropsy and pregnancy are, the en-
largement of the tumour without regularity; its cold, fluctuating feel;  the  mouth of

  (a) Scaiipa Menoria sulla gravidanza sus.    (6)  Visseuk, On Tapping  during Preg-
seguita da  Ascite, ed ossesvazioni pratiche  n.ancy;  in London Medical  and Physical
su i avantaggi della nouva maniera  d'usare  Journal, vol. vii. p. 40.  1802.
la paracentesi  dell'addomine in simili casi.    (c) Bonn, Ueber die Harnverhaltun? n 31
Trevisio, 1817.  8vo.                                                *'1'
                                 19* 
218
TYMPANITIS.
 the womb is thin, tense, and contracted, and does not rise after the third month; its
 occurrence in girls not arrived at puberty, or in old women, who throughout their
 whole life have been unfruitful; the breasts are generally withered and contracted,
 though the contrary is  also observed.  The absence of the child's motions and of
 the audible beating of the heart; and, in some cases, the existence of the disease for
 more than nine months confirms the diagnosis.
   1928.  In dropsy of the pregnant womb,  which may be accompanied
 with ascites, the belly soon acquires a  regular  distention  as at the end
 of pregnancy, on striking the  belly nothing more  is felt than a slight,
 deep, dull  fluctuation  ; the quick distention of the womb, the bowels
 violently  thrust up against the diaphragm, in consequence of which there
 is difficulty of breathing, and even danger of suffocation ; the feet gene-
 rally swell.   A  considerable -quantity  of water  is not  unfrequently
 passed, from time to time, often periodically by the vagina, with symp-
 toms of threatening abortion.   The birth,  however, usually occurs at the
 due time, and after  the discharge of the proper waters.   The seat of this
 dropsical accumulation is either between  the womb and the foetal mem-
 branes, between the chorion and amnion, often probably in a proper sac;
 or there may be a very  considerable collection of the liquor amnii.   The
placenta  also may be  affected  with hydatids   during  pregnancy.  An
 hydatidous degeneration of the ovum may even produce an accumulation
 of water in the womb, and^render the diagnosis  extremely difficult (o).
   1929.  The causes of dropsy of the unimpregnated womb  are, closing
 of the mouth of the womb by spasm, its  stopping up or growing together,
 and a diseased condition of the secretion  of its inner surface.  The re-
 moval of the water is effected either by the use of the remedies specially
 employed for dropsy, which act upon the kidnies, the alimentary canal,
 and the absorbing vessels; or if the mouth of the womb be closed, by
 warm or  steam  baths,  softening injections,  or by the introduction  of a
 female catheter into  the mouth of the womb when it is stopped up with
 plugs of lymph, and the like.  If there be adhesion of the mouth of the
 womb, the above-mentioned remedies  are useless;  if the symptoms be
 severe, as when dropsy of the  womb accompanies pregnancy, danger of
 suffocation, and the  like, paracentesis uteri is required.
   1930.  This operation, when the mouth  of the womb  is closed, is per-
formed as already described, {par. 1823,) or between the navel and the
pubes, the bladder having  been  previously emptied and a belly-band ap-
plied ; or above the vaginal portion of the womb, in the fluctuating part
of the tumour, with  a trocar (6).
   1931. In distention of the alimentary canal with air, {Tympanitis,) the
operation of paracentesis has been proposed by some surgeons, if the
ailment be idiopathic and not a symptom of any other disease, if it have
existed  three or four days, have withstood all remedies, and the patient
be exceedingly restless and distressed;  the pulse strong and quick, not
small and soft; and  there be general heat over the whole body unaccom-

  (a) Sacrpa,  above  cited.—Cruvelhier,   (6) Scarpa, above cited.—Devilliers ; in
Essaies sur  l'Anatomie pathclogique en ge- Journal de Medecine, par Sedillot, vol. xliii.
neral, vol. i. p.  280.  Paris,  1816.—Geril,  1812.         #
(Praeside Naegele,) Dissert, de Hydorrhoea
Uteri gravidi.  Heidelb., 1821. 
HYDROCELE.
219
 panied with coldness of the limbs.   Other practitioners  have decidedly
 opposed such treatment.
   In performing the operation a long thin trocar with a canula perforated
 on the sides, is thrust into  the middle of a  line drawn  on the left side
 from the front end of the second  upper false rib to the front iliac spine,
 to the depth of four  or five  inches, which  directly opens  the colon de-
 scendens.   The trocar is then withdrawn, whilst the canula is held in, and
 the air contained in  the bowel escapes, after which  the tube  is  to be
 removed as already directed.   The patient  should take but the smallest
 quantity of drink, indeed only  a little iced  almond  milk, and his thirst
 quenched with a slice of Seville orange, sugared, and kept in his mouth,
 or with a cool rather than a lukewarm bath.   If there be no subsequent
 discharge from the bowel, purgative, and afterwards  nourishing clysters
 may be given;  and to  relieve  the  loss of tone which the  intestine for
 some time suffers, cold applications  and swallowing  small pieces of ice
 may be ordered,  (c).


                         IX.—OF HYDROCELE.

             (Hydrocele, Lat.;  Wasserbruch, Germ.; Hydrocele, Fr.)
   Heister, L., De  Hydrocele.   Helmst., 1744; in Halleri Diss.  Chir., vol. iii.
 No. 76.
   Douglas, John, A Treatise on the Hydrocele.  London, 1755.
   Else, Joseph, An Essay on the Cure  of the Hydrocele of the Tunica Vaginalis
 Testis.  London, 1776.  8vo.  Third  Edition.
   Bonhoeer, De Hydrocele. Argent., 1777.
   Warner, Joseph, An Account of the Testicles, their Coverings  and Diseases.
 London, 1779.  8vo.  Second Edition.
   Dease, William, Observations on the Hydrocele.  Dublin, 1782.
   Pott, Percival, A Treatise on the  Hydrocele, or Watery Rupture, &c.;  in his
 Chirurgical  Works,  vol. ii. p. 191.  Edition 1783.   -
   Murray, A., In Hydroceles curationem Meletemata.  Upsalse, 1785.
   Delonnes, Imb., Traite  de l'Hydrocele; cure  radicale de cette maladie, &e.
 Paris, 1785.  8vo.
   Dussaussoy, And. Cl.,  Cure  Radicale de l'Hydrocele par le caustique.   Paris,
 1787.   8vo.
   Keate, Thomas, Cases of Hydrocele ;  with observations on a peculiar method of
 treating that disease, &c.  London, 1788.  8vo.
   Bell, Benj., A Treatise on the Hydrocele, &c.   Edinburgh, 1794.  8vo.
   Earle, Sir James, A Treatise on Hydrocele, &c.   London, 1796.  Second Edit.
   Farre, J. R., M.D., Cases of Hydrocele; in Medical  Records and  Researches,
 p. 182.  London, 1798.
   Cooper, Sir Astley, Observations on the Structure and Diseases  of the Testis.
 London, 1830.  4to.
   Benedict, Bemerkungen iiber Hydrocele, &c.  Leipzig, 1831.
   Brodie, Benj., Clinical  Remarks on Hydrocele; in London  Medical Gazette,
 vol. xiii. pp. 89, 136.  1834.
   Dupuytren, Le Baron,  De l'Hydrocele et de ses principales varietes;  in his
 Lecons Orales, vol. iv. p. 433, Art. 4.  Paris, 1834.  8vo.
   Curling, T. B., A Practical Treatise on the Diseases of the Testis, &c, p. 119.
 London, 1843.  8vo.
   Bertrandi, Memoire sur l'Hydrocele; in Mem. de l'Acad. de Chirurgie, vol iii
 p. 84.

  (a) Combalusier, F. P., Pneumotopathologie.  Paris, 1747.—De Marchi; in  Brerer
 Giornale, 1813.—Levrat; in Nouvelle Bibliotheque Medicale.  1823.—Zang, Onerationen'
vol. iii. pp. 290, 291, 317.                                           * 
220                       HYDROCELE J
  Sabatier, Recherches historiques sur la Cure radicale de l'Hydrocele ; in Mem.
de l'Acad. de Chir., vol. v. p. 670.
  Loder, Ueber den Wasserbruch; in Med.-Chir. Bemerk., vol. i. ch. vii.
  Heden's Neue Bemerkungen und Erfahrungen, vols. ii. and iii.
  Richter, Vom Wasserbruche; in Med. und Chirurg. Bemerk., vol. i. ch. vii.
  Larrey, Memoire sur l'Hydrocele;  in Mem. de Chirurg. Milit., vol. viii. p. 409.
Paris.  8vo.
  Blandin, Art. Hydrocele; in Diet, de Medecine et Chirurgie Pratiques, vol. x.
p. 108.
   [Smith, N., In Surgical Memoirs.   Baltimore, 1832.—g. w. n.]
   1932. Hydrocele is a collection of  watery fluids  in the tunics of the
scrotum, or of those  of the testicle; it therefore varies  according as the
water is collected  in the cellular tissue  of the scrotum, in  the vaginal
tunic of the testicle,  or in that of the spermatic  cord.   The latter two
are, however, in  general alone considered as hydrocele, and the former
as oedema.
   1933. The collection of water in  the cellular tissue of the scrotum
forms a soft swelling, which retains the impress of the finger, and when
it enlarges, becomes  tense and firm, unfolds the wrinkles of the scrotum,
spreads on to  the penis and covers it, and  by the swelling of the prepuce,
the discharge  of  the  urine is  often prevented.   Inflammation, suppura-
tion, and mortification may result  from this swelling.
  1934. This disease is either symptomatic and connected with general
dropsy and the like,  or arises from pressure on the lymphatic vessels by
an ill-fitting truss, or  from accidental tearing of a hydrocele of the vaginal
tunic, and in children from pressure during the birth, and irritation of the
scrotum by the urine.   The cure depends on the removal of these causes
and the use of means specially fitted to oedema.
   1935. The collection of water in the vaginal  tunic of  the testicle, True
Hydrocele {Hydrocele  tunice vaginalis  testis) is always produced slowly,
as a swelling  rising gradually from the bottom of the scrotum towards the
abdominal ring, at first  sometimes accompanied with painful distention,
but  at other  times without any peculiar  sensation.  The swelling has
generally an  oval form (1), is elastic, tense, sometimes distinctly fluc-
tuating, and  the  appearance of the skin over it  is  unaltered; in  com-
parison with its size it is  light; it increases neither on  coughing nor on
any exertion, and cannot be returned into the belly.   The testicle is felt,
when the swelling is  large, generally on its upper and hind part as a hard
part (2);  its  position, however, may vary.  The spermatic cord  is felt
above the  swelling, if it extend  not  to the abdominal  ring.  If in the
dark a light be placed behind the  swelling, it is found to be  transparent,
if the fluid contained within it be clear, and  the vaginal tunic be not
thickened.  Sometimes  when  the distention is very great, the vaginal
tunic and the  cellular tissue upon  it and the m. cremaster are thickened,
the swelling feels harder, is not transparent, and no fluctuation is felt;
the vaginal tunic may be even bony.  In long-continued hydrocele the
spermatic cord and  the  testicle  are  varicose, the  testicle sometimes
wasted.   From pressure on the swelling, as in old bulky ruptures, the
vessels of the cord are  sometimes separated, and thrust either aside or
in front of the swelling.   If the swelling be very large,  the veins of the
scrotum swell, the skin  inflames and sometimes ulcerates. 
CAUSES.
221
  [(1) The general form of a hydrocele is pear-shaped, largest at bottom, and nar-
rowing regularly upwards; but very often it is more oval, and sometimes even con-
tracted in the middle, so as to assume an hour-glass  appearance.  Care must be
taken, however, to ascertain that this hour-glass form is not caused by the existence
of two hydroceles, one above  the other, of which Astley Cooper  mentions one
instance, (p. 90,) and Brodie a still more remarkable  one, in which  "he drew off
the water from the lower part,  and in doing that emptied the upper part.  The pa-
tient came to him a year afterwards and said he wished to have the water drawn off
again.   Brodie observed that the  contraction of the hour-glass was narrower, and,
on drawing off the water from the lower part, found  that  the upper one was not
emptied, and was consequently forced to puncture that afterwards, so that it was
evident what had been originally a partial contraction, in the course  of a year had
become a complete one."  (p. 91.)
  (2) Astley Cooper says:—"The testis is generally placed two-thirds, of the
swelling downwards  and at the posterior part of the scrotum; pressure at that part
gives the sensation of squeezing the testis."  (p. 87.)   I think, however, from my
own observation, that the testicle is generally situated  still nearer the bottom of the
swelling than stated even by Cooper.
  The quantity of water in a hydrocele varies from twelve to sixteen ounces, but I
have occasionally drawn off between twenty and  thirty.  The largest quantity on
record is, I believe, that of  the celebrated Gibbon the historian, from whom the elder
Cline drew off six  quarts;  and Brodie says that he has " seen a hydrocele hanging
down to the patient's knees."  (p. 89.)
  The serum of a hydrocele is generally straw-coloured and transparent, but some-
times so dark that the light of a candle held behind a swelling cannot be perceived.
I have recently had a  case of-this kind, in which the serum was dark greenish-brown,
and could  not  be seen through, though  transparent, on account of its colour; the
vaginal tunic itself was thickened, the hydrocele being  very large and  of long stand-
ing.  Transparency, as a  diagnostic mark, must  therefore  be received with some
caution.
  AstleV Cooper also mentions, that the serum "sometimes contains a quantity of
white flaky matter, produced by chronic inflammation," and "when produced under
acute inflammation, the fluid is sometimes of a red colour, from a mixture of red
particles of the blood."  He has also seen "in the fluid of hydrocele, loose bodies,
of which there is a specimen in the Museum at St. Thomas's." (p. 92.)]

   1936.  Hydrocele of  the  vaginal  tunic of the testicle is distinguished
from scrotal rupture by  the way in which it begins, and by the swelling
enlprging neither by cough nor exertion, and from hardening of the tes-
ticle, by  its elastic, uniform,  painless  fluctuating  character, whilst the
hardened testicle is hard, irregular, and painful.   Hardening, swelling,
and hydrocele of the testicle may exist at  the  same  time {Hydrosarco-
cele.)   Hydrocele  has   many resemblances  to medullary fungus of the
testicle, and sometimes the fluctuation at different parts may at first ren-
der the diagnosis  difficult.   The  transparency of the hydrocele, when  a
light is held behind it in the dark,  is in all  cases to be considered as its
most certain character.

   [Hydrocele may be accompanied with either scrotal  rupture or diseased testicle.
The rupture-sac may  descend as low as the hydrocele and no further, which is com-
monly the case when the two diseases exist, together; but it may also descend be-
hind the hydrocele, and the existence of the latter niay  not be noticed  till strangula-
tion  of the rupture taking place, it is discovered during  the operation.  Cases of this
kind have  been already mentioned in speaking of  the varieties of strangulated rup-
ture, (par. 1199, note.)  The  diseased  condition  of the testicle itself is usually
without difficulty made out,  though imperfectly,  before  the  operation for tapping
the hydrocele is performed; but its nature cannot be easily discovered, and  there-
fore the surgeon must be  guided by circumstances in  regard to the steps he must
take with  it.—j. f. s.]
   1937.  The causes of hydrocele  are in most instances unknown; it 
222                  hydrocele;  Prognosis;
arises of its own accord in  healthy subjects, and  is  especially frequent
in children and old persons.   Its cause often seems to be a slow inflam-
mation of the  vaginal tunic; frequently it occurs after bruises of the tes-
ticle in riding, and the like; sometimes from cold;  after inflammation or
other affections of the urethra; from wearing ill-fitting trusses, and from
syphilis.
  According to  Rochoux! (a), the swelling of the scrotum, consequent on a clap, does
not, as generally supposed, depend on inflammation of the testicle, but on a hydro-
cele arising from inflammation of the vaginal tunic  (a vaginalite, as he calls it.)
The grounds of this opinion are, that the testicle, surrounded by a firm, thick, fibrous
membrane, cannot swell up to such a degree, in a few days, and sometimes even in
a few hours, to  double its natural  size, and even more; that  such swelling of the
testicle rarely goes on to suppuration, whilst inflammation of that organ from other
causes, commonly has that result;  that at the onset there is always fluctuation with
this swelling, and  that, in some cases, fluctuation is perceptible on  examination.
Gausseil (b) holds that a turbid, thick, somewhat sanguinolent fluid, corresponding
to the size of the swelling, and a thick glutinous matter are found.   And Rochoux (c)
has shown from the examination of six bodies that it depends  almost exclusively on
fluid in the vaginal tunic.  He believes, that if, in the  after-course of the disease,
fluctuation be no  longer perceptible, it depends on the sensitiveness of the part,
which will not  bear a close examination, and that, when dispersion begins by the
absorption of the thin  fluid, the swelling takes on the same character as if depending
on swelling of a solid organ.
  Velpeau (d)  considers  that there may be an outpouring into the vaginal tunic,
but that this is slight, and does not constitute the disease, that the pain of an inflamed
testicle is greater than when depending merely on fluid, that no transparency can be
observed, and that the examination of the swelling with the fingers shows the epidi-
dymis participating in the disease.  Blandin (e) holds  that the  state of the parts
differs according to the period at which they are examined ; that at first the inflam-
mation descends from the vasa deferentia to the epididymes and the  testicles, and a
swelling of these arises, but that afterwards, and when the dispersion begins,  the
effusion is a principal symptom of the disease.  Pigne (/) remarks, in opposition to
these statements, that in young persons affected with this disease, whose hydroceles
have been operated on with setons, in spite of the  escape of fluid from both open-
ings, a hard, irregular, painful tumour, of the  size of a turkey's egg, is produced,
which can only depend on  swelling  of the testicle.  To this I would add, that
after the  operation by incision, the  hydrocele, sometimes from the swelling of  the
testicle itself, most decidedly acquires the size of the swelling previous to the ope-
ration.
   1938. The  prognosis of hydrocele is favourable,  and proper treatment
effects a cure, if it  be simple and  without complicatibn; but if there be a
hardened testicle, the cure is only possible when the  testicle can be brought
back to its natural  condition, or is removed.  If the hydrocele be left to
itself, nature alone cannot effect  the cure, which however is not infre-
quent in children.
   1939. The  cure of hydrocele is palliative or radical.  The former con-
sists in drawing off'the water by a puncture with a  trocar or lancet; it is
required in all those cases, where the radical cure is  not  proper, in very
old persons, when  there  is also hardening of the testicle, and when  the
patient will not submit to  its extirpation; if there  be intestinal rupture,
connected with the hydrocele-sac, or with the testicle, in very large  col-
lections of water, and  in  those cases where  the condition of the testicle

  (a) Archives generales de Medecine, vol.    (c) Acad, de Medec, Seance du Sept. 27,
ii. p. 51.  1833!                          1836.
  (b) Archives generales de Medecine, vol.    (d) Above cited.
xxvii. p. 188.                              (e) Gazette Medicale, vol. iv. p. 638. 1836.
                                         (/) French Translation of this Work. 
SPONTANEOUS CURE.
223
cannot be  previously ascertained.   The trocar is,  in general, to be pre-
ferred to the lancet, for emptying the hydrocele, because  the  fluid will
pass by the canula, and not escape into the cellular tissue of the scrotum.
The lancet may be used when there is but little water, and accompany-
ing intestinal rupture, or hardening of the testicle, because with  it all
possible injury may be easily avoided.
  [Spontaneous cure of hydrocele sometimes, though very  rarely, takes  place.
Brodie relates a case of this kind, in which the patient not liking  to submit to the
operation, the swelling grew so large, that he was obliged to resort  to the " old cle-
rical cassock to conceal his infirmity.  When, however, he had had the disease for
some years, the  tumour began to disappear, and  ultimately went away entirely, so
that he was  never troubled with it afterwards." (p. 90.)  Astley Cooper mentions
another mode of spontaneous cure:—"If an hydrocele be suffered to remain and be-
come of large size; if the patient be under the necessity of labour to obtain subsist-
ence, inflammation of the tunica  vaginalis and scrotum will arise  from excessive
distention.  A slough of the scrotum and tunica vaginalis is produced, and  as it
separates, the water escapes; a suppurative inflammation succeeds, granulations
arise, and the patient in this way receives his cure." (pp. 95,  6.)   It seems to me
that this is  precisely what would  have happened in the second case of spontaneous
cure related by Brodie; had he not checked the mischief by tapping the hydrocele,
and drawing off " some ounces of fluid not like that of hydrocele, but a turbid serum,
such as  you find effused from inflammation." (p. 90.)  Hydroceles are sometimes
burst by a  blow, but, according to both Cooper and  Brodie, the disease  is not
thereby  cured, but after a time reappears, the rent in the tunic having probably
healed up.]
   1940. The  situation of the testicle must be ascertained before punc-
turing the hydrocele:  it usually lies at the upper and hinder part of the
swelling, and the  best place for the puncture is  the fore and under part.
The testicle, however, may be situated  elsewhere, it may  be  connected
with the front of the vaginal tunic,  in which case, a puncture at another
part is most proper.   The puncture is  always to be made  in the middle
line of the swelling, because, in old  hydroceles especially, the several
vessels of the cord are often  driven out of  their  place.   According  to
Richter (a), the  swelling is  sometimes oblique, or  even completely
transverse, so that  in hydrocele  of the left side, the  puncture must be
made on the  right side of the scrotum.   In large  hydrocele, a narrower
part of the swelling sometimes extends upwards, even  as high as the ab-
dominal ring.   Under these circumstances,  a part of  the  canalis tunice
vaginalis is distended, and by the  puncture of the larger swelling, the
 water escapes from this diverticulum.   In children, in whom  the punc-
ture is rarely  necessary, the testicle  generally is lower than in adults, the
puncture  must therefore be made  rather higher than  usual.   The en-
larged  blood-vessels of the scrotum must  be  avoided in making the
puncture.
   1941. The patient must be placed on a seat, so that the scrotum may
hang down loose.  The surgeon grasps the swelling at its  hind  part, and
tightens the skin, whilst an assistant places his hand at the upper part of
the  swelling, and  presses the water down.  The  operator holds a thin
trocar in his  right hand, and puts the forefinger of the same hand on its
canula, to within half or three-quarters of an inch from  its point, and then
thrusts the trocar in rather obliquely upwards at  the  place determined.
When  it  is ascertained, by the resistance  ceasing, that  the trocar has
(a) Anfangsgrilnde der Wundarzneik., vol. vi. p. 59. 
224
HYDROCELE; TREATMENT
penetrated the cavity, the point of the trocar is to be withdrawn, and the
canula thrust in deeper into the vaginal tunic.   The  trocar having been
withdrawn, the  canula is to be held  steadily, so that it do  not  escape
from the vaginal tunic whilst the  water passes off.   If there be  a large
collection of  fluid, its flow must  be often checked  by placing the finger
on  the  aperture of the canula, so that  the testicle  should  not  be too
quickly  relieved  from pressure.   When the emptying is  completed, the
canula is to be gently withdrawn,  whilst the edges of the wound are held
together with the  finger and thumb of the  other hand; and afterwards
is to be closed with sticking plaster, and the parts supported in  a bag
truss.
  The elder Travers (a) has endeavoured  to effect the radical  cure  of hydrocele
with simple punctures.   The scrotum is made tense with one hand, the patient being
so placed that the  light may  pass through the  swelling, to avoid  the veins, or any
thickened and adhering  part.  The punctures are  to be made with an acupuncture
needle, or what is still  better, with a  fine  trocar, at equal distances, very  quickly
after each other, so that the tension of  the scrotum may  be kept up.   The principal
point in the  operation Travers  holds  to be the trifling discharge of  fluid, and the
escape of the remainder into the m. cremaster and cellular tissue.   On  the third,
or even on the second day sometimes, the fluid is  absorbed, and  only when, on ac-
count of the smallness of the punctures, but a few  drops escape, is the cure delayed
beyond a month, or even it does not succeed; but in a large number, the  cure is
effected.
  Lewis (b) considers a single  puncture more  efficacious  and less dangerous^ I
have never witnessed a cure  by these means in very many cases.
  [I have employed this treatment several times, and like Chelius, have not found
it successful. The rapidity with which the absorption of the water emptied into the
cellular tissue  of the scrotum generally takes  place is very remarkable; but the
punctures in the vaginal tunic soon heal, and the water quickly re-collects, under
which  circumstances, I have several times had occasion to' perform the cure by
injection.  The danger from this treatment, which Lewis dreads, seems to me quite
chimerical.—j. f. s.]
   1942.  If a lancet  be used, it must, after the scrotum has been made
tense, as  already  directed, be introduced   with its edges  above  and
below, at  the  appointed  place, and the opening enlarged as it is with-
drawn.   Whilst the  water flows, the skin must be  sufficiently tight, so
that the membranes shall  not fall  together, and  prevent its escape ; but
if this happen, a probe must be passed in, and the flow restored.  If the
hydrocele be  accompanied with  intestinal rupture, it is  most advisable
to make a cut an  inch long  at  the bottom of the swelling, to lift up the
vaginal  tunic with the forceps,  and divide it with a  bistoury  held flat.
   1943.  If after the puncture the  fluid will  not  pass  out, on  account of
its  consistence,  or because it is  contained  in various  chambers, either
the radical cure  by incision must  be at once  performed or  the  opening
closed with sticking plaster, and the radical cure afterwards  undertaken.
  I have  always found the fluid thin, and not contained in different sacs, when the
testicle has not been otherwise  diseased.   But I  have not unfrequently found, on
the  outer surface of the  vaginal  tunic,  a pretty considerable quantity  of consistent,
gelatinous fluid, collected in the cellular tissue;  whilst the fluid in the tunic was of
its usual character.   Sometimes bodies of various size, externally cartilaginous, but
bony within, are found swimming in the fluid.   They arise, as I have often noticed
in the operation for hydrocele and in dead  bodies, from the surface of the testicle
and epididymis, overspread the  vaginal tunic, are always strung together  at their

  (a) London Medical Gazette, vol. xix.  p.    (b) Lancet, 1835-36, vol. ii. p. 206. 
BY PUNCTURE.
225
place  of attachment, and at last get loose; or are enclosed in a cyst between the
vaginal tunic, and the tunica albuginea, from  which, when it is opened, these little
bodies escape.
   1944. The  puncture generally soon  closes ;  if  inflammation occur,
cold  applications and leeches are requisite ; and if  it cause effusion into
the cellular tissue of the scrotum, a  cut must be made  into it.  If sup-
puration occur, it must also be quickly  opened.
   The emptying of the hydrocele most commonly  effects only transient
relief, and the fluid re-collects more or  less quickly.  In rare cases is it
followed by a  radical cure.  If the swelling speedily acquire considerable
size after the discharge, blood has been poured out into the vaginal tunic,
which must be cut into; and if the spermatic artery be wounded, it must
be tied.
   [Simply puncturing a hydrocele but rarely cures the disease  ; "but to give the
patient the best prospect of it," Astley Cooper recommends " a strong stimulating
lotion to be immediately applied."  And  he continues:—"Exercise sometimes
produces inflammation ;" and instances a person who had a cure after the inflamma-
tion set  up by  travelling all night, after the hydrocele having been tapped the
previous  morning  (p. 98);  this, however,  was a lucky chance, and should not
induce another  person  to try a like foolish trick; for, in  another  case, he relates
directly after, an elderly gentleman, who had been tapped for  hydrocele, died  in
consequence of the inflammation excited  merely by a long walk on the same even-
ing, (p. 99.)
   In old  people, simple tapping is the only operation for hydrocele which ought to
be performed ;  the others are very dangerous, on account of the inflammation which
 may ensue, and being without power, may run on to gangrene.—j. f. s.]
   1945. The radical cure of hydrocele may be managed  in two ways;
either by increasing  the activity  of the absorbents, by diminishing the
exhalation, and producing  contraction of  the vaginal  tunic, whilst  its
cavity is preserved,  or by exciting such a degree of inflammation as will
produce a growing together of the vaginal tunic with the testicle.
   1946. The  first land of radical  cure may be  effected  by the use of
solutions of hydrochlorate of ammonia dissolved in vinegar and spirits of
wine, by fumigation with cinnabar,  with sugar, with vinegar, by emetics
and  purgatives, and by repeated blisters  and the like  applied to the
swelling.   In adults  these remedies are seldom of  use, but in  children
they almost always disperse the  hydrocele.  Perhaps in  grown  persons
 they would be  more effectual,  if the water had been first  drawn off.
 Kinder  Wood {a)  found  that when the   swelling had  been  opened
 with a broad lancet, and the water discharged,  if a little piece of the
 vaginal tunic  were drawn out with a hook,  and cut off with scissors, and
 simply  dressed, only a  slight  degree of   inflammation  ensued which
 restored the  exhalents  and  absorbents to  their natural condition and
 caused  a cure without the vaginal tunic growing  to the testicle.   When
 this tunic is thickened, such treatment is inapplicable.
   1947. The second kind of radical  cure of hydrocele is effected, first
 by incision ;  second,  by injection ; third, by seton  ; fourth, by caustic ;
fifth, by the tent; and sixth by cutting away the vaginal tunic.
   1948. In the operation by incision, the patient  is placed upon  a  firm
table ; an assistant grasps the back of the swelling, and  tightens the skin.
The  operator  cuts freely through the skin, or through a  fold of it, in the

                   (a) MedicChir. Trans., vol. ix. p. 38.  1818.
   Vol,  hi.—20 
226           HYDROCELE )  TREATMENT BY INCISION J
mesial line, and to the extent of two-thirds of the  swelling  (1);  if the
scrotal artery bleed, it must be tied.  The operator then placing the fore-
finger of his left hand on the  middle of the swelling, thrusts a  bistoury
with  its back upon the volar surface, into the  vaginal tunic,  and carries
the finger in with it, so that when the knife is withdrawn, the finger may
completely fill  up the hole.  The blunt-ended blade of a pair of scissors
is now  passed on the finger, and the opening  in the tunic enlarged up-
wards and downwards, care being taken that the testicle do not protrude,
and if it  should, it  must be  gently returned.  An  assistant, with his
fingers crooked, seizes the tunic at each angle of the wound, and  lifts it
up, so that its inner surface is laid open.  A thin fold of linen dipped in
fresh  oil is then laid in the cavity of the tunic between it and the testicle,
so  that its edge  projects in a ring around the cut.  The cavity thus
formed  by the linen is to  be filled with lint dipped in oil, and the  edges
of the wound having been brought together  with  sticking plaster, the
whole is covered with a compress, and put into a suspendor.
  (1)  To render the cure satisfactory and perhaps, indeed, that it may be most com-
plete,  the cut should not exceed a third, or at the most,  half the length  of the
swelling, as is proved by Ficker's (b) and Scwreger's (c) practice, as well as by
my own.
   1949. The after-treatment is to be guided by the degree of the ensuing
inflammation.   If not very severe, it must be borne ; but in the  other
case,  it must be allayed by taking out some of the lint, by warm poultices
and antiphlogistic remedies.  On the third or fourth day, the dressings
are to be  changed, but the linen is not to be removed  till it is quite
sodden with pus.   The space between the testicle and vaginal tunic is
to be  constantly filled  with lint, and as it diminishes less lint should be
introduced.  When the suppuration takes place, collection and burrow-
ing of the  pus must  be  prevented.  After-bleeding requires that the
vessels should be tied, or  cold water applied.
   1950.  If in the operation by incision, the testicle be  found hardened,
its extirpation must be at once performed.  Hydatids on the surface  of the
testicle, or in the cellular tissue of the scrotum,, must be seized with  forceps,
and cut off with Cooper's scissors.
   1951.  In the operation by injection, the puncture  must be first  made
with the trocar, as already directed,  and the testicle examined, to ascer-
tain'if it be hardened.  One part of red wine diluted with two of water,
and moderately warmed,  is now to be injected tbrough^he canula  of the
trocar into the vaginal tunic with a syringe, fitting into the  canula, till
the tunic  be completely  or almost distended to its previous  size.   The
fluid  is generally kept in about  five minutes with  the finger upon  the
opening of the  canula.  The sensitiveness of the patient is to determine
the strength of the injection and the length of  time it should  be retained
in the tunic.  In irritable persons, or if pain arise  after the injection, it
must  be kept  in  only half  the time.   In not sensitive persons,  when
the hydrocele is old and the tunic thickened, pure wine must sometimes
be injected, retained for  a  longer time, and  several times repeated, to
produce a sufficient degree of inflammation.  In repeating the injection,
it must be carefully observed that  the canula has not escaped from the

  (a) Aufsatze und Beobachtungen, vol. i. p. 244.  (b) Chirurgische, Versuche, vol. i. p-125. 
BY INJECTION.
227
 tunic.   If by moving the outer end of the canula from side to side, its
 inner end move freely, the injection may be made, but if this be not the
 case, it must first be  put right.   When the injection has produced the
 desired effect, it must be carefully drawn off or pumped out  with the sy-
 ringe so that none remain.   The greatest care must be taken, when, after
 the  instrument  has  been  thrust  in,  and the stilette of the  trocar with-
 drawn, that the canula be sufficiently deep in the tunic there  kept un-
 disturbed, and the skin of the scrotum and vaginal tunic be firmly nipped
 with  the  fingers  round the  canula, or otherwise the  tunic will  easily
 slip off" and the  injection be made into  the cellular tissue  of the scro-
 tum.
   1952. After the operation, the puncture is to be covered with sticking
 plaster, and the scrotum supported with a bag  truss.  In general, on the
 next day, redness, pain, and swelling  come on ; lukewarm  applications
 are  to be  then  made, or if the inflammation be  not very violent, it may be
 left  alone  entirely ; but if it be great,  antiphlogistic remedies  must be em-
 ployed.
   1953. In persons  peculiarly sensitive, the  mildest injection may be
 sufficient; thus the  injection of  the water just  drawn  off,  or  blowing
 air  through the canula of the  trocar to redistend the scrotum.   The
 air may be left in twelve minutes, then let out, and the skin of the scrotum
 rubbed against the  opening.  After  some minutes  the injection of air
 must be repeated. A bougie should be  left in the little wound, so that, if
 sufficient inflammation be not excited, the inflation maybe repeated (a).
   Various fluids have been employed  as injections in the operation for hydrocele.
 Celsus used a solution of saltpetre; Lembert, lime water, with corrosive sublimate;
 Earle, port wine,  with  infusion of roses;  Jinceer,  Medoc  wine, with water;
 Levret, a solution of lunar caustic, or of zulphate of zinc; Boyer, red  wine alone or
 mixed with a little alcohol, or boiled with ro^es: Dupuytren, Rousillon wine boiled
 with  roses and a little spirit of camphor; Velpeau (b) has, after numerous success-
 ful cases, recommended injections of iodine, one or two drams of the tincture of
 iodine to an ounce  of water; the patient suffers little by this plan, and  next day
 can stand without pain, and go about.  Velpeau's successful treatment has been
 confirmed by others.  In eleven hundred  and forty-eight cases  (c) treated with
 iodine injections, only three cases failed.   In ten, injections with port wine failed.
 Injections of iodine succeeded in nine  cases where previous use of port wine and
 sulphate of zinc had failed (d).
   [The injection  of tincture of  iodine diluted with  water,  I  am convinced, by
 repeatedly practising it for some years, is the most effectual and least  painful to the
 patient.  Velpeau has the credit of introducing the practice, but I am informed by
 medical friends who have been in India, it has long been practiced there, and, if my
 recollection be not treacherous, without drawing the injection off again.   And this
 mode 1 have adopted, making use of a very fine trocar and canula, drawing off the
 water, and injecting an ounce of fluid containing two drams of tincture of iodine and
 six drams of water, and  then immediately withdrawing the canula,  to which the
 wound  always  clings very tightly, ..as  the solution is  very  astringent.   The pa-
 tient most commonly suffers no pain, or at least a very trifling degree ; and though
 on the following day the scrotum is a little reddened and rather firm, yet the patient
 is not thereby prevented moving about with ease and comfort to himself.   Indeed, I
 am informed that as soon as the injection is made the person walks away, and re-
 quires no further attention. The scrotum, according to my own observation, increases

  (a)  Schreger, Ueber Heilung der Hydro-    (c) Proriep'.s N. Notizen, vol.  viii. 1836,
 celc  durch  Lulteinblasen; in his Cliirur-  Nov.
 gische Versucli., vol. i. p.  J3-\ Niirnberg,    (d) Oppenheim; in Hamburg.   Zeitschr.,
 lall.                                 vol. viii. pt. iv. 18^8.—Fricke; in same.
  (6) Hydroceles  dc la Tunique Vacinale;
in his  Logons Orales, vol. i. p. 262.  1840. 
228
HYDROCELE;
a little, and becomes rather more solid for three or four days, and then begins to sub-
side, and in the course of a fortnight the  eure is completed without confining the pa-
tient more than two or three days, rather as precautionary,  than that I believe it
really necessary.  I have employed this treatment in both large and small hydroceles,
merelylnjecting the quantity mentioned or a little less;  and never either shaking the
scrotum about or distending the cyst by repeated injections, and afterwards drawing
it off, as  Velpeau practises and recommends.  I  am quite sure that whoever once
employs  the iodine injeetion as I have mentioned, will not treat a hydrocele for the
radical cure by any  other means.
  Hydrocele is sometimes not even at first  cured by injection; and this Astlet
Cooper  seems to think depends on the after treatment; " for," he says, "I some-
times fail, and should very often but for great care in the after-treatment, upon which,
I think, much  depends.   I sometimes, when water is  reproduced a few days  after
the operation, tap it to remove the serum, and to produce, by this operation, a larger
share of inflammation." (p. 106.)
  But occasionally the injection cures  for a time, and  then  the disease reappears.
Brodie mentions two remarkable instances  of this kind, one of  which occurred
to a patient of Everard Home's, in which the  disease  recurred  after seventeen
years; and another, which  happened under his own care, in which the disease re-
turned after twenty years, the operation by injection having been performed in both
cases by Home.
  Sometimes the inflammation set up by injection is  so  great as  to  terminate in
suppuration; when this happens, and  the existehee of pus  is decidedly shown, a
free  cut  into the vaginal  tunic should be made, so that the pus may readily flow
out; after which  all the symptoms of constitutional excitement soon cease.  If by
accident  the injection should be  thrown into the  cellular tissue of the scrotum in-
stead of  into the cavity of the hydrocele, no time  must be  lost, but a free cut made
through the skin, so that it may readily escape from the loose cellular tissue, other-
wise there will be sloughing, and it may be the patient will loose his life, which has
happened.—j.  f. s.]
   1954. For the  introduction of a seton, after the  puncture   as already
directed has  been made with the trocar and  canula, and the former with-
drawn,  a  long  tube is passed  deeply  through  the canula, till it  reach
the  fore and upper part of the  scrotum.   A long  and pointed straight
sound, with an eye at  its other  end  armed with several threads, is then
thrust through  the tube  outwards,   carrying  with  it  the threads, and
then the  canula  is withdrawn.  The  ends of the  seton-threads  are
tied loosely  together,  the wounds  covered with  sticking  plaster, and
a bag truss put on.   About the  tenth or  fourteenth  day, some  of the
threads  are withdrawn  at each dressing, and  this is  continued  till  all
be taken out.
  J.  Holbrook (a) lets the  water escape as usual, then takes up a fold of the skin
of the scrotum and of the vaginal tunic, and passes with a  common  needle a single
or double thread from above downwards, which  he  removes on  the third day.
  Onsenoort (b), with a needle curved and having a handle, passes  a ligature
through the middle third of the swelling from above downwards, or from below
upwards.  After (he fluid has completely escaped, the thread is tied tightly.  Two
days after, the  ligature is tightened, and  after the  cutting through  is completed, on
about the fourth or fifth day,  the wound remains open from the bottom till the cure
is perfected.  In very large hydroceles he thrusts  the needle into the middle of the
swelling, carries its  point upwards out through the skin, leaves one end  of the thread
loose, carries the point of the needle back  into the cavity of  the vaginal tunic, thrusts
it through the skin below, and brings  the other end of the thread out, and as he
draws the needle out leaves the thread  double in  the middle wound, and cutting it
through there, forms two ligatures, each of which  he ties.

  (a) Observations on Hydrocele, etc.  Lon-   gature ; in Graefe und Walther's Journal,
don,  1826*.                              vol. xiii. p. 628. 1828.
  (b) Heilung der Hydrocele durch die Li- 
TREATMENT BY SETON.
229
  [My friend Green, from having observed the difficulty of regulating the inflam-
mation, in treating hydrocele by injection, the  impossibility of determining,  at the
time of the  operation, what the effect will be  in respect to the quantity of inflam-
mation, and the dangerous results from the injection having been thrown  into the
cellular tissue of the scrotum, instead of into the vaginal tunic, was led  to employ
the seton (a), but differently from either of the above-mentioned modes.  He  thought,
"if a seton were carried through the tunica vaginalis, there would be a source of
irritation sufficient to  produce the required inflammation, and  at the same  time the
opportunity given of regulating its degree, that is, that the seton might be allowed
to remain till there were symptoms of such a degree of inflammation as is  requisite
for the change necessary to be produced in the tunic, and  that this being  effected,
the seton might be withdrawn; and that the extraneous irritant being thus removed,
it would have no further effect than was necessary, either for the-change  of the sur-
face of the membrane, or for the obliteration of the tunic, (pp. 73, 74.)  The  requi-
site degree of inflammation is one which is attended with the ordinary symptoms of
that process, that is to say, pain, heat, swelling, some redness, and some constitu-
tional affection.  There should be, I think, some affection of the pulse, some indi-
cation of febrile action in the  system, before the seton is withdrawn.  As soon as
this has been  observed the threads  may be removed, and I believe that you may
then expect you  have excited inflammation enough to cure the disease.  So  that it is
not whether the seton has remained in ten, twelve, or twenty hours, for this must be
regulated by circumstances, but whether then  the requisite degree  of inflammation
is  produced.  I should say that  twenty hours was about the  average time for the
seton to remain; but it will vary in different instances."  (p. 76.)  Green's method
consists in drawing off the water, as usual, with  a trocar and canula, and when the
hydrocele is emptied, the  "canula still remaining in,  to pass a needle  six inches in
length, and as thick as a probe, with a trocar point at one, and an eye at the other
end, armed  with twelve threads of ordinary seton silk, into  the canula, and having
carried  it upwards to perforate the tunica vaginalis and integuments, near the upper
and fore part of  the swelling, and draw it out at that aperture.   The canula is then
removed, and the ends of the  threads loosely tied together over a space of about two
inches," (p. 59,) and these allowed to  remain in till the inflammatory symptoms
above mentioned make their appearance.
   I formerly employed  this practice a  good many times, but one great objection
seems to me the close wTatching it requires for  some  hours, and the difficulty there
always is in determining the precise time when the seton threads  should  be with-
drawn; and that often, even with the greatest care, either very severe  inflammation
would occur, or when enough only was  supposed present to effect the cure,  that it
suddenly subsided, and  a  second operation was requisite.  After using the  iodine
injection, I never recurred to this plan of treatment, although it was grounded upon
better reasons than either of the other modes of using setons seem to have originated
 in.—j. f. s.]
    1955.  The  use of  a tent consists in  the  introduction, after puncturing
the swelling, of a tent of  lint, or  a  piece  of bougie, through the opening
into the cavity of the vaginal tunic.
    1956.  Caustic, consisting  of a paste  made  with nitrate of silver and
water, is  applied in the  usual way upon the  front of the swelling, and
allowed to remain  for  six or eight hours.   When  the slough has  fallen
off, the cauterized  part is  to  be  punctured with  a  lancet, and covered,
after the emptying of the swelling is complete, with wadding.
   According to  Hesselbach (b), a plaster full  of holes, and spread with powdered
nitrate  of silver, as thick as a knife, should  be  applied on the front of the swelling,
over which a wad of linen and some sticking plaster should be placed, and the whole
fastened with a  compress and a bag truss.  After eight hours the caustic and the
plaster are  to be taken off, the scrotum cleansed with water, and some  lint  spread
with digestive ointment, applied  to the slough.  When this  falls off, the vao-inal
tunic is laid bare, and being raised, by the pressure of the swelling, like a  ball°this,

     (a) St. Thomas's Hospital Reports.
     (b) Jahrbucher der philosophisch-medicinischen Gesellichaft zu Wurzberff,  vol i
                                     20* 
230   hydrocele; treatment by caustic, and cutting

rounded part is then cut with the scissors, and  the water emptied.  The wound is
to be eleansed daily with water, or with camomile tea, and bound up with lint.  At
every dressing, pieces of the tunie separate until the whole  has come away.  The
wound  daily diminishes, the suppuration ceases, and the wound closes.
  1957.  In cutting away the vaginal tunic, the skin of the scrotum, and
the vaginal tunic are divided, the latter  drawn out of the wound with
the fingers, and cut off throughout its whole extent by  a cut lengthways.
The dressing and after-treatment  are the same as in the  operation by
incision.
  Boyer (a) recommends cutting through the skin the whole length of the swelling,
for the  purpose of isolating the vaginal tunic as far as possible opposite the testicle,
then to open it, and cat off the flaps.  Dupuytren considers it more simple to grasp
the swelling, at the upper and back part, with one hand, so as to tighten the skin as
much as possible in front, then to cut into the skin, to shell the vaginal  tunic out,
by pressing from behind forwards, and then to open and cut it off.  Textor (b)
endeavoured to unite  the wound  by quick union, as Douglas had  previously done.
Balling (c) strongly recommends excision : the part to be cut off should be some
inches, of a semicircular form,  After  the operation, moderately cold  applications
should  be employed till a layer of lymph appear on the wound, and the union is to
be effected with sticking plaster.
  [1 apprehend no one would, in the present day, employ either  of the latter two
very painful and uncalled  for  modes of practice, which  are now mere matters of
history.—j. f. s.]
   1958.  The preference and rejection of  the several methods above de-
scribed must be  decided on  the  following grounds.  It. is not advisable
to produce upon the testicle  any irritation like that on the vaginal tunic.
By incision, all the complications can be most distinctly made  out, at the
same time any existing  intestinal rupture can be properly treated, the  in-
flammation be more properly excited, and effect a more safe cure.  The
bleeding which  occurs  in  this operation  is easily stanched ;  the severe
symptoms occurring after it are most commonly the result of bad practice.
After  the cut, it is in most  cases  necessary to insert a half  unravelled
piece of linen between the wounded edges of the vaginal tunic.   Injec-
tions operate uncertainly, as  the irritability of the individual cannot be
previously determined ;  they act as  violently on  the testicle  as on the
scrotum; if a part of the injection be poured into the cellular tissue, which
is possible,  even with  the greatest care  and  attention, very  dangerous
symptoms may arise therefrom ;  in a diseased state of the testicle, which
cannot always be decidedly made  out, injections  are necessarily hurtful.
The superiority of injections, to wit,  that by  their use the  cure follows
more quickly, and that the patient does not need to be kept so long quiet,
is of no  value, as even  after injection the cure is  often longer protracted
than by incision, and with the latter  keeping so long quiet is not neces-
sary.  The  same  observations  apply also to  the  cure by seton and by
tent, except that with them the cure  is still less sure.  Caustic also acts
uncertainly;  its  operation is  slow- and painful: incision is therefore to be
considered the most sure.   Extirpation is to be  confined to those cases
only where the vaginal  tunic is highly disorganized or bony (d).
   [I have thought it more  convenient to notice the advantages and disadvantages of

  («) Maladies Chirurgicales, vol. x. p. 209.    '(d) Textor, above cited.—Klein; in Hei-
  (6) Ueber cine neue Art. die Hydrocele zu  delb.  klinisch.   Annal.,  vol.  ii. p.  109.—
heilen; in N. Chiron., vol. i. p. 4i6.         Spangenberg ;  in Graefe und Walther's
  (c) Heidclb.kfet. Annal., vol. vii. pi 130.  Journ., vol. ix. p. 1. 
    AWAY THE VAGINAL TUNIC ;  CONGENITAL HYDROCELE.   231

the several modes of treating hydrocele, when describing each method.  To these,
therefore, the reader is referred back.—j. f. s.]
  1959. Congenital hydrocele {Hydrocele congenita) consists in a collec-
tion  of water in the canal of the vaginal tunic, which remains open either
throughout its whole length, or only at certain  parts,  in consequence of
which several kinds of hydrocele are formed: first,  the canal is open
throughout its whole length, and  filled with water;  second, the canal is
closed above the testicle, and remains open only at the upper part;  third,
the upper part closes and the water is  contained in the lower part, and in
the vaginal tunic of the testicle; fourth, the canal is  obliterated  above
and below, and there remains only a bladder-like cavity at one part, which
contains water.
  1960. If the whole vaginal process of the  peritoneum  remain open
from its orifice in the belly to its bottom, and  the water collect in it, a
long roundish  swelling appears, which reaches from the abdominal ring
to the testicle.   The testicle is  either little, or not at  all felt, because it
is completely surrounded with water; but, on the contrary, the spermatic
cord is  distinctly felt along the hind surface of the swelling, though rather
more outwards.  The possibility of pushing back the fluid, and its return
by the  abdominal aperture of the vaginal  process causes the diminished
size or  total disappearance of the swelling, in the horizontal posture, or
by pressure, and its increase  in the upright posture, by  exertion, cough-
ing, and  the like.   The subsidence and  reappearance of the swelling
does not take place with equal readiness in all cases:  if, for instance, the
upper part of  the vaginal canal  be somewhat narrowed, a longer con-
tinued pressure upon the swelling from below upwards is  necessary, in
order to force the water back; or it must also be raised  somewhat inwards,
so as to bring the vaginal process in a right line with  the inguinal canal:
the water retires slowly, and only slowly returns.
   The  natural  cure is in these  cases not rare.  If the  disease continue
beyond the first month,  it becomes larger;  sometimes it attains quickly,
sometimes slowly, a considerable size.  The end of the first twelvemonth,
the  third and seventh year, and the period of puberty, have considerable
 influence on the development and subsidence  of this kind of hydrocele.
   Closely resembling hydrocele  of the vaginal process in man, is the congenital
 hydrocele of women, in which, by the collection of water in the peritoneal sheath of
 the round ligament, a swelling is formed, which passes through the inguinal canal
 into the lower part of the labium pudendi, and is at first returnable, but afterwards
 not so (a).
   1961.  This hydrocele may have already formed in the foetus, and after-
 wards  become further developed; but it may first arise after birth, as the
 vaginal canal often  remains open for some time.   The circumstance of
 the  vaginal process often remaining  a  long while  open, and no water
 being collected in it, proves that the water does not merely flow from the
 belly into the vaginal process, but that its  collection  depends on undue
proportion  between absorption and secretion on the inner surface of the
 vaginal canal.   This  disease is  frequent,  but  in many cases is not ob-
served, partially on account  of  its slight  degree, and  the child's con-
 stantly lying on his back, and in part because it subsides of itself.   It

         (a) Sacchi ; in Annali Universal-! de Medicina, vol. lvii. p. 437.  1831. 
232               COMPLICATED  HYDROCELE ;
is  not unfrequently  accompanied with • protrusion of the intestine or
omentum.
   1962.  The cure depends on getting rid of the water, and closing the
vaginal process by the adhesion  of its walls.   Viguerin endeavours to
effect it by pressing back the wrater into the belly, and closing the abdo-
minal ring with a truss.   Desault, after returning any existing rupture,
and  carefully  closing the abdominal ring by  pressure, punctured the
swelling, emptied  the water, and injected red  wine, which after a little
time  he  withdrew, and wrapped the whole scrotum  with compresses
steeped in red wine, and applied a truss {a).
   1963.  Although the treatment of  congenital hydrocele, with injec-
tions, has, in many instances,  been successful, it cannot,  however, be
denied, that it  always has a very serious effect on  little children, and
that dangerous inflammation may ensue.  Viguerin's practice is, there-
fore, always preferable, and  may, perhaps, cause a more certain cure, if
the pressure be  sufficiently strongly made  on the  upper part of the
vaginal process, and a suspender, moistened with spirits of wine, vinegar,
and muriate of ammonia, or any other astringent fluid, be  at  the same
time worn.
   1964.  If the vaginal process  be adherent merely above the testicle,
and  thence  open into the cavity of  the belly, a  bladder-like swelling
is  formed by the collection  of the water in  this open  part, which may
extend even into the cavity through the  abdominal ring.  The water can
be returned but slowly into the belly.   The treatment is the same as in
the previons case.
   1965.  If the abdominal  mouth of  the vaginal canal be  closed to the
pillars of the abdominal ring, and the other part remain open, the water
collects in that part  even to the  bottom of  the vaginal tunic.  In  this
case  the  swelling  terminates at  the  ring,  and  the water cannot be
pressed back into the belly.
   1966.  If the vaginal canal be obliterated above and  below, a cyst is
formed in the part remaining  open  by the  collection of  water, which
cyst is connected with the peritoneum, and extends from the abdominal
ring to the testicle.  After lying on the back the swelling is less tense;
but  it becomes more full and   elastic after long standing.   If  com-
pressed,  it recedes  a little, but quickly  reappears.  The  spermatic cord
may be felt below or behind the swelling.
   1967.  The treatment of these last two kinds of congenital  hydrocele
requires, in most  cases, only the use of dispersing remedies, by which,
in children almost always, their  cure is  effected.   These are rubbing in
mercurial ointment, or spirituous fluids; the  steam of vinegar;  fumiga-
tion  with mastic,  amber,  or sugar; lotions of spirits of wine, red wine,
the acetated liquor of ammonia, alum  dissolved  in water, with a little
sulphuric acid ; dispersing plasters, and the like.   If not thus  cured, the
water must be emptied  by puncture, and the radical cure  by injection,
or by blowing in  air, resorted  to.   In cystic hydrocele, in  children, the
discharge of the water is best managed  by puncture with the lancet; but
in adults, the  cyst should be laid bare with a cut, and removed with
Cooper's scissors.
(a) OBuvres Chirurgicales, vol. ii. p. 441. 
DIAGNOSIS.
233
  The following works may be consulted on Congenital Hydrocele:—
  Schreger, Neue Darstellungen  aus dem Gebiete der Hydrocele; in his Chi-
rurgische Versuche, vol. i. p. 1.
  Wall, C. A., De di versa Hydroceles congenita? nature.  Berl., 1820.
  1968. When a hydrocele  is connected with a rupture, that is, when
the sac of a  congenital or accidental rupture has its usual contents of
collected water and protruded intestine, the  hydrocele in general  rises
up to the pre-existent rupture; the hydrocele is rarely first present,.and
the rupture subsequent.   In most cases rupture, complicated with hydro-
cele, is always accompanied with  adhesion, and the hydrocele is the
unnatural secretion  of the inner surface of the  rupture-sac, in consequence
of the inflammation which has  caused the adhesion.   This inflammation
may arise from  undue  pressure of a truss, from catching cold,  external
violence, and the like.   A collection of water soon forms in strangulated
rupture.
  1969. The symptoms vary according as the hydrocele connected with
a rupture  is larger or smaller.  For  example, first, if  the  protruded
intestine be quite full, and close the upper part of the rupture-sac, and
the water collect only in the  lower  space,, as  happens when  an inguinal
rupture is  added to a pre-existing congenital hydrocele, or a hydrocele
to a congenital rupture, or an omental or intestinal rupture  adherent at
the neck of the sac is complicated with hydrocele, then the form of the
swelling is at first conical, with its base towards the abdominal ring; but,
in proportion as the water collects, the upper part of the swelling becomes
narrower.   If the  rupture or the hydrocele  be congenital, the swelling
extends to  the bottom of the  scrotum, then it is surrounded with water,
and cannot at all or not satisfactorily be distinguished.  On the contrary,
if the  swelling be  confined to the testicle, it can be felt at the under
hinder part.   Second. If the  protruded  intestine  completely enter  the
rupture-sac, and the water only spread over its surface  and the inter-
spaces,  as  in hydrocele accompanying  ruptures which  are  moveable,
enlarge easily, are very old, or are attached to the bottom of the rupture-
sac, then the swelling enlarges more in breadth than in length, and mostly
assumes an oval form.  Third. In a congenital rupture, when the upper
part of  the vaginal  canal is narrow, and little extensible,  the water may
completely fill the whole bag, and merely a small portion  of intestine or
omentum protrude  externally  through  the  abdominal ring, and be sur-
rounded with  the  water.  m Fourth. A  small intestinal  rupture,  when
accompanying a previously existing hydrocele, may remain in the canal
between the internal and  external abdominal rings,  in which  case the
rupture is prevented by the stricture of the canal exceeding the bounds
just mentioned.
  1970. The diagnosis of these different forms of hydrocele, complicated
with rupture, is, in many instances, accompanied with great difficulty.
The following circumstances, however, lead  to it.  In the first case, the
upper part  of the swelling, when intestine is there,  is firm, elastic, and
hard, but doughy, with an omental rupture;  the lower part, which  con-
tains the water, is yielding by elastic, sometimes even fluctuating.   With
a reducible rupture, there remains, after its  return, a fulness at the bottom
of the sac which cannot be produced by a piece of intestine, because it
is not  attached to  the  abdominal ring, and  when this is the case, the 
234        COMPLICATED HYDROCELE ;  TREATMENT.
water can be driven backwards  and forwards.  In old  and adherent
ruptures the diagnosis maybe more difficult, though it can be determined
by a close examination, and the case may be distinguished from a growth
of the protruded parts, or from an  enlargement of the swelling by newly-
projected parts.   In the second case, examination does not present the
simple  elasticity of intestinal rupture, nor  the  regularly distended con-
dition of  hydrocele, as at the part where  the intestine is, it  is  more
rebounding,  and the fluctuation scarcely at  all decided, and only ob-
scurely  perceivable at some spots.   In this and the previous case, there
is this peculiarity, that  in long-continued horizontal posture the bulk of
the swelling, lessens, as a part of the water, if the neck of the sac be not
entirely closed, by the adherence  of the rupture itself, returns into  the
belly; on the contrary, in long-continued standing, the swelling enlarges,
by  the  re-descent  of the  water.   In the  third and  fourth cases,  the
diagnosis may indeed be difficult; here, however, the history of the dis-
ease, as well  as  a  certain fulness of the inguinal- region, immediately
above  the external  abdominal ring,  directs the practitioner, as well as
the circumstance, that  if the rupture follow a  pre-existing hydrocele,
instead  of the appearance of the fulness in the inguinal region, the water
is returned wTith  more difficulty into the cavity of the belly, and that it
returns  freely, when the rupture has entirely, or, for the most part, been
reduced by the previous attempts at reduction acting on the region of the
abdominal ring.
  1971. The treatment of hydrocele accompanied with rupture, is espe-
cially directed in reference to the condition of the latter,  whether  it be
moveable or adherent.
  1972.  With a  moveable rupture, a cut an inch in length is first made
through the skin,- so as to return the intestine, the exposed rupture-sac is
then lifted up with  the forceps, and a slight opening made in it with the
scissors for the purpose of introducing an injection-tube, through which,
the  abdominal ring being carefully closed,  one  of the above-mentioned
injections {par. 1951) may be thrown  in to excite adhesive  inflammation,
and with moderate compression, to produce union.  After the reduction
of the rupture, this  may be effected by making a cut  and introducing a
tent  A  truss must be worn till the  complete  adhesion of the sac has
been effected, and even longer.
  Desault (a) first emptied the water by a puncture with a trocar, then whilst the
canula was remaining in, replaced the rupture, and injected red wine.
  1973. When  the rupture is adherent, and the adhesions are firm and
considerable, the treatment,  with  an  intestinal  rupture, must be  merely
confined to palliation by puncturing with a lancet, after previously making
a cut through the  skin, or opening the exposed rupture-sac as in  the
operation for strangulated rupture, and by the use of a suspendor.   Con-
genital  omental rupture allows an  earlier radical cure of hydrocele, as the
omentum more readily assumes the process of adhesive inflammation.  If,
however, the union be slight, which may be determined by the possibility
of reducing the greater part of the  rupture, the sac must be carefully
opened  by a cut as in the operation for hydrocele, the adhesions divided,
the taxis employed, and then by introducing a tent of lint a sufficient
(a) CEuvres Chirurg., vol. ii. p. 441. 
ENCYSTED HYDROCELE.
235
degree of inflammation excited for the purpose of furthering the adhesion
of the rupture-sac (a).
  [I do not think that under any circumstances a conjoined congenital hydrocele and
rupture, or a congenital  hydrocele followed by protrusion of intestine, should  be
meddled with in any way beyond the use of cold  astringent washes and the appli-
cation of a truss.  Injections or the introduction of tents, I should think exceedingly
dangerous practice, and on no account to be resorted to.—j. f. s.]
   1974. Hydrocele  of the general  vaginal  tunic  (Hydrocele  tunice
vaginalis communis)  is either an cedematous swelling in the  cellular
tissue, which  surrounds the  spermatic cord, or the water collects in one
or more cells  of the spermatic  cord, or is found in hydatids, {b).
   1975. In the first case, the swelling which is along the spermatic cord,
at first produces  no  inconvenience,  the scrotum  is not altered,  except
that if it be  not wrinkled, it drops lower on  one side than the other.
The testicle is felt in its  natural state.   The  swelling  is  broader below
than above, seems to diminish  by  gentle and  pushing pressure, though
it resumes  its appearance wdien  the pressure is removed, both when the
patient lies down and stands up.   If fluctuation be observed, it  is only
distinct  at  the bottom, because  the water sinks down especially, tears
some of the cells, and so forms  a larger  cavity ; therefore, no considera-
ble  quantity of water can be drawn  off when a puncture is made any
where but  at the  bottom of the  swelling.   If the base  of the tumour be
pressed, the  water  quickly  rises up  towards the top, and  distends  it.
And if  the swelling  be within  the abdominal ring, it distends it also.
When it acquires a certain size, the patient often feels pain and dragging
in the loins.  The disease may  be  accompanied  with  a varicose state of
the  spermatic cord, and with omental  rupture.   Its confusion1 with 'the
latter  of these is very easy, and the following may be remembered as
distinguishing characters  between  them, that the hydrocele of the sper-
matic cord has less consistence,  and  has not  so  irregular surface as
omental rupture; it is also  usually broader towards its base, whilst the
 contrary is the case with omental rupture (c).
   1976. So long as the swelling in  infiltration of the  spermatic cord is
 small, a suspendor should be worn  : when the disease becomes inconve-
 nient, the  swelling must be opened with a cut, without wounding the
 cord, and lint put into the wound,  which is to be cured by granulation.
   1977. Hydrocele in one or more cysts (Hydrocele  cystica) is mostlv
 situated in the middle of the spermatic  cord.   The  swelling it produces
 is very much  distended, so  that  the  fluctuation  is  not  always  dis-
 tinguishable, circumscribed, painless, and  transparent.  It can never be
 diminished.  If it lie near the abdominal ring, it can be often somewhat
 pushed into  it.   The testicle  and cord are distinctly felt.   If the swell-
 ing enlarge deeply towards the  testicle,  the latter is felt on its hind part.
 Children  and young persons are  more subject to this  hydrocele than
 adults; it  is very probable that in most cases this results from a partial
 opening of the vaginal canal, whilst it  is obliterated  above and  below
 and losses itself in the cellular tissue, (par. 1966) {d).
   (a) Schreger, Ueber Erkenntniss und Be-  aqueuse des Bourses; in Mem. de Chirurff.
 handlung der init Hernie complicirten Hy-  Militaire, vol.  iii. p. 419.
 drocelen ; above cited, p. 86.               (c) Scarpa.
   (b) Larrey, Observation sur uue Tumeur   (d) Scarpa, above cited.—Froriep's Chi-
                                     rurg.  Kupfertaf., pi. cii. ciii. 
236
URTNARY STONE.
   1978. In  children this  swelling is often  dispersed by  the remedies
already mentioned (par. 1967);  in adults it is stubborn.  If an operation
be required, the cyst is to  be laid bare by a  simple cut through the skin
opened, and so much of it removed as can  be  done  without wounding
the spermatic cord ;  some  lint is to be put into the wound, the suppura-
tion destroys the rest of the cyst, and the~wound heals by granulation.
Fourth Section.—FORMATION OF STONY CONCRETIONS  IN  THE
                       FLUIDS OF THE BODY.
   1979. In the various fluids of the body, especially in  the urine, bile,
spittle, and. feces,  when they are retained, or when their properties are
altered by individual  constitution, disease,  mode  of life,  influence of
climate, or of food, in  regard to their quality and quantity, hard, stony
concretions may be formed by the union  of the several constituents, or by
the production of new substances.  Sometimes there may be  a foreign
body around  which the constituent parts of the fluids are deposited so as
to incrust it.   The  phenomena  which  these concretions produce, are
different according to their  seat,  their  form, and their  quantity.  The
treatment consists in their solution or  removal.
  At present merely the stony concretions in the urine are to be considered.
                      I.—OF URINARY STONE.
  Beverovich, J., De Calculo  renum et vesicae liber singularis; cum epistolis et
consultationibus magnorum virorum.   Lugd. Batav., 1638.
  Tenon Recherches sur la nature des Pierres ou Calculs  du Corps humain; in
Mem. de l'Acad. des Sciences,  1764, p. 374.
  Scheele, C. W., Untersuchungen des Blasensteins; in Schwedischen Abhand-
lungen, vol. xxxvii.  1776.
  Austin, William, M. D., On the component parts of the Stone in the Urinary
Bladder.  London, 1780.
  Link,  H. F., De Analysi Urinae et Origine Calculi.  Gotting, 1788.
  Walter, F. H., Anatomisches -Museum, vol. i. Berlin,  1796; with five plates.
  Wollaston, W. H.,  M.D., 0» Gouty and Urinary Concretions; in Phil. Trans.,
vol. lxxxvii. p. 886.  1797.
  Pearson, George, M. D., Experiments and Observations to  show the com-
position and properties  of the Urinary Concretions; in Phil. Trans., vol. lxxxviii.
p. 15. 1798.
  Fourcroy,  Examen des Experiences et des Observations de M.  Pearson; in
Annales de Chimie, vol. xxvii.  p. 225.
  Guyton; in same, p. 294.
  Fourcroy, Observations sur les Calculs  urinaires de la Vessie de l'Homme; in
Mem. de la Societe Medicale, vol. ii. p. 64. 1799.
  -----, Des Calculs urinaires de  l'Homme ; in his Systeme des Connaissances
Chimiques, vol. v. p. 501.   Paris, 1801.
  Fourcroy, Sur le Nombre, la Nature, et les Caracteres distinctifs des differens
materiaux qui forment  les  Calculs,  les Bezoards et les  diverses  Concretions des
Animaux; in  Annales du.Musee d'Histoire Naturelle, vol. i. p. 93.  Paris.
  Brande, William, On the differences in the structure of Calculi, which arise
from their being  formed in different  parts of the Urinary  Passages; and on the
effects that are produced on them by the internal use of solvent medicines; in Phil.
Trans., vol. xcviii. p. 223.  1808. 
ORIGIN OF URINARY CONCRETIONS.              237
   Wollaston, W. H., M.D., On Cystic Oxide, a new species of Urinary Calculus;
 in Phil. Trans., vol. c. p. 223.  1810.
   Marcet, Alexander, M.D., Essay on the Chemical History and Medical Treat-
 ment of Calculus Disorders.   London,  1817.  8vo.
   Magendie, Recherches physiologiques et medicales sur les Causes, les  Symp-
 tomes et le Traitement de la Gravelle.   Paris, 1818.
   Brugnatelli, L. V., Litologia umana ossia  Ricerche chimiche e mediche solle
 Sostanze Petrose che si  formano in diversi parti de corpo umano, soprattuto nella
 Vesica Urinaria.  Opera postuma, public, dal D. G. Brugnatelli.  Pavia, 1817.
 fol.   3 plates.
   von Walther, P., Ueber die Harnsteine, ihre Entstehung  und Classification; in
 Journal fur Chirurgie und Augenheilkunde.  vol. i. p. 190—p. 387.
   Henry,  William, M.D., On Urinary and  other Morbid Concretions; in Med.-
 Chir. Trans., vol. x. p. 128.   1819.
   Prout, Wtilliam, M.D., An Inquiry  into the Nature and  Treatment of Gravel,
 Calculus, and  other diseases  connected with a  deranged operation of the Urinary
 Organs. London, 1818.
   Wetzlar, G., Beitrage zur Kenntniss des menschlichen Harnes und die Entste-
 hung der Harnsteine.  Mit einer Vorrede und einigen Anmerkungen begleitet von
 F. Wurzer.   Frankfort, 1821.  8vo.
   Laugier, Sur les  Concretions qui se forment dans le Corps.  Paris, 1825.
   Brodie,  Sir B. C, Lectures on the Diseases  of the Urinary Organs.   London,
 1842.   Third Edition.  8vo.
   Martin, E.  A., De  Lithogenesi, prasertim urinaria.  Jenae, 1838.
   Crosse,  J. G., A  Treatise on the Formation, Constituents,  and Extraction  of the
 Urinary Calculus.   London, 1835.  4to.
   Civiale, Traite de l'Affection calculeuse, etc.  Paris, 1838; with five plates.
         .-, Translated into German by Hollstein as, Ueber die medicinische Be
 handlung und Verhiitung des  Steines und Grieses, nebst einer Abhandl. iiber die
 Steine aus  Cystin; mit Bemerk., u. s. w. Berlin, 1820.
   Willis,  Robert, M.D., Urinary Diseases and their Treatment.  London, 1838.
 8vo.
   Jones, H. Bence, On Gravel, Calculus, and Gout; chiefly an application of Pro-
 fessor Liebig's Physiology to the prevention and cure of these diseases.  London,
 1842.  8vo.
   Taylor,  Thomas, A Descriptive and Illustrated Catalogue of the Calculi and other
 Animal Concretions  contained in the Museum of the Royal College of Surgeons in
 London. London, 1845. -4to.
   1980.  The deposits from the urine are either powdery or crystalline,
gravel, or hard large concretion, stones, which are formed by the union
 of these sediments.
   [For the  accompanying notes on the chemical  part of this subject marked T. T.,
 I have to thank my friend Thomas Taylor.—j. f. s.]
   1981. From the earliest times various opinions have been advanced as
to the manner and way in  which the formation of these concretions take
place, which, however,  has only been placed on a sure base by  the pro-
gress of chemistry., and by  the careful examination of  these concretions,
especially by Scheele,  Wollaston, Fourcroy, Vauquelin, Brande,
Marcet,  Prout, Magendie, Fuchs, Liebig,  Woehler, Willis, Tay-
lor, and  others.   Passing  over the old opinions, those theories  only
which have of  late years been advanced in reference  to the formation of
stone will  be  here given.
  Wurzer  (a) has collected the most valuable notions of the old practitioners and
naturalists on this subject.  So also Martin (b).
   1982. Magendie, who treats specially of uric acid concretions imagines

     (a) Programma de Analysi chemica Calculi Renalis Equini.  Marburg, 1813.
     (b) Above cited.
   Vol. iii.—21 
238
ORIGIN OF
that the causes of gravel and stones of this kind depend on an absolutely
increased quantity of uric acid, on a diminished quantity of the urine with
the like quantity of uric acid, and  on the diminished temperature of tfte
urine, in consequence of which the uric acid is deposited either in the
form of gravel, or, being united by some connecting matter, forms the
larger concretions.   The quantity of uric acid is increased by the use of
food abounding with azote, flesh meat, strong wine, liquors, want of ex-
ercise, and the like.  The quantity of urine diminishes whilst the quan-
tity of uric acid  still  remains the same, in violent  sweating.  And the
temperature of the urine diminishes in advanced age, on which account
gravel is then of  common appearance.   The above cases  are also espe-
cially favourable  to gout;  and,  therefore, between gout and stone there
is a close alternation.
   1983. von Walther assumes, besides the excessive production of uric
acid, a change in its quality, at least in reference to its degree of oxida-
tion, and a more or less  copious secretion of a connecting gluten..  These
three circumstances arise from a vital influence of the urinary organs on
the fluids contained in them ; and the activity inducing lithogenesis, con-
sists, if not in an inflammation of the mucous membrane of threse parts,
(as believed  by the English physician, W. Austin,) at least in a state
analogous to it.   Hence  originates a more copious production of the
connecting substance which takes up the precipitated  particles of the
strongly oxidized uric acid, and thus gradually forms the nucleus of the
stone.   Without  this connecting matter, sand and gravel  alone are pro-
duced.   The presence of this gluten, especially prevents the crystalliza-
tion of the constituent parts of the stone and the ammoniaco-magnesian
phosphate alone  is most frequently crystallized in stones.  Lithogenesis
is to be" considered as a medium  between  chemical crystallization and
organic growth, but it  has  always the greater  disposition towards the
latter.
   Stones are characterized  by their organic structure; and their process
of formation  is comparable  to the origin of  indurations, scirrhus and the
like,   von Walther  distinguishes between  urinary  incrustations of
foreign bodies, in which the phosphoric acid salts of the urine are depo-
sited in a similar way to that in which the dippling of a foreign body into
a solution of salt produces its crystallization, whereby the outermost layer
of most  urinary stones  consists of phosphates,  and urinary concretions,
the formation of which takes place as above  described.   In regard to the
several kinds of stones, he considers the relative want of hydrogen in the
urinary system, to be in all cases a necessary condition in the production
of stone, both as regards  the concretions of uric acid,  and those which
contain oxalate  of lime.   Excess of azote appears  to determine the
origin of the former as  the want of it does  that of the  latter.   Between
the concretions of uric  acid and  the gout  there  is a relation similar to
that between the  phosphatic concretions and the  imperfect development
of the bony system.
   1984. Wetzlar has endeavoured  to controvert both these opinions.
In  opposition to Magendie, he  asserts that,  although in many cases
gravel depends on the  absolutely or relatively increased quantity of the
uric acid, the production of concretions of  uric acid often occurs under 
URINARY  CONCRETIONS.
239
circumstances which do not produce uric acid in excess; nor does any
deposit take place when the urine contains very much  urate of soda;
for instance, in the critical urine of  fever, where  sediment does  not
form  until  after the  urine  has cooled.  Against Walther's  theory,
Wetzlar objects  that  stones,.although  existing in an organip  fluid,
are not to be considered as organic bodies;  and that their structure and
form have nothing which entitles them to be called so: that the assump-
tion of a changed  condition of the uric acid, and a  peculiar  affection of
the urinary passages,  is hypothetical;  that  an increased production of
uric acid is by no means necessary for the formation of stone, as no pre-
cipitation of the uric acid is  caused by it;  that the natural  quantity of
uric acid is sufficient to yield material for concretion; and that the free
state of uric acid, hitherto considered as a natural condition,  is an unna-
tural one, and  the  proximate  cause of stone.  He is of opinion that the
uric acid  occurs  in combination  with  soda, and when,  instead  of the
weak lactic acid,  which is the free acid of the urine (1), and may co-
exist with the  urate of  soda, a stronger acid is  secreted, which decom-
poses  that  salt, then  the uric  acid  is  precipitated; an opinion which
Prout had already advanced, with regard to the  occurrence  of uric acid
 with ammonia, in  the urine,  and the precipitation of the former by the
 development of another free acid.   Although Magendie has  not ad-
 mitted the transmission of acids  into  the urine,  yet Wetzlar believes
 that an excess of acids in the juices  may occur  from  acid  drinks, sour
 wines, bad sour beer, unnatural acidity in  the prime vie, especially in
 children; and  that it  may also  occur from  the relative want of another
 element, as hydrogen.  The  secretion of  the urine in the kidneys is as-
 sumed to be from a process of oxidation and combustion; if this be more
 quick, active,  and  energetic, then, instead  of the weak lactic  acid,  a
 stronger acid  is secreted, which decomposes the urate  of soda.   Here
 the doctrine of Austin and  Walther, of  a sort of inflammatory irrita-
 tion of the urinary organs, may, in some cases,  be  well  founded, as an
 inflammatory condition of the kidneys is the excitant of a more powerful
 oxidating process  for the secretion  of urine, and  is thus  actually the
 cause  of lithogenesis.   The  connecting medium, the animal gluten, is,
 according  to Wetzlar, not necessary for the production of stone.  This
 always goes on slowly, and it is easy to comprehend how as this preci-
 pitation slowly takes  place, the first molecules of  uric acid unite, attract
 animal matter, especially mucus from the neighbourhood of the fragment,
 and  gradually increase.  This, however, is  no  organic  growth.  That
 the materials of which stone is composed are nearly all uncrystallized in
 it, as von Walther  concludes, from its organic formation, is very na-
 tural,  as even  without the animal mucus  which prevents crystallization,
 these constituents  have little disposition  thereto, even out of the body.
 In sand and gravel there is a deposit, because there is an excessive pro-
 duction of urate of soda.  This salt is very quickly separated  and dis-
 charged with  the  urine.
    [(1) Liebig (a) denies altogether the existence of lactic acid,  either in the urine,
 or in fresh milk.  He attributes  the acidity of healthy urine to the superphosphates
 of lime, magnesia and soda.—t. t.]
   (a) Ueber die Constitution des Harnes  der Menschen und fleischfressenden Thiere; in
 Annalen der Chemie und Pharmacie,  vol. 1. p. 161. 1814. 
240                      URINARY  STONE,
   1985.  According to Willis, it is not necessary to seek anxiously after
 a chemical cause for the deposit  of  uric acid ; it is sufficient to say, that
 in certain conditions of the constitution, under the influence of peculiar
 disturbance of the vitality of the kidneys, a very insoluble constituent is
 produced from these organs.  He considers the production of uric acid,
 and  urates, of oxalates, of cystic and xanthic oxides  as  very similar,
 and thinks that, according to the results of modern chemistry, by which
 a quantity of organic substances  may, by a peculiar treatment, be  con-
 verted into one another, the origin of these various concretions may be
 cleared up.   Urea,  of which the ultimate elements are 46,65 nitrogen,
 19,97 carbon, 6,65 hydrogen, and 26, 65 oxygen, (N4 C4 H4 02,) is con-
 verted-into uric acid, when the  proportions of nitrogen and  hydrogen
 are diminished, and the quantity  of carbon and oxygen increased, 33,37
 nitrogen, 36,00  carbon, 2,36 hydrogen, 28,27 oxygen (N4 C5 H* O.)
 If the proportions of nitrogen, caibon, and oxygen, remain  as in  uric
 acid, while the quantity of oxygen  is  diminished about one  atom,  uric
 oxide (xanthic oxide, according to Marcet) is produced (N4 O H402.)
 If the quantities of nitrogen and carbon be diminished, whilst the  quan-
 tities of  hydrogen  and oxygen  are relatively increased, cystin (cystic
 oxide of  Wollaston) is produced, 11,85  nitrogen, 29,88  carbon, 5,12
 hydrogen, 53,15 oxygen (N C3 H6  O1.)   If,  on  the one hand,  nitro-
 gen  and  hydrogen  combine, and on  the  other, carbon and  hydrogen,
 in nearly  the  same proportions as the former exist in uric  acid,  and
 the  latter  in  cystin, oxalic acid  is  produced,  33,99 carbon,  53,33
 oxygen.
  [(1) Sulpur forms an essential constituent of cystic oxide; and  Thaulow (a)
 ascertained that it contained about 25 per cent, of that element. The  accuracy of
 this statement has been confirmed, by the analyses of two stones in the  Museum of
 the Royal College'of Surgeons (b).   According to Thaulow, cystic oxide consists
 of carbon, 30,01 ; hydrogen, 5,10; nitrogen, 11,00; oxygen, 28,38; sulphur, 25,51;
 and that it is represented by the formula C6 H6 N. O.^ S2.—t. t.]
   1986.  Jones assumes on Liebig's principles, that uric acid is produced
 from tissues which afford albumen and gluten, (gelatine1?) in consequence
 of a change of  matter, and the effect of oxygen.   That the uric acid is
 converted by the influence  of oxygen, into alloxan  and urea; that, by
 a further  operation of the oxygen upon the alloxan  the latter is  either
 changed  into oxalic  acid and urea, or into oxaluric and parabanic  acid,
 or into carbonic acid and urea;  and that the quantity of uric acid which
is separated, alternates in inverse  proportion  to  the  quantity, which is
still further altered within the  body, and  with  the amount  of action of
the oxygen.   On  these principles we may, perhaps, establish a general
 theory of the causes of lithogenesis  as follows:—When the  health is
good, and the operation of the.oxygen  perfect, there is no deposit in the
urine; if  the  oxygen  act  in a slighter  degree,  there is  a deposit of
oxalate  of lime ; if, in a  still less  degree, urate of ammonia, or uric
 acid,  is formed.  If the  health be  disturbed,  or if  the urine become
alkaline,  from the irritation which the stone produces, the phosphates are
precipitated y and if the effect of  the oxygen be  still further  restricted,
(a) Annalen der Pharmacie, vol. xxvii. p. 200.  1838.
(b) Taylor's Catalogue, above cited, part i. p. 137. 
CONSTITUENTS OF.                      241
only an exceedingly small quantity of phosphoric acid  is produced, and
carbonate of lime is precipitated.
   1987.  For the proper explanation of the origin of stone, it seems most
convenient  first to ascertain the  origin of those  substances which alone
are capable of forming the so-called nucleus of urinary stone, or of being
precipitated  as gravel, as the deposit of various substances upon a stone
once formed is less difficult to  understand  and to explain.   It must  not,
however, be overlooked that the altered condition of the kidneys, and of
the urinary  organs in general, has an important influence in the  produc-
tion of stone.
   1988.  The general constituents of stones, excepting the  animal matter
existing in different quantity as the connecting material, are:—

   1.  Uric Acid.                        6.  Carbonate of Lime.
   2.  Urate of Ammonia.                7.  Silica  (1).
   3.  Phosphate of Lime.                8.  Cystic Oxide.
   4.  Phosphate  of Ammonia  and     9.  Xanthic  Oxide.
        Magnesia.                     10.  Iron (1).
   5.  Oxalate  of Lime.

   Of these  substances the following  occur in the nuclei of stones, or they
may form their entire bulk :—

   (a) Uric  Acid.                      (d)  Cystic Oxide.
   (h) Urate of Ammonia.            (e) Xanthic Oxide.
   (c) Oxalate of Lime.               (f) Phosphate of Ammonia  and
                                             Magnesia.

   From these six substances, which form  the nucleus, or the  entire bulk
of a stone, the various kinds of gravel are also produced.
  Besides the ten above-mentioned constituents, von Walther has also given phos-
phate of ammonia and lime, and the acid phosphate of lime (2).   Both these substances
appear to me  doubtful.  Not merely is the phosphate of ammonia and lime altogether
new as an addition to the  contituents of  stone, but also new as a combination of
phosphoric acid, for phosphate of ammonia  and lime, is not admitted by  any chemist.
In respect to the  acid phosphate of lime, von Walther supposes that it alone is
capable of forming concretions, but that on the other hand, the neutral  phosphate of
lime only  occurs in the layers.  It  is to  be  regretted that von Walther has not
given the careful analysis of Fuchs  on this subject; as it is difficult to understand
how the acid phosphate of lime, which is so very soluble, that even  in the  air it
softens into a molten glass-like mass, can  form stones.  It is important here also to
observe that the acid phosphate of lime is  not met with  in gravel, in which, how-
ever, all the other substances are found which are capable of forming the nucleus of
a stone.  Walther's assertion that phosphate of lime occurs only in the layers, is
contradicted  by the observations of Wollaston (a), who examined urinary stones
which  consisted entirely of phosphate of lime.  Their surface, he says, is pale brown,
and as smooth as if polished; their interior  consists of regular layers, which can
easily be separated into concentric plates.   These stones are, according to Marcet,
very rare.   Perhaps  this contradiction may be reconciled by the fact that these are
such stones as are formed in the prostate gland, (prostatic stones of Marcet,) which
consist of a neutral phosphate of  lime,  coloured by the secretion of the prostate, by
which, according to  Marcet, these  stones can be distinguished from  true urinary
stones.  Or there  may perhaps have been a nucleus which'was overlooked.   The
carbonate of  lime (first mentioned by  Bergmann, since by Crampton, and  most

             (a) Philosophical Transactions, vol. lxxxvii. p. 395.  1797.
                                   21* 
242                        URINARY  STONE,
 recently by von Walther) is found, according to the latter, in the outer substance
 of the stone with the phosphates, but not in the layers, and it appears to enter into
 no combination with  the  uric acid, the urate of ammonia, and the oxalate of lime.
 Goebel (a) describes a stone which consisted, he says, of carbonate of lime 96,025,
 and animal matter with silica 3,125.   Silica is met with but rarely in urinary stones,
 and is always accompanied by uricacid or oxalate of lime.   According to Berzelius,
 this earth exists in'small quantity in the urine; he derives it from the  water and the
 food.  Marcet found in one stone a substance corresponding with the fibrin of the
 blood (fibrin stone.)  Iron is found in combination with uric  acid, with phosphate
 and carbonate of lime, and as iron ochre.  Brugnatelli has found benzoate of am-
 monia in a stone, which he describes  among the more rare, consisting of little stones
 connected  together, of a grayish colour, with a smell like castor, light but hard, and
 containing also phosphate and oxalate of lime.
   [(1) Silica  and iron cannot be said to be general constituents of stones, as they
 never form an entire stone, and they have only been detected in very minute quanti-
 ties in some few  instances.
   (2) By  acid phosphate of lime is meant, not the super-phosphate, but the neutral
 or di-phosphate of lime, the "phosphate acidule de chaux " of Fourcroy.  Berzelius
 has commented upon the absurdity of the French chemist describing a solid concre-
 tion as composed of  an acid phosphate of  lime.   His criticism, however, is only
 partially correct.  The fact is, when  the di-phosphate of  lime calculus  is digested
 with  water, it  is  decomposed into an  insoluble sub-phosphate, and a soluble super-
 phosphate, which of course possesses an acid reaction.  It was from observing this
 latter fact  that led Fourcroy into the error of describing these concretions as com-
 posed of a  super-phosphate of lime.   Di-phosphate of lime constitutes the accidental
 bezoar, an intestinal  concretion found in  the stomach, &c, of the deer of South
 America (b).
   (3) "  Calculi, from the human subject, composed entirely of carbonate of lime, are
 of extremely rare occurrence, and have been noticed only by a few authors.  The
 existence  of  such  concretions was  first pointed out by Brugnatelli (c), who
 describes forty-eight small concretions, which were extracted from the bladder of a
 young man.  They were each about the size of a pea, possessed a lamellar structure,
 and broke  with a shining  surface.  The same author also mentions several ash-
 coloured  calculi composed of carbonate of lime, with a trace of carbonate of iron, that
 were  taken after death from tbe bladder of a woman.  Dr.  Prout (d) has also seen
 small calculi of this salt which were ' perfectly white and very friable.'  A remark-
 able collection  of these calculi is in the possession of R. Smith, of Bristol; *  * *
 " five were extracted by the lateral operation from  the bladder of a boy aged sixteen,
 by H. Sully, and the others, fifteen in  number, were passed by the urethra of the
 same patient previous to  the operation.  The former, are exceedingly irregular in
 figure, their external surface is rough, and is  dusted over with a white powder.  The
 largest of these calculi was about the size and figure of a large almond; when sawn
 through,  it did not  appear to consist of concentric layers, but  exhibited irregular
 waved lines of various shades of brown, resembling very closely  the section of a
 compact  mulberry calculus.  It was so extremely hard as to require a lapidary's
 wheel to  divide it, and the cut  surface  readily acquired a fine polish.   The calculi
that were passed by  the urethra are  about  the size of peas,  of a  rounded figure,
 with  flattened  surfaces.   They  present  a   compact lamellar  structure, and their
external surface is of a light brown colour"  (e).—t. t.]


                     Uric Acid and Urate of Ammonia.

   1989. According to  the  experiments of  Prout  and L. Gmelin, it is
 extremely probable that uric acid does not occur,  as Wetzlar asserts,
combined with  soda ; but in combination with ammonia.   Also, that the

  (a) In Trommsdorff's Neuc Journal  de    (d) Above cited, p. 93. .
Pharmacie,  vol. vi.  p. 198.                    (e) Taylor's Catalogue,  part. i. pp.  132,
  (6) Taylor's Catalogue, part ii.  p. 252.     133.
  (c) Litologia  Umana—Archiv.  Gen.  de
Med. 1819, vol. iii.  p.- 444. 
CONSTITUENTS OF.                      243
acid property of the urine does not depend on free lactic or acetic acid,
but on acid phosphate of ammonia, which salt  keeps the phosphate of
lime in a state of solution {a).   That the circumstances stated by Magen-
die, to wit, the absolutely or  relatively increased quantity of uric acid,
and diminished  temperature of the urine, is the cause of the precipitation
of the uric acid, Wetzlar has indeed too confidently denied ; since uric
acid, when, from its being in  excess,  it  is free, and  not combined  with
ammonia, must, on account of its insolubility, be disposed to precipitation.
That the sediment of uric acid in critical urine takes place only when it
is cooling, may be readily explained by the ammoniacal state  of the urine,
which exists in such cases.  Perhaps the precipitation of the uric acid is
rarely the result of its increased quantity, and rather to be  met with in
gravel than in the actual formation of stone; and the doctrine laid down
by Prout is more commonly  correct,  namely, that the uric  acid is often
precipitated only because another free acid, as the phosphoric, sulphuric,
hydrochloric or carbonic, purpuric or acetic is produced.   In consequence
of this, the ammonia entirely or in part quits the uric acid with which it
was in combination, and is precipitated pure, or combined  with a  little
ammonia;  but  not,  as Wetzlar supposes, by the soda  being with-
drawn.
   According to Liebig (b), there is produced, by the action of the uric and hippuric
acids upon the phosphate of soda,  an acid salt of soda from  these acids  on the one
side, and an acid  phosphate of soda on the other side.  From which, and from the
sulphates contained in the urine, he deduces the acid condition of the  fluid.
   1990. To attribute the development of such an acid in the urine  from
an excess of  acidity  of the juices, cannot be considered groundless, on
account of Magendie's assertion that  acids, do not pass into the blood.
If we cannot, indeed,  prove the  presence of free acids in the blood, as
it has always an alkaline nature, yet, it is to be remembered, that if even
no free acid can be found in  the blood, yet from its  approximation to a
neutral state a change  is caused,  which renders possible the  secretion of
free acids through the urine.  To this former opinion of Magendie's, a
later one, advanced in an essay read before the  Academie des Sciences,
on the  18th  of September, 1826 (c),  stands opposed, where he brings
forward the daily use of sorrel, which contains much oxalic acid, as the
exciting cause of almost every stone consisting  of pure oxalate of lime.
With this, also, Howship's {d) observations  agree, which show that if a
patient, who, on account of phosphatic gravel, has used acids, take  more
acid than is necessary to neutralize the  alkaline condition of the urine,
and  to  dissolve the  precipitated earthy constituents, the white gravel
indeed disappears, but red, uric acid gravel is soon produced in its stead.
Morichini's (e) experiments also support this view; he found that people
who have  lived long, and almost exclusively  upon sour fruit, present
citric and  malic  acid in their urine.   But Woehler's {f)  experiments
are still more conclusive.
   (a) Hcidelb. Jahrbiicher.  1823.  No. 49.  affect the Secretion and Excretion of Urine-
   lb) Above cited, p. 193.                London, 1823.  Svo.
   (c) Revue Medicale, 1826, vol. iv. p. 140.    (e) Meckel's Archiv. fur die Physiologie,
Froriep's Notizen.  1826.  No. 33.        vol. iii. p. 467.
   (d) A Practical Treatise on the Symptoms,    (/) Versuche iiber den Uebergang von Ma-
Causes, Discrimination and Treatment of  terien in den Ham; in Tiedemann's Zeit-
some of the most important Complaints that  schr. fur Physiologie, u. e. w., vol. i. p. 125. 
244
URINARY STONE,
   Strong mineral acids are not capable of rendering the urine acid, probably because
 their strong affinity for the soda in the blood destroys its combination with the albu-
 men, whereby neutral salts are formed, which pass off as such with the urine.

                           Oxalate of  Lime.

   1991.  Walther doubts whether simple oxalate of lime and  the con-
 necting material can form urinary stones.   It is frequently'found as the
 nucleus of a stone, though never alone, but combined with uric acid and
 urate of ammonia.  In the layers it is most commonly found with phos-
 phates {a).  The inquiries of Rapp, however (&), and the stone from six
 to seven lines long and two  thick, noticed by Magendie, and examined
 by Desprets, which consisted almost entirely  of pure  oxalate  of lime,
 are  in favour of the possibility of such a formation ;  as well, also, as that
 gravel  and formless sediment, according to Prout, is never combined
 with uric acid.
   1992. Prout believes that the oxalic acid is produced by the decom-
 position of the uric acid, as in urinary stones a  nucleus.consisting of uric
 acid is frequently found, surrounded with oxalate of lime; thus the oxalic
 diathesis follows that of the uric acid, and are allied to each other.   He
 does not, however, suppose  that the oxalic acid is in any way produced
 in the urine by the action of the hydrochloric acid upon  the urine ; but
 he considers  it  more  probable, that  the oxalic acid has  been  already
 secreted as such from the diseased parts of the  kidneys;  this oxalic acid
 then comes in contact with the uric acid which  is secreted by the healthy
 part of the kidneys, and throws down from it the lime, in a state of oxa-
 late ; perhaps at first in a plastic form, as the somewhat crystallized  state
 of such stones would make us'suppose.  Walther contradicts this state-
 ment (c),  as the origin of oxalic acid is more  easily deduced from the
 conversion of the benzoic acid, (which  is so similar to it,) free carbonic
 acid, or lactic acid, contained  in the urine, than from the uric acid; for,
 in oxalic  acid, as well as in other vegetable  acids, hydrogen and carbon
 are  the oxidizable bases,  but the  urea is a  very azotized  production of
 animal life.   Oxalic acid is  formed in the urine, not only when the hy-
 drogen is wanting, in order to saturate all the relative excess of  oxygen,
 and to  combine with it as water, but also the nitrogen, as the acid which
 would  be otherwise formed  would  be uric, which is distinguished  from
 the  oxalic acid by the quantity of azote.  A relative want of hydrogen
 seems in  all cases to be one of the conditions of the formation of stones,
• whether concretions of uric acid or of oxalate of lime.   Liebig, Willis,
 and Jones have held the conversion of uric into oxalic acid, as the con-
 sequence of a diminished oxygenation.
   1993. Besides  the production of oxalic acid  by the conversion of the
 uric acid, its origin from the food must also be  admitted.   In support of
 this opinion, it must be observed that various vegetables which serve for
 food, contain  a large quantity of oxalic acid ; that Magendie has noticed
 the  production of a stone of oxalate of lime, after long-continued use of
 sorrel; that in  England, where animal food is the most common  diet,

   (a) Above cited, p. 208.                schaftlichen Abhandlungen, vol. i. p. 138.
   (b) Ueber Harnsteine;  in Naturwissen- Tubingen, 1826.
                          (c)  above cited, p. 219. 
                         CONSTITUENTS OF.                    245

stones of oxalate of lime are, in comparison with those of uric acid, more
rare, whilst, on the other hand, in  those countries where chiefly vegeta-
bles are  eaten, the oxalic stones  are much more frequent, as Rapp has
noticed in Wiirtemberg, Walther in Bavaria, and I myself in our own
neighbourhood. Woehler has, by his experiments, put beyond all doubt
the transition of oxalic acid into the urine.
   1994. That  under the above-mentioned circumstances, which cause
the presence of oxalic acid in the urine, the uric acid may also at the
same  time  be diminished, depends on the greater quantity of vegetable
food, but is not to be considered  a  condition for the production of oxalic
acid.   The ordinary combination of oxalate  of  lime with uric  acid, or
urate  of ammonia, contradicts this.   Wetzlar's (a) assertion, that mul-
berry stone is most  frequent in childhood, when but little uric  acid is
contained in the urine, has been disproved by the observations of von
Walther, Rapp, and others (6).
   1995. If oxalic acid occur in the urine, on account of its greater affi-
nity for lime, it takes the latter from the phosphoric acid.   In proportion
as the phosphate of ammonia existing in the urine is in a more or less
acid state, the phosphoric  acid may unite partly with this, and  partly
with the ammonia combined with the uric acid ;  and from these different
circumstances we may explain how the oxalate of lime can  be precipi-
tated  either alone or in combination with uric acid, or urate of ammonia;
how the oxalic diathesis, is  preceded or followed by the  uric, and how
both diathesis stand in near relation to each other.   These occurrences
may also be explained by deriving the oxalic acid from conversion of the
uric acid.

                              Cystin.

   1996.  Stones of cystic oxide, first discovered by Wollaston, are rare,
although Civiale believes that cystic oxide  is  much more frequently
present than has been hitherto supposed.   They  usually consist  entirely
of this substance;  whence  it has  been concluded that the cystic  oxide
diathesis prevents the formation of other stones more than any other dia-
thesis (c).  Wollaston  had seen  two stones of cystic oxide covered
with a loose layer of phosphate  of lime.  Bird {d) has, from chemical
examination, disproved the assertion that the cystic oxide diathesis is
never present with other diathesis ; the simultaneous presence of uric acid
diathesis is proved by cases in which stones of cystin have been observed,
where the patients, either before or  after, have passed stones of uric acid.
Yelloly found a stone of cystic oxide, with a nucleus of uric acid, in a
child, in whom a new stone was  formed a year  after, which had also a
nucleus of uric acid, though its exterior consisted of phosphates: a stone
of uric acid had as its nucleus a small  portion of cystic oxide (Henry) ;
a stone of oxalate of lime had been previously removed (Prout) ; Civiale
found one  stone of cystic oxide in the bladder,  and one of phosphates
under the prepuce; Lassaigne found a small quantity of phosphate and
oxalate of lime combined with cystic oxide (e).
  (a) Above cited, p. 55.
  (b) Chelius, Ueber Scrotalsteine; in Hei.
delb. Med. Annalen, vol. i. pt. 1.
(c) Marcet, above cited, p. 77.        * ,
(d) Guy's Hospital Reports, vol. i. p. 492.
(e) Civiale, 511. 
246
URINARY STONE,
  1997. The circumstances under which stones are formed from cystic
oxide have, in reference to the place where they are produced, the greatest
analogy with those which attend the formation of uric acid and oxalate
of lime.  They are principally formed in the kidneys, and their origin is
to be considered as the  consequence of a transformation of the urea, or
of the uric acid, to which the cystic  oxide is allied  by its nitrogenous
contents.   According to the experiments of Thaulow and others, cystic
oxide contains,  besides carbon, hydrogen, nitrogen, and oxygen, a large
quantity of sulphur (C6  N2 H12 O4 S2.)  It  is a peculiar circumstance,
that persons  of  the same family are affected with stones of cystic oxide,
as out of  twenty-two cases of such stones, ten occurred in four families,
in which  sometimes  two, sometimes three individuals were subject to
them, and among these,  in three  instances, brothers (a.)

                            Xanthic Oxide.

   1998.  The xanthic oxide, uric oxide, first mentioned by Marcet (b),
and more precisely defined by the inquiries of Woehler and Liebig (c),
occurs very rarely.  The earlier opinion that  it was nearly allied to, per-
haps only a modification of uric acid, has been confirmed by the obser-
vations of Woehler and Liebig, who have proved that it has  the same
constituents  as uric  acid, but with one atom less of oxygen;  that uric
acid and  xanthic oxide are radically the same, but in two  different stages
of oxidation (C5 N4 H4 O2.)  Xanthic oxide, however, is  never found in
solution,  nor as a precipitate in the urine; yet it is probable that it occurs
 in the precipitates from uric acid (d).
   Besides the stone which Marcet mentioned, and that which Liebig and Woehler
 examined, Laugier (e) has also examined a xanthic oxide stone.
   Berzelius (/) believes that he has sometimes met with xanthic oxide, or acid in
 gravel.       '

                  Phosphate of Ammonia and Magnesia.

   1999.  As the acid property of urine  depends on the acid phosphate of
 ammonia, which salt contains phosphate of lime in solution, it necessarily
 follows that  every change of the urine, in which  alkalescence becomes
 prevalent, whereby the acid which holds those earths in  solution is neu-
 tralized,  causes the precipitation of those  earths.   This applies also to
 the neutral phosphate of lime, if further observations should  prove the
 possibility of its forming the nucleus of stone; as also to the  combination
 of phosphate of ammonia and magnesia, and of phosphate of lime, which
 Marcet has described  by the name offusible calculus.  .
   Jones (g) divides the phosphate diathesis into true and false; in the former, the
 urine, in consequence of the general state of the constitution, becomes alkaline, and
 the phosphates are precipitated; in the latter, the alkalescence depends on retention of
 the urine, or on a diseased secretion of it, which causes a speedy change of the urea,
 as in irritation of the mucous membrane of the urethra.

   (a) Civiale, above cited, p. 608.           (e) Journ. de Chimie  Med., vol. v. p. 315.
   (6> Above cited, p. 85-94.              1829.
  , (c) Poggendorff's  Annalen, vol.  xli. p.    (/) Lehrbuch der Chemie, vol. ix. p. 491.
  393.  1837.                            (g) Above cited, p. 74.
   (d) Willis, R., p.  108; and on the  con-
  trary Jones, p. 105. 
CAUSES  OF.
247
                         Connecting Material.

  2000. The connecting material, animal  mucus, exists in gravel, but
specially in all stones, in various quantity, and appears to be subject to
different changes in the several kinds of stones.   Upon the presence of
this material, many ground the distinction between the formation of stone
and the secretion of gravel and sand.   Others hold that such connecting
material is not required for  the  production  of stone, inasmuch as the
attraction of the individual constituents suffice for its formation.   If we
reflect that the inner surface of the urinary organs is naturally overspread
with mucus; that in persons troubled with gravel, there is often as great
irritation  of the urinary  passages,  as  in  stone  patients,  whereby an
increased secretion of mucus is caused;  further, that in actual blennor-
rhceal affections of the  mucous membrane  of the urinary  passages, with
copious secretion of viscid mucus, the  latter is often mixed with much
sand, and yet no stone forms:  it follows  that  the difference between
gravel and stone cannot be derived from this connecting material alone.
The difference appears for the most part to rest in this;, that in the pro-
duction of gravel and  sand, the  precipitation of  the  substances forming
them  follows  quickly,  and in large  quantity from any great excess  of
living;  whilst  in  the  formation of stone, it is  slow but more conti-
nuous {a.)
   2001.  Accordingly to what has been  hitherto  said about the produc-
tion of gravel and urinary stone, it may be  attributed to  two principal
causes, to wit, an  increased acidity of the  urine from the acid naturally
existing in it being secreted in greater quantity, or from a new acid being
 developed; and, an increased alkalescence.   The  remote  causes  may be
 luxurious living, excess, the use of strong wine, want of exercise, mental
 exertion, especially after eating, the use of food difficult of digestion, as
 heavy, milky diet, sour beer, sour wine, cider; acidity and irregularity
 of the bowels, the  use of  vegetables containing oxalic acid, and circum-
 stances connected with climate, as low marshy districts.   To these may
 be added the hereditary disposition, specially observed in gravel.   In the
 same  manner, the  relation between gout and certain kinds of stone, is to
 be explained ; as also its  more frequent occurrence in certain districts, in
 advanced age, and in the male sex.   According  to  Deschamps {b), the
 latter peculiarity is only apparent in women, as on account of the short-
 ness and  width of the urethra, little stones readily pass and more rarely
 need the operation; experience, however, refutes this.   Stone is as fre-
 quent in children as in advanced  age, and  in  them the production of
 stone is  in  close  relation with scrofulous and ricketty disposition, and
 with  disturbed  development of the bony system.   Therefore, also, in
 children, urinary stones contain  relatively less uric acid, but on the con-
 trary, more phosphate of lime, and phosphate of ammonia and magnesia,
 and the  contrary proportions occur in the urinary stones of old  gouty
 persons (c).
   (a) Henry ; above cited, p. 134.          Remarks on the tendency to Calculous Dis.
   (b) Traite Historique et  dogmatique de  eases; with Observations on the Nature of
 l'Operation de la Taille, vol.  iv.            Urinary Concretions, and an Analysis, &c.;
   (c) Walther; above cited.—Yelloly,  in Phil.  Trans., 1829, p. 55.—Eschirsch, 
248
URINARY STONE,
    [The calculi of children consists almost invariably of urate of ammonia.  After
  they have caused irritation in  the bladder, they become  coated with the mixed
  phosphates, like all other concretions.—t. t.]
    2002.  Foreign  bodies introduced into the urinary passages, become
  covered with a crust of phosphatic salts, or often  with some uric acid (1).
  The general  opinion is that the phosphatic salts of urine arrange them-
  selves and form incrustations around the foreign body, according to the
  same laws  by which a foreign body put into a solution of salt, hastens
  crystallization in it.  According to Prout, however, (a), these incrusta-
  tions arise because the irritation of a foreign  body  causes an  excess of
  phosphatic salts to be  produced;  or because the  foreign body enters the
  bladder at a  time  when the urine there is  disposed to incrustation from
  excess  of phosphates.   Such foreign  bodies  as  serve for  the nuclei of
  these incrustations  pass either through the urethra into  the bladder (2),
  or through wounds (3), or they are swallowed and penetrate through the
 intestinal canal into the bladder (4).   Blood, sloughs, and  the like may
 also be the nuclei of stones.   This is indeed doubted by von Walther,
 but there are  stones which have cavities within them, and it is probable
 that the mucus of the bladder, or a similar albuminous animal substance
 had, at an early period, filled it, and in the course of several years had
 dried up.   Deny's (6) experience also appears to agree with this  view.
 But Walther's opinion is most decidedly contradicted by Lisfranc's (c)
 observation ;  he  found  in an urinarystone, as big  as  the fist,  a blackish
 nucleus  of slight consistence, which resembled a clot of blood, and on
 chemical examination,  presented  a fibrinous substance (5).   One of the
 just-named animal  substances may also be deposited on the nucleus of a
 stone, over it again a stony mass,  so that, if in such stones the enclosed
 animal substance be dried by time, the nucleus no longer appears  to fill
 up the cavity, and when shaken, it moves and rattles.    Two examples
 in my collection  of urinary stones prove this (d).
   Cruvelhier (e) showed, in the Anatomical Society at  Paris, a very large urinary
 stone, of which  the nucleus was originally a clot of blood.
   [ (1) The circumstances of a foreign body in the bladder becoming coated by uric
 acid is exceedingly rare.  There is only one specimen of the kind in the Museum of
 the Royal College of  Surgeons.   It  has a splendid piece of steel for its nucleus, A
 126.—T. T.]
  (2) The  quickness with which catheters, especially those of elastic gum are
 coated with earthy deposits after  remaining constantly in the bladder for three or
 four days, is known to every one who has had the  least experience.  Upon  this
 account, it becomes necessary when a catheter is constantly worn, that if elastic, it
 should be replaced by a new one,  or if of silver or other metal, should be withdrawn,
 cleaned, end returned every four or six days, otherwise the deposit upon that part of
 it in the bladder becomes so considerable, that  it will often be removed with diffi-
 culty, and almost always scrape the urethra as it is withdrawn, and add much to the
 patient's uneasiness.  There are few Museums which have not specimens of extra-
neous bodies introduced into the bladder, which havebecome nucleiof stones.   Inthe
 College Museum, there are examples of a silver bodkin, of a sewing needle, of a pea,

Ueber Lithias; ihre medicinische Begriin-    (b)  De Calculn, p. 14.
dung in  zoologischen  Bodenverhaltnissen    (c) Archives generales de Medecine, 1827.
und ihr Zusammenhang mit Ausbildung des vol. i. p. 1.
Scelet-Systems; in Med. Correspondenzblatt   (d)  Eggert, Versuch.  die Entstehungdes
bayerischer Aerzte.  1843.—Textor Cur- Blasensteines zu erortern ; in Rust's Maga-
nin, Versuch iiber   das  Vorkommen  der  zin. vol. xiii. pt. iii. p. 367.
Harnsteine in Ostfranken. Wilrzburg, 1843.   le) Behrend's Allgemeines Repertorium,
  (a) Above cited, p. 181.                p .75. 18^3. Oct. 
DIVISION OF.
249
a hat-pin, a bougie, a piece of bone, &c.  There are  also two instances in which
soap has formed the nucleus.   It is probable that in these cases "a solution of soap
had been injected into the bladder; mutual decomposition of the soap and the  salts
of urine has  been the necessary result; the alkali of the former uniting with and
forming soluble compounds with the phosphoric and other acids of the urine, while
the earthy bases of the urine have precipitated, in combination with the fatty acids
of the soap, in the form of  a semi-gelatinous sparingly soluble compound, being in
fact  an earthy  soap,  consisting of margarate and  oleate  of lime"  (a).   In the
Museum at St. Thomas's, there is  a stone having a large piece of brass nail as its
nucleus.  And another stone of good size, and about an ounce in weight, which had
formed  nearly on the middle of a female catheter, that  had escaped from the  fingers
of the surgeon, whilst drawing off the water, who, fearful of getting into trouble, said
nothing about the accident.  .Some months after, the woman had symptoms of stone,
and was cut  by Astlev Cooper;  the  catheter lay across the bladder, and its  ends
were pretty tightly fixed;  but one end  having been freed by introducing the  finger,
it was easily withdrawn.   Brodie (b) mentions a  hazel nut as forming the nucleus
of a stone in a female; and in another case, a man occasionally subject to retention
of urine "passed a flower  stalk through the urethra into the bladder, using it as a
bougie.  In an evil hour, the extremity of the flower stalk was broken off, it became
incrusted with calculous matter forming the  nucleus of a stone,"  for which he was
operated on by Everard Home.  He also mentions some small oblong stones  from
a female bladder, "each of which has a small fine hair running longitudinally
through its centre."
   (3) In St.  Thomas's  Museum there is a beautiful example of a pin forming the
nucleus of an oblong  stone.  The child, a male infant, had been  put upon the floor
by his nurse, and immediately began to scream violently, and without any apparent
cause.   Some months after he had symptoms Of stone in the bladder, for which he
was cut by Astley Cooper, and this stone removed.   Foreign bodies of such size
are sometimes pushed up into the vaginr. and slip beyond  the reach of the patient,
who, being ashamed of making her condition known at the time when she might be
relieved, the  foreign body remains fixed, and will produce  ulceration of that part of
the bladder against which  it presses, and incontinence of urine;  at the same time
also it becomes more or less covered with calcareous deposit. The College Museum
has a remarkable instance of this kind, H. a. 13.  "A tumbler in an entire state was
introduced into the vagina of an unmarried female, about twenty years of age.   On
her attempting to withdraw it, its upper edge was broken, by which the bladder was
 wounded, and incontinence of urine  produced.   In this situation it remained for
 nearly  two years, when it was removed by Mr. Anthony White, who, finding the
 tumbler to be closely embraced by the vagina, and quite immoveable, broke away the
 sides of the glass with instruments having notches, filed at their extremities like the
 wards'of a key, until he was enabled to introduce a lever behind it. *  * *  A  large
 horizontal slit was found in the bladder immediately above its cervix" (c).  My friend
 Arnott tells me of a woman  about forty-two years of age, admitted into the  Mid-
 dlesex Hospital with presumed disease of the uterus, and  with incontinence of urine.
 On examination, a gallipot was found in the vagina, mouth downwards, and coated
 inside and out with what proved to be triple phosphate.   An attempt was made to
 extract it whole by the application of large-bladed stone-forceps, but the pot  was so
 closely impacted by the swelling of the external parts, that only one blade could be
 introduced.  It was therefore broken with strong «forceps, and removed  piecemeal
 with difficulty.   The finger being then introduced into the vagina, a large aperture
 was found into the  bladder, in which was  a large stone.  As she was much ex-
 hausted, the removal  of the stone was deferred for a few  days, and then removed by
 enlarging the aperture.  In the course of a few weeks she was able to retain four
 ounces of urine in the bladder which she had not been able to do  for many years.
   (4) In the College Museum is an example, H. a. 14,  of a  pin, which had  been
 swallowed five years, forming the nucleus of stone in a young man of twenty-two
 years  of age, which  had caused symptoms  only the  latter two  years.  It was re-
 moved by the lithotritic operation.
   (5) Astley Cooper mentions a case  in  which, having removed a triple phos-

     (a) Taylor's Catalogue, part, i. p. 129.     (b) Lectures, above cited,  p. 245.
                       (c) Taylor's Catalogue, part, i. p. 129.
   Vol. hi.—22 
250
URINARY STONE,
phate  stone,  "the disease.returned, and he again performed  the operation, and
found  a large coagulum of blood in the bladder surrounded by a triple phosphate
deposit" (a).  In the College Museum there  is a stone H. a. 7, " consisting  of
uric acid, deposited upon a hollow crust or shell of impure oxalate of lime.  This
crust was most probably formed upon a clot of blood, which has afterwards shrunk"
(6).]
  2003. Urinary stones are divided according to their situation, the mode
in which they arise in the urinary passages, according  to their external
differences, and according to their chemical composition.
   2004.  According to the situation where they are found stones are dis-
tinguished  as—
   a.   Renal Stones     Calculi  renales       Nierensteine.
   b.   Ureteric ,,        ,, ■   ureterici      Steine in den Harnleitern.
   c.   Vesical  , ,        , ,    vesicates      Blasensteine.
   d.   Urethral , ,       . , ,    urethrales    Steine in der Harnrbhre.
   e.   Stones which form in collections of urine in the cellular tissue.
   Stones either lie loose, or they are firmly enclosed by the walls of the
cavity, or are connected with them.
   2005.  The external characters of stones are very different, and a divi-
sion  founded  upon such  difference  is only so far  of value, as it  gives
sometimes a clue  to their internal chemical composition.   Their structure
is more  or  less solid, granular, sandy,  chalk-like,  crystallized, friable,
brittle ;  their surface is smooth, tubercular,  mulberty-like ;  their interior
compact, homogeneous, laminated,  consisting of various layers.  The
layers usually show mixed  and varied colours, as  gray,  white, reddish-
yellow,  brown, black, violet, and so  on.   The middle  ox nucleus (Kern,
Germ.;  Noyau, Fr.,) of the stone is formed either of a foreign body  or
consists of  one of the substances already mentioned (par. 1988.)
   Stones composed of uric acid  have  a brownish  or yellowish colour, a
smooth, but sometimes tubercular surface, a radiated fibrous fracture, and
mostly an oval or flattened form ;  when  cut through, they are generally
found made up of concentric layers.
   Stones formed of urate of ammonia have nearly the same figure  as
those of uric acid, but have a milk and coffee colour; they are composed
 of concentric layers; their fracture is very close  and similar to that of a
 hard chalk stone.
   Mulberry stones, however complicated they may be, contain in their
 nucleus or  in their layers oxalate of lime (1).   Their colour is dark brown,
 approaching to black; they are hard, when cut  through present an im-
 perfectly lamellated structure ;  they rarely  exceed a moderate size.  If
 in these stones there be not this irregular surface, the  cause seems to be
 the simultaneous existence of  several stones, and  their  consequent fric-
 tion, (c).
    Marcet's hempseed stones are smooth, contain oxalate of lime (2), and
 are  pale coloured.
    Stones consisting of the earthy phosphates have a white or grayish-white
 colour, are friable, and brittle, and only  in  rare cases hard and compact,

   (a) Surgical Lectures, vol. ii. p. 242.      alate du Chaux, qui ne sont pas murales; in
   (6) Taylor's Catalogue, part. i. p. 85.     Annales de Chimie et de Plysique, vol. vi. p.
   (c) Martkes, Sur des  Concretions d'Ox-  220. 
DIVISION OF.
251
and when broken they present a crystalline and more or less transparent
structure.
  The stone consisting of phosphate  of lime  has mostly  a pale-brown
colour, is smooth as if polished ;  its structure consists of regular plates,
which are striped perpendicularly to their surface ; it is rare, and seldom
attains moderate size (a).
  The stone, consisting of a mixture of phosphate of lime  and phosphate
of ammonia and magnesia (fusible stone) is usually white and very friable.
It resembles a  lump of chalk, and leaves a whitish stain on the fingers ;
it is in general not laminated, but sometimes  separates  into layers, the
interspaces  of which are often  filled with glittering crystals.   Those
which have no layers often attain considerable size.
  The cystic oxide stones  are usually crystallized throughout, yellowish,
semi-transparent, iridescent ;  if examined with a lens, an  irregular group-
ing of granules  is observed, which,  in  large stones, are separated by
interspaces; this, according to Civiale, seems to prove that the cystin
is not deposited  on its nucleus in  a fluid form, and this appears  from the
structure of the stone, which, at least in its pure state, is  wrinkled like
shagreen.   These  stones are usually  small,  and do not exceed the
middle size.   Civiale has, however seen three stones of this sort of con-
siderable size (3).   When  cystic oxide is combined  with other sub-
stances,  for instance, with earthy substances,  the stones appear to be so
modified by the  nature of their combination and the proportions of their
constituents, that there is great uncertainty about the nature of the stone.
   Stones of xanthic oxide have  a pale-brown, smooth, glossy, in part
whitish,  soft and earthy surface ;  when broken they have a brown flesh-
colour.   They are made  up  of concentric and  easily separable layers,
and   have  not any crystalline or fibrous structure.   By  rubbing they
become  smooth,  with a wax-like  gloss, and have nearly the same  hard-
ness  as stones of uric acid.
   Those stones which contain carbonate  of lime  are of a chalky colour,
hard, and friable.   Smith (b) has described  stones of this kind, which
closely resemble mulberry stones.
   Urinary stones sometimes  smell of urine ;   in sawing them  through
some have  a peculiar animal odour,  resembling sawn  bone or musk ;
many have no smell at  all;  a  few  have a  distinct  and  well-marked
flavour.   Their  sizOis very various ;  it appears, however, in some de-
gree  relative to their composition.  Their shape  depends on the place in
which they are found, and partly on their number (4).
   [(1) Several mulberry stones have a nucleus of uric acid.
  (2) Hempseed calculi consist either of oxalate or of urate of lime, either pure or
mixed with urate of ammonia.
  (3) A  cystic oxide stone found in  the Museum of St. Bartholomew's Hospital
half of which is now in the College Museum, weighed, when entire, 740 grains.
Another specimen, in the Museum of  University College, (London,) weighed 850
grains.
  (4) Only three xanthic oxide stones have ever been seen .—Marcet's, which
weighed  only eight grains; Langenbeck's,  about the size of a small hen's egg, first
examined by Stromeyer, and afterwards  by  Liebig and Wohler;  and that de-
scribed by Laugier.—t. t.]

       (a) See par. 1988 [note].      (b) Medico-Chirurg. Trans,, vol. xi. p. 14. 
252
URINARY STONE.
  2006. The division of stones according to their chemical composition
has been  arranged  in various ways by Fourcroy, Brande, Thomson,
Wollaston, Marcet, Yelloly, and Taylor, and the grounds upon
which this division has been founded are either the  simple  or compound
nature of the stone, or the prevalence of one or other substance.  It seems
most  convenient to divide urinary stones according  to the principles laid
down by von Walther,  who gives the  acids entering into their compo-
sition as their distinguishing characteristics.
  2007. According to these principles may be distinguished :—
  Firsj;, Urinary incrustations of foreign bodies.   These consist of phos-
phates, often also with some uric acid.
  .Second, Urinary concretions without foreign bodies.
  a.  Stones of pure uric  acid or urate of ammonia.  These are soluble
in the fixed alkalies, with or without giving off ammonia.
  b.  Stones which contain oxalate of lime.  This is  found in the nucleus,
either pure or  commonly combined with urate of ammonia, most com-
monly in the interspaces  between the nucleus and the crust, which latter
usually consists of phosphates.  Sometimes they contain a  little silica in
a state which is still questionable.  They are insoluble in alkalies, and
soluble with difficulty in  dilute acids.
  c.  Stones consisting of cystic oxide, sometimes covered with a crust of
phosphate  of  lime.  A piece of cystic oxide placed upon ignited char-
coal gives out a garlicky  or phosphoric smell ; on a  platina plate, heated
to redness, its sulphur blackens the plate to the extent of some lines.
   d.  Stones of xanthic oxide, soluble in  hydrochloric acid,  although with
more difficulty than uric acid, without the least development of gas, form,
after  evaporation, a lemon-coloured residuum, which dissolves in water
with  a pale yellow colour.
   e.  Stones consisting of phosphoric acid in combination, so as to produce
neutral salts, either of phosphate of lime or  phosphate of ammonia and
magnesia,  simply or combined, with phosphate of lime;  or they have a
nucleus of uric acid or urate of ammonia and the crust  consists of phos-
phates, or  of these and alternating layers  of uric acid.
   f.  Stones containing carbonate of lime.  These have a nucleus of urate
of ammonia, and the carbonate of Itme  is mixed with phosphates.  They
effervesce with acids.
   2008. The frequency of the different  kinds of stoics  varies according
to the circumstances of climate, mode of life, and soon.   The uric acid
stones, however, occur  most frequently, so that,  according to Prout,
they  make one-third of the whole number.    To this may be added, that
uric acid,  in most other instances, forms the  nucleus around which other
layers are  deposited, so  that its  frequency  may perhaps be estimated at
two-thirds.  Oxalate of  lime stands  next  to uric acid,  and then follow
the phosphates.
  If the number of substances composing stones  be reviewed, they may be divided
into simple and compound,  thus :
  Simple.  1. uric acid; 2. urate of ammonia; 3. oxalate of lime ;  4. phosphate of
lime, 5. phosphate of ammonia and magnesia.
  Double.  1. uric acid and phosphates;  2. uric acid and oxalate of lime; 3. urate
of ammonia and phosphate of  ammonia and  magnesia; 4. phosphate of lime and
phosphate of ammonia and magnesia. 
AMORPHOUS URINARY  SEDIMENTS.              253
  Triple.  1. uric acid and  both phosphates; 2. urate of ammonia and  both phos-
phates ; 3, oxalate of lime, with uric acid or urate of ammonia and phosphates;  4.
carbonate  of lime, with phosphate of lime and iron.
  Quadruple. 1. uric acid, with oxalate of lime and  phosphates;  2. uric acid, with
urate of ammonia, silica, and a phosphate.
  Quintuple.  Uric acid, with urate of ammonia, oxalate of lime, and phosphates.
                      [Amorphous Urinary Sediments.

   The deposits from the urine, either as mere sediments without form, or in a state
 of crystallization, as gravel, are of so great importance, both as regards themselves,
 and in reference to  the production of stone, that I have taken the liberty of supply-
 ing the deficiency of the special consideration of the subject of urinary sediments
 in  Chelius's  work, by the following  extracts from the  excellent work of Dr.
 Prout.
   " Lithic or Uric Acid Sediments.  These sediments assume at different times very
 different appearances, especially in point of colour; and they occur at different times,
 and in different persons, of almost every shade of colour, from  nearly perfectly
 white to deep mahogany brownish  red.  * * *  I  shall  consider them under three
 heads only, which  will be found quite sufficient for all practical purposes, namely:
first, yellow sediment; second, red or lateritious sediments; and third, pink sedi-
 ments.
   " 1.  Yellow  Sediments. These sediments vary in colour, from  nearly white to the
 wood-brown of Werner, a colour which is stated  to be identical with that of ripe
 hazel  nuts.  They  consist essentially of the  lithate (urate) of ammonia,  tinged
 with the  colouring  principle of the  urine,  but  usually contain more or less
 of the phosphates, and sometimes a little  of the lithate (urate) of soda.  In general,
 perhaps, the nearer they approach to  white, the more of the phosphates they contain;
 but there are many exceptions to this, and I  have seen sediments belonging to this
 class almost perfectly white, and consisting of nearly pure lithate (urate) of ammonia.
 This class of sediments may be termed the sediments of  health, if the term may be
 allowed, being such as are produced in  the urine of healthy or slightly dyspeptic
 individuals,  by errors of diet  and all  the other circumstances  before mentioned
 which seem, independently of actual fever, to procure turbid urine.  Perhaps there is no
 healthy individual whose urine does not occasionally deposit this species of sediment.
 * * *  When  these sediments are of an unusually pale colour, as is sometimes the
 case, a tendency to the phosphates is indicated.  Children are very subject to this
 form of sediment; and in them, as well as in all who labour under  such a suscepti-
 bility, it is frequently the forerunner of gravel or calculus.   Indeed  nothing is more
 common than for this form of sediment to alternate in the urine  of  the same person
 with the crystallized sediment ox gravel, to be presently described.
   " 2.  Red or Lateritious Sediments.  These sediments vary in tint from nearly white,
 in which state they are with difficulty distinguisheoVfrom the last variety, to a deep
 brick-red or brown.  They consist essentially of the lithate (urate) of ammonia, or
 lithate  (urate)  of soda, tinged with a large proportion of the colouring principle of
 the urine,  and  more or  less of the purpurates of ammonia and soda.  Sometimes,
 also they contain a  small proportion of the earthy phosphates.t In  general, the deeper
 the tint, and the more approaching to brick red, the more of the  lithate (urate) and
 purpurate of soda they contain ;  but there are some exceptions to this observation.
 When the purpurates exist in the urine, (indicating, as was formerly attempted to
 be shown, the  secretion by the kidney of nitric acid,) feverish, or inflammatory ac-
 tion, is almost constantly indicated; and this law is so general, that I have never seen
 a decided  exception.  * * *  They owe their  peculiarity of tint to the colouring
 matter of the urine, which, in common with all its other principles,  appears on such
 occasions to be secreted more copiously than usual.  Hence urine  which  deposits
 these sediments is usually of a deep red or brown colour, and of high  specific gravity.
 The deeper the  colour of the  sediment, and the more  approaching  to red, the
 more severe in general the symptoms.  * * *  The  urine of all  persons labour-
 ing under  feverish  and inflammatory affections  and whose  urine  is  naturally
 healthy, is liable to deposit this species of sediment.  * * *  There are certain 
254             AMORPHOUS  URINARY  SEDIMENTS.
diseases, also, in which this variety of sediment  appears  to  occur in a greater de-
gree, and in a more decided form than usual;  such are gout, also rheumatism, he-
patic affections, &c.
  " 3.  Pink Sediments. The third and most rare variety of amorphous sediments is
what is usually denominated pink sediments, the colour of which is very aptly ex-
pressed by the term pink.  Like the other varieties, they consist essentially of the
lithate  (urate) of ammonia ; but they differ from both these, in  being almost entire-
ly devoid of the yellow tint derived from the colouring matter of the urine; and con-
sequently, in owing their colour chiefly to the purpurate of ammonia.  This class of
sediments, therefore appears to indicate the absence of the large proportion of the
colouring principle of  the urine, so constantly present in active inflammatory fever,
and to  denote  the secretion of a greater quantity of nitric  acid,  and the consequent
formation of more of the  purpurate of ammonia. * * * The most perfeet specimens
of this kind of  sediment which I have ever seen, were obtained from the urine of
dropsical individuals :  they occur also occasionally in the  urine  of the hectic, and of
those obviously labouring under eertain chronic visceral affections, especially of the
liver."   (p. 121-25.)
  "Besides these amorphous sediments, consisting  chiefly  of lithic (uric) acid, I
have seen two or three instances in which large quantities of perfectly white lithate
(urate) of soda were deposited from the urine.  In one ease, in particular, the
quantity was immense, and voided not only  mixed with the  urine, but in a state of
consistency like mortar, especially during the night, so as to produce considerable
difficulty in passing the urine.   The urine was acid."  (pp. 127, 28.)
  Phosphatic sediments.  " The phosphates, like the lithates,  (urates,)" says Prout,
"appear in the urine under two distinct forms, viz., in an amorphous state, and in
the crystallized form;  but here  the  analogy ceases, for in the  ease of the lithates,
(urates,) the amorphous form is of comparatively the least consequence, whereas
when the phosphates are concerned, the amorphous sediment is by far the most im-
portant, and the crystallized form is usually of a  much milder character."  On this
account Prout considers "the crystallized form, in the first place, as a preliminary
step to the more formidable disease."  (p. 174.)  It will be more convenient, how-
ever, for our present purpose, to  reverse his arrangement, and  first to notice  the
amorphous phosphatic sediments.  " These sediments consist invariably," says Prout,
" of a mixture of the phosphate of lime, and of the triple phosphate  of magnesia and
ammonia.—[Note.—I am aware that it is the opinion of  many eminent characters,
that the inner coat of the bladder is the source of the earthy matters deposited by the
urine on these occasions.  I do not deny this altogether;  but, on  the contrary, think
that the  posphate of lime, at least, is sometimes derived from this source—the inner
coat of the bladder apparently assuming, in such instances, the character of the inner
surface of the abscess sometimes found in the prostate gland, which  is known to secrete
this earthy salt in great abundance.   I am doubtful, however, if  any portion of the
triple phosphate is  ever derived from this source, but from  the  kidney only, from
which same souree, in various cases, a large proportion of the  phosphate of lime is
likewise undoubtedly derived.]—The proportions of the  two salts vary very much
in different instances ;  but, sometimes, the phosphate of lime seems to constitute by
far the greater proportion, and, in this case, the symptoms are commonly much more
decided and severe; and it is to this form of the disease that  the following observa-
tions are to be understood as chiefly applicable.  A deposition of the earthy phosphates
from the urine has been long observed to be attended  by very distressing symptoms,
though no one  seems to have  hitherto generalized  them.   They  consist in great
irritability of  the system, and derangement of the chylopoietic viscera in general;
such as flatulency and nausea, obstinate costiveness, or peculiarly debilitating diar-
rhoea, or both  frequently alternating; and the  stools are extremely  unnatural, being
either  nearly black, or clay-eoloured, or sometimes like yeast.   These are  always
accompanied by more  or less of a sensation of pain, uneasiness, or weakness, in the
back and loins.   There is a sallow, haggard expression of countenance; and as the
disease proceeds, symptoms somewhat analogous to  those of diabetes begin to ap-
pear, such as  great  languor and  depression of spirits, coldness of the legs, complete
anaphrodisia, and other symptoms of extreme  debility: and the disease, if not
speedily checked, seems capable of ending fatally.   The urine in this  form of dis-
ease is invariably pale-coloured, and, upon  the  whole, voided in  greater quantity
than natural.   Sometimes (generally, I think, by day) it  is  voided in very profuse 
GRAVEL.                             255
abundance, and, in this case, is of very low specific gravity;  1 *001 or 1 '002, for
example.   At other times, it is voided in less quantity, and its  specific  gravity is
proportionally higher;  but  it is  seldom very high, that is, surpassing 1 '025.  In
the former case it is generally perfectly pellucid, and colourless, and  deposits no
sediment;  in  the latter, it is sometimes  opaque when passed,  and always, after
standing for a greater or less time, deposits a most copious precipitate of the mixed
phosphates, in the state of an impalpable powder.  In all cases the urine is extremely
prone to decomposition, becomes alkaline by the evolution of ammonia, and  emits a
most disgusting smell.
  With respect to the causes of this complaint, they may be either general or local;
for the most part, however, they seem  to partake of both characters.  A large pro-
portion  of those cases which have come under my own observation, has been dis-
tinctly traced  to some  injury of the back.   This injury has  been of a character not
very capable of being understood or described ;  but perhaps some idea of it  may be
acquired by my stating, that for the most part it has arisen from a fall from a horse,
in which the person  has received  a violent general concussion of the spine, and often
at the same time some  local injury about  the back, but not of such a nature as to
confine  him long, or to lead him to think that he has received  any material injury;
and generally it has  been quite forgotten till the patient's attention has been called
to the subject.   Among the general  exciting causes may be also mentioned severe
and  protracted debilitating  passions, excessive fatigue, &c.  The local causes are
generally some irritation about the  bladder, or  urethra, especially when operating
constantly for a considerable length of time ;  as, for example, any foreign substance
introduced into the bladder, and producing irritation of that organ, including  all sorts
of calculi under certain circumstances; the retaining of a bougie or catheter in the
urethra; strictures of the urethra  in some rare cases, and in particular constitutions;
all which, and many other similar causes, are capable of producing, in a greater or
less degree, a condition of the urine more or less resembling that above described,
and readily depositing the  phosphates.   Thus  it has been long known that  any
foreign substance introduced into the bladder almost invariably  becomes incrusted
with the phosphates, and not the  lithic (uric) acid.  With respect to the proximate
cause of this form of disease, we may suppose  it to consist in  a  diminished or sus-
pended action of the  usual acidifying powers of the kidneys, and the formation,
instead of lithic (uric) acid, of a greater quantity of alkaline matter than natural, as
urea, (equivalent to ammonia,) and particularly of magnesia and lime; but this being
little more than a simple expression of obvious facts, of course  throws no light upon
the immediate cause of these depraved actions." (p. 177-82.)
   " Oxalate of lime very rarely, if ever, appears alone under the form  of an amor-
phous  sediment.  In  some  instances, it  occurs  with the lithic (uric) amorphous
sediments; but even this is not very common." (p. 153.)
   Cystic oxide.  Prout had  the opportunity of examining the urine of a man  of thirty
 years old, who had passed a stone of pure cystic oxide.  He found it had  "a yel-
 lowish green  colour, and strong peculiar smell.   It very  faintly reddened litmus
 paper, and its specific gravity was 1,022.  There was a slight deposition on standing
 for some time, consisting of a mixture of the cystic oxide with a little of the triple
 phosphate.  A considerable proportion of the cystic oxide was precipitated from the
 urine on the addition of acetic acid, which of course held at the same time the phos-
 phates  in solution." (p. 167.)
   The  treatment of  these several kinds of  sediment will be considered in speaking
 of the treatment of the  various kinds of gravel.]
                              I.—OF  GRAVEL.

         (Sabulum, Arena, Lat.;  Gries,  Germ.; Gravelle, ou Gravier, Fr.)

   2009. The term gravel is applied to-sand, or small crystallized stones,
of different colour, form, and number, which are  voided  with the urine.
It consists usually of uric acid, or urate of ammonia, when it is reddish;
or of oxalate of lime, when  it has a dark blackish  green;  or  of phosphate 
256                     GRAVEL—SYMPTOMS.
of ammonia and magnesia, where it is whitish ; or of cystic oxide, when
it has a bright yellow colour.
   Crystalline deposits, of different kinds, are never met with, at the same time, in
the same urine, although, not unfrequently, accompanied with formless and dust-like
sediment (a).
   Magendie (b) notices a peculiar kind of gravel, in which the sediment of the
urine consists sometimes of a small quantity of white powder, with a great number
of small hairs, the length of which varies from two lines to an inch and more ; some-
times it is whitish, irregular, and of so little consistence, that it may be crushed be-
tween the fingers, without the fragments, which are connected by the  little hairs,
being separated; but they remain hanging together in a sort of cluster.  These hairs
can be separated only by maceration.  Magendie calls this hairy gravel (gravelle .
pileuse,•) it consists of phosphate of lime, and some magnesia, and uric acid.
   Gueranger (c), speaks  of a gravel composed of silica.
   In reference to xanthic oxide gravel, see par. 1998.
   2010.  The symptoms of gravel are very various; sometimes it causes
little or no inconvenience; often only in  making water: frequently it  is
accompanied  with pain  or weight in the loins ; the kidneys, ureters, blad-
der, and urethra may be,  however,  severely irritated; and suppression of
urine, inflammation, and fever, may result from it.  In most  cases it  is
accompanied  with  disturbance  of  the digestive organs,  acidity of the
stomach, flatulence, and the like.   Patients  labouring under this disease
frequently complain of heat and dryness in the throat and gullet, and are
therefore  constantly hawking  and  spitting.   The complaint  is often
accompanied  with  organic disease  of the  kidneys,  or of the  urinary
passages.  The  general health  and appearance will often remain good
for a long while  with deposits of uric  acid (1):  but phosphatic gravel  is
always accompanied with symptoms of increased  sensibility and irrita-
bility, general weakness,  disturbed  digestion, and  unhealthy pale coun-
tenance.  In  phosphatic gravel, the  urine is most generally pale, after
standing some time a glistening film is formed on its surface, which con-
sists chiefly of phosphates ;  little crystals often  attach themselves to the
vessel.   The  specific  gravity of the  urine is often very much altered;
and it very readily becomes putrid (2).
   [(1)  "This form of sediment (crystallized uric acid) varies  considerably," says
Prout,  " in its colour and appearance, according to circumstances.  When unaccom-
panied by fever, its colour is alwdys identical with the deeper tints of that of the first
(yellow) class of amorphous sediments before described.   When it is accompanied
by fever, it is generally more or less of. a red  or lateritious colour.  I  have never
seen this form of sediment of a pink colour, and, for obvious reasons, it is not likely
that such an occurrence should take place.  Sometimes large quantities of impure
or imperfectly crystallized  lithic (uric) acid is voided by old people in the shape of
globules, varying in size from a pin's head to that of small peas : these are generally
pale-coloured.   Occasionally,  also,  when  the  kidney  is diseased, large  irregular
masses of this acid, in an impure state, are voided.  * * *  Children, in general, and
particularly the children of dyspeptic and gouty individuals, or who inherit a ten-
dency to urinary diseases, are exceedingly liable to lithic acid deposits in the urine
* * * If the child be attended to, there  will be found to be a frequent desire to pass
urine, which is  voided in very small quantities, and with manifest uneasiness.   The
irritation about  the urinary organs also frequently induces the  child to wet the bed
by night, &c.   *  *  *  Between the age of puberty and forty, there is, generally
speaking, less disposition to the formation of lithic (uric) acid deposits than at any
other period of  life. * *  *   About the age  of forty, an  important change com-
monly takes place in the constitution, which for the most part materially influences
     (a) Prout, above cited, p. 85.        (6) Revue Medicale, 1826.  vol. iv. p. 140.
               (c) Journal de Chimie Medicale, vol. vi. p. 129.  1830. 
CONSTITUENTS OF GRAVEL.       ,            257
the disposition of lithic acid in the urine.  It willbe generally now observed that
the lithic acid is apt to be deposited at intervals in larger quantities than usual, and
that for some time previously to  this occurrence, there is  more or less of feverish
indisposition and derangement of the general health : about this period of life, also,
there is a disposition in the constitution, at the above periods particularly, to separate
the lithic (uric) acid in a concrete state, thus giving origin to the formation of renal
calculus. * * * Frequently about the age of sixty or seventy, another change takes
place in the mode in which the lithic acid is separated from the  system.  At this
period  of life the  urinary organs not only begin to participate in the general decay of
the constitution, but are apt to be deranged in a particular manner from other causes,
and more particularly to suffer from the delinquencies  of early life.  Frequently,
also, they become organically diseased, and this circumstance, in conjunction per-
haps with others  that will be noticed hereafter, produces a disposition in the system
to secrete neutral urine, or even the earthy phosphates.  Under these circumstances,
where  the  urine  had previously for years deposited the lithic (uric) acid chiefly in
the state of crystals, these will in a great measure disappear, and instead of them,
impure or imperfect lithic  acid, in the  shape of minute globules of various sizes,
will be separated from the kidneys in great abundance.  In most of these cases,
there is a good deal of pain in the back, and irritation about the urinary organs, even
when the concretions are only of small size.   In others, there is much less irritation
under these circumstances than one could imagine.  In all instances, however, this
may be considered as a most dangerous state of disease, not only from the constant
liability of the patient to the formation of renal or vesical calculi, which all other cir-
cumstances likewise conspire to render probable.  But, on the other hand, from the
danger there is of suddenly checking the secretion of lithic (uric) acid, which is
sometimes followed by great  derangement of the general health, and apoplexy."
(p. 130-35.)
   (2)  " Crystallized sediments, composed of the phosphates, almost invariably con-
sist," says Prout, "of the triple  phosphate  of magnesia and ammonia, and exist in
the form of perfectly white shining crystals.— [Note.—I have  said almost invariably ,■
for, if I am not mistaken, I have once or twice seen a crystallized compound of the
triple phosphate  of  magnesia and  ammonia, and the phosphate  of  lime.   These
crystals  were much larger 1han  those of the triple phosphate, and less distinctly
formed.]—This form  of  disease  sometimes occurs  alone,  but very frequently it
alternates, or is accompanied by the pale-coloured lithic (uric) amorphous sediments,
or the amorphous variety of phosphatic sediment."  When the  triple phosphate of
magnesia and ammonia "abounds very  much, the crystallized deposit  is formed
before  the urine is discharged from  the bladder, and consequently immediately sub-
sides to the bottom of the vessel in which it is passed ; in this case, the urine is
alkaline when voided: most generally, however, the  crystals do not  begin to form
till the urine has become cool and sometimes not till it has begun to putrify: and
these circumstances indicating the periods when the urine becomes alkaline, may be
considered as pointing out  the degree of severity of the disease. * * *  It may be
also remarked that children are more subject to this form of deposit than adults; a
circumstance perhaps  to be referred to the irritability of the system at this age,
and the great derangement of the digestive organs to which  they are  subject."
(p. 174-77.)
   Oxalate of Lime.   "Its  appearance is still more rare," says Prout, "under the
form of crystallized gravel," than under that of an amorphous sediment.  "I have
only seen one instance of this, and am able to refer to one more.   Brande  states,
also, that in this diathesis there is little or no sand  or gravel voided."  (p. 153.)
   Although oxalate of lime can scarcely  be said to form gravel, yet  it  is very fre-
quently deposited from the  urine in the form of small flattened octohedral-shaped
crystals.  Indeed, as far as my own observation goes, there are very few cases of
habitual disorder of the digestive  functions, in which  this salt cannot.be detected in
the urine, either alone, or as is most commonly the case, accompanied by uric acid
and urate of ammonia.  Persons  in whom this, diathesis prevails are usually of a
spare habit, with a pale countenance, and  have more or less nervousness of manner
about them.   They  usually complain of a feeling of languor, and disinclination to
mental or bodily exertion, pain in the loins, and  uneasiness and weight, if not of
pain, in the region of the stomach, particularly after eating; palpitation of the heart,
and a capricious, sometimes  an inordinate, appetite, although a small quantity of 
258                      URIC ACID GRAVEL,
food produces oppression with nausea.  In general they suffer from acidity of the
stomach, and are subject to itching and tingling of the skin, boils, and cutaneous
eruptions, particularly of the scaly kind.  Their urine is generally acid when first
passed, and perfectly bright; on cooling, it becomes more or less turbid, from the
deposit of urate of ammonia, with crystals of uric acid and oxalate of lime.   Some-
times no deposit of urate of ammonia occurs, the urine remains perfectly clear; but
crystals of oxalate of lime  are to be found entangled in the mucus of the bladder,
which has subsided to the bottom of the vessel.
  In order to detect this salt in the urine,  it is merely necessary to allow the urine
to stand for some hours, to pour off the greater portion of the fluid, and to place a
few drops of the remaining liquid on a glass plate beneath the  microscope, using a
power of about 200 linear.  The oxalate of lime will then, if present, be observed in
the  form of very regularly shaped highly flattened octohedra.  If the drop of urine
be allowed to evaporate  to dryness, the crystals will appear as squares, with a dark
square  in  the centre, the  sides of which face the angles of  the outer squares,
       somewhat resembling this diagram.  When-much urate of ammonia is present,
       it is well to add some boiling water to the deposit, which dissolves the whole
       of that salt, and allows the oxalate to be distinctly observed.
  The  causes producing this diathesis, independent of the use*of food containing
oxalic  acid, as rhubarb  tarts and sorrel, are those habits which are calculated to
diminish the vital energy, and the powers of assimilation, and of these severe mental
study,  or anxiety, or inordinate venery, appear to me to be the most common. The
treatment must be guided by general principles; an entire change of habits, change
of air,  and a vigorous diet, consisting almost  exclusively of meat and  bread, with
the avoidance of sugar in every form, are the most important circumstances to be
attended to.
  The nitro-muriatic acid, which has been much recommended, causes certainly in
many cases, the oxalate of lime to disappear from the urine, and frequently substi-
tutes that of uric acid.  Its use cannot, however, be long persisted in, and without
attention to the above rules, it has no permanent advantage.—t. t.]
   2011.  As to the aetiology of gravel and its various kinds, all that has
been already said generally applies, and therefore its indica' ions determine
the treatment.  Its object must be to prevent the increased production of
the acid, or the formation of a new one, and to encourage the removal of
the gravel already formed.   If the gravel cause violent  pain, difficulty in
making water, fever, and the like, these  must be got rid of by blood-let-
ting, leeches,  cupping  on the loins, lukewarm  baths, fomentations by
calomel with antimony and opium, or hyoscyamus, by the introduction of
the catheter, and so  forth, according to the different state of the patient,
and the violence of the symptoms.   If there be suspicion of any  accom-
panying  local disease in  the  kidneys after the inflammatory symptoms
have been soothed, a large galbanutn plaster, an issue, or a seton  in the
loins may be  useful.
   2012.  In uric  acid gravel, the excessive production  of  the uric acid
must be prevented, and the excessive acidification  of the urine by other
acids must  be guarded against.   The patient  must keep to a strict diet,
 both as regards the quantity  and quality of his food; all substances con-
taining much  azote, especially salted and dried meats, acid fruits, thin
soups, wine, especially that which  is acid, and bad beer must be most
carefully avoided.   The proper action of the skin must  be attended to by
 wearing flannel next the body, and regular relief from the  bowels by
 proper exercise, and avoidance of mental excitement.   It must be sought
to  neutralize the  acid by the use of alkalies, carbonate of soda, of potash,
 of magnesia.   These partly neutralize the acids in  the  alimentary canal,
 and  in the juices, by which the ever-continuing decomposition of  the
 urate of  ammonia is got  rid of, and partly by the passing over of  the 
TREATMENT OF.
259
alkalies into the urine, the  solution of the gravel is effected.   The car-
bonate of soda  and  potash  must  be given dissolved in water, and the
dose gradually  increased.   Frequently during their  continued  use, the
digestion is disturbed, which renders their suspension  necessary.   Car-
bonate of magnesia  is given either in  powder or mucilaginous fluids; it
is less effective, but more easily borne.  According to Prout (a), if these
remedies  are to be really efficacious, they must not be given  alone, but
combined with  alteratives and purgatives.   A pill of calomel and  anti-
mony should be given at night, and a solution of Rochelle salts and car-
bonate  of soda  in bitter drink  next  morning.    Through the  day  this
mixture should be taken twice or thrice, or a little magnesia in a glass of
soda  water.  This  treatment must be  continued  for a  certain  time,
according to the severity and obstinacy of the symptoms, and the altera-
tive pills given at more distant intervals, with a corresponding diminution
of the  doses of  the other  medicines.   If violent  irritation  also  exist,
opium, or hyoscyamus, which is still better, must be employed.   Hydro-
 cyanic  acid may be given with advantage in flatulence and acidity of the
stomach;  and, if  there  be  gouty complication,  the  vinum seminum col-
 chici.   This treatment must, however, be modified according to the cir-
 cumstances of the case.  The easier discharge of the gravel  is promoted
 by drinking much water, or any diuretic  mineral water, as that of Vichy,
 Wildungen, Sellers, Carlsbad, and the like.
    Wetzlar (6) proposes for uric acid  gravel a solution of borax, as it dissolves the
 uric acid with great readiness, and  perhaps acts less injuriously  on  the digestive
 organs than alkalies.
    The peculiar property of vegetable acids, combined with alkalies, being converted
 in animal bodies into carbonic  acid, and as such to pass into the  urine, led to the
 proposal of employing them instead of carbonic acid, as they are more easily borne
 than it, and allow of greater variety.   Most vegetable alkalies can  be used for a
 length of  time, and in large quantity,  without disturbing the digestion, and are not
 unpleasant to take, as the supertartrate, tartrate, and borate of potash, Seignette salts,
 acetate  and citrate of potash and soda; cherries, strawberries, and different kinds of
 fruits (c).
    According to Jones, the question of the treatment of the uric acid  diathesis depends
  upon which way the greatest oxygenation can be produced upon the uric acid in the
  body.  This appears  to be attainable, first, by the large addition of oxygen, as by
  exercise, cold air; by medicine, as carbonic-acidized waters and iron; second, by the
  diminution of the other substances on which the oxygen acts more easily than on the
  uric  acid, that  is those bodies which consist of hydrogen, carbon, and oxygen, by
  their exclusion from the food, and their removal by purging and sweating remedies ;
  third, by retaining in solution all the uric acid formed, by means of water and
  alkalies.
     Upon the effect of vegetable diet on the diminution of uric acid, compare Liebig
  npon the composition of the  urine (d).   Wilson Philip (e), on  the contrary, has
  come to the conclusion, after a number of experiments, that a diet  for the most part
  animal diminishes the deposit of uric acid, and increases that of the phosphates.
     [" Different doses of the alkaline remedies will be required," says Brodie, " in
  different instances.  Indeed a  good dealof care is generally necessary to adjust the
  dose to the peculiar circumstances of the  individual case.  If you give too  little of
   the alkali, the result is not obtained, and the lithic  acid is deposited, although in
   smaller quantity.   If you give too much,  you not only prevent the formation of the
   red sand, but you render the  urine alkaline and a white sand (the triple-phosphate
   of ammonia and magnesia) is deposited in its place.  Other ill consequences follow

          fa) Above cited, p. 78.                    (c) Woehler, p. 315.
          {b) Above cited, p. 78.                    (d) Above cited, p. 193.
                       (e) Medical Transactions, vol. vi. p. 212. 
260                       URIC ACID GRAVEL,
 the too liberal exhibition of alkalies.  They alter the  quality of the blood.  After
 some time the patient is liable to petechiae; he perspires too easily; becomes low-
 spirited, and less capable than when in health  of physical exertion.  Magnesia does
 not produce these effects  at any rate,  not to ihe same extent, as no more of it can
 enter into the constitution than what is  rendered soluble by its combination with acid
 in the stomach.   Too large doses of magnesia, however, are mischievous in another
 way, by causing  the formation  of magnesian calculi in the intestines.   These are
 composed of magnesia mechanically blended with the faeces and intestinal mucus.
 They are not uncommon in these times, when  so many individuals are in the habit
 of taking  magnesia in a careless and profuse manner.   I have, in several instances,
 known a person to suffer a good deal of distress from such a calculus being lodged in
 the rectum.   But cases have occurred, in which the accumulation of magnesia in the
 intestine has taken place to a very great extent.  Mr. Wilson examined the body of
 a patient,  in whom, if I recollect rightly, many pounds of magnesia were found col-
 lected in the colon, above a contracted part of the rectum.   In the exhibition of alka-
 line remedies, then, you must make each case the subject of a distinct  experiment.
 *  * * You should be provided with paper coloured blue by an infusion  of litmus,
 and also with the same paper, slightly  reddened by immersion in a very weak acid.
 Healthy urine ought to turn the blue litmus paper  red ; and you should avoid giving
 alkaline remedies in such  a dose  as to destroy this  property altogether; still less
 ought you to render the urine alkaline.  If the urine turns the paper blue, the patient
 is in danger of suffering from a deposition of the phosphates and the alkalies must
 be given in smaller quantity."—(pp.  202, 203.)]
   The following are the excellent remarks of Prout on "the treatment to be adopted
 in  what is usually denominated a fit of the gravel.
   " A Fit of the Gravel consists in the secretion of a large portion of lithic (uric) acid
 by the kidr\ey, under the circumstances above-mentioned, and is usually  preceded,
 as well as  accompanied, by much constitutional  derangement, with tendency to fever
 and inflammation.   The principles of the treatment to be adopted in this form of the
 disease closely resemble those recommended in  gravel, except that they must  be
 more active.  When the attack is acute, venesection  or cupping from the region of
 the kidney, with active doses of calomel and  antimonial  powder (or omitting the
 latter, if nausea be present, and substituting opium or hyoscyamus) should be imme-
 diately had recourse to, and precede the use of diuretic remedies.   [Note.—I have seen
 great mischief done  by the incautious use of stimulating diuretics at the  commence-
 ment of the attack.  The sufferings of the patient have been all aggravated, and his
 life has been placed in extreme danger.]—When these have begun to operate  sen-
 sibly upon the system, though, perhaps, before  the purgatives have produced actual
 stools, the patient may have recourse  to warm fomentations about  the region of the
 kidneys—or, what is much better, the warm bath, and commence the  use  of the
 diuretic purgatives formerly mentioned, with the addition  of colchicum.- and these
 means, if judiciously and vigorously applied, seldom fail of removing the inflamma-
 tory spasmodic action of the kidney, and of producing a flow of urine.  If the attack
 has been taken in time, the formation of a calculus in the kidney will thus be cer-
 tainly prevented;  or, at least, what is formed will be very small, and scarcely ever
 fail to be brought away without producing those distressing symptoms which usually
 accompany the descent of a calculus down  the ureter.  It need scarcely bp men-
 tioned, that a strict antiphlogistic regimen is to be adopted; and that the  collateral
 and subsequent  treatment  must  be regulated  by the  symptoms present."   (pp.
 151, 52.)
  Jones, speaking of the treatment of the uric acid diathesis, in correspondence with
 Liebig's views, observes, that "exercise which produces perspiration  is  the most
 beneficial;  and this  the more so, the colder the air is, because thereby a greater
 amount of oxygen is absorbed ;" but it should be taken, "always stopping short of
 great fatigue, which  might depress the vital powers, so as  to admit of the produc-
 tion of an excess of uric acid."  * * * Sleep, tending as it does to  render the respi-
 rations as light and as few as possible, should be indulged  in only as far as is ne-
 cessary to repair the fatigue which exercise has produced.   Hot rooms  should be
 avoided.  * * * Nitrous oxide water,  known also as oxygenated water, is the best
diluent in these complaints.  Soda water very  rarely  contains any alkali, but con-
 sists of ordinary water with carbonic acid forced into it; so that, except for the quan-
tity of water, it is in no way beneficial; and in this  respect it is not so  good as 
TREATMENT  OF.
261
ordinary fountain water, inasmuch as the atmospheric air suspended in the latter is
better lhan the carbonic acid in the former. * * * By the various preparations of iron
we may also increase the amount of red particles in the blood, and thus influence the
quantity of  oxygen which  is absorbed.  Perhaps  the greatest practical benefit has
been derived from the sesquioxide of iron."  It should " not be given in the enor-
mous doses recommended, by which  the whole intestinal canal becomes loaded; but
in moderate doses, and in  such a state as we know  offers the least impediment to
its absorption; that is, in the minutest state of subdivision.   To effect this, it should
be given newly  precipitated from some soluble salt of iron; as, for example, from
the sesquichloride or persulphate of iron, from which hydrated peroxide of iron may
be formed by the addition of carbonate of ammonia or soda." (p. 34-6.)
   "With regard to the treatment by diminishing the non-nitrogenous  principles in
the blood," Jones observes:—" It has been shown  that the substances which contain
no nitrogen, by combining with the oxygen which  has been inspired, hinder the ac-
tion on  the uric acid ; and it is highly probable, that no albumen undergoes  meta;
morphosis until  it has served the purposes of life.  These are the first principles  by
which the practice must be governed; and hence, by far the most beneficial diet is a
moderate quantity of meat, with a much smaller quantity of bread.   The kind and
quantities of both must be regulated by experiment and consideration of  the habit
and exercise of the patient. The quantity of starch  in flour, as compared with ani-
mal food, renders it unsuitable to live only on bread.   Meat alone would be far
more beneficial. * * * Sugar and  starch comprehend much the largest part of those
substances in vegetables which can be absorbed;  nitrogenous and oleaginous sub-
stances  are present generally in small quantities, though the relative amount of these
principles varies much  in  different species.  Thus  potatoes and rice are  those  in
which most starch is found, and  these  are therefore most inadmissible; whilst  in
greens  and peas there  is  much  nitrogenous matter, which in  peas is similar  to
cheese.  Fruits usually contain large quantities of starch and  sugar; on this account,
apples and pears are most objectionable. * * * Among non-nitrogenous substances
fat must be included.  If the formula for .this is taken, as C 11, H 10, O, then 31
equivalents of oxygen are required, in order to convert this  into carbonic acid and
water;  and by taking this substance as food, so much oxygen  is prevented from
acting on the uric acid.  Butter is only the  fatty particles of milk, separated from
the albuminous and  watery parts; this must on no account  be taken in excess.
Gelatine may be used as a partial substitute for meat; but as  the albuminous tissues
cannot be formed from it, it cannot be entirely substituted for it without the  strength
failing.
   "For drink the oxygenated water has been mentioned as best; then water which
has been distilled, and therefore contains no substances whatever in solution, and
on this  account it is, generally speaking, the best solvent;  that is, it can hold more
in solution, and  remove more from the body than another water which, when drunk,
already contains  substances dissolved in it.  But this  cannot be procured every
where,  and, therefore, it is  desirable  to point out  how the best drinking water can
be obtained."   Filtering, or boiling water, or getting rid  of the  free carbonic acid
gas by adding a little more lime, according to Reid's plan, are inefficient, and neither
of the latter "causes any other salts of lime which rnay be dissolved in the  water to
be precipitated.   To effect this, a few grains of carbonate of potash or soda should
be added to the  water before boiling, and the boiling should be continued for some
minutes.   By this means these salts  of lime will be decomposed, and sulphate of
potash and soda, or chloride of potassium and sodium, in very small  quantities, will
exist in the water after it has been filtered, or the chalky sediment has been allowed
to settle to the  bottom.   Good fountain water or soda water are far better than beer
and wine, which are objectionable for the spirit and sugar which they contain.  The
spirit is a substance which may be represented by C 4, H  6, O, and the sugar by
C 12, H 14, 0 14, the first requiring 12 equivalents  of oxygen, and the last 24,  to
convert them into carbonic acid and water.   The excess of sugar and acid in home-
made wines renders  them more injurious than foreign wines or spirits, of which o-in
and whisky most certainly also retard oxygenation, yet, by producing an excess°of
water in the urine, they cause  that deposit which arises  from the want of action of
the oxygen to be dissolved, and thus the evil which they and other substances occa-
sion is for a time concealed, (p. 37-41.)
   " We can also diminish these non-nitrogenous bodies in the blood by aperients
   Vol. hi.—23 
262
CYSTIC  OXIDE GRAVEL,
which act on the liver.  These will be found more particularly useful when the de-
posit is dark-coloured; indeed, the deeper the colour the less action there is of the
liver.  *  * *  Of such medicines calomel, aloes, colchicum, and colocynth are bene-
ficial, both in large and purgative doses, and  also when given in such a way as to
increase the secretion of the liver.  Hence the efficacy of blue pill as an alterative.
* * * The use of these medicines as purgatives must be judged of by their effects
and the strength of the patient.  * * *  Sudorifics are occasionally given with great
advantage. * * *  With regard to baths generally their action may be considered to
be on the nerves and on the blood, and on each the action is of two kinds;  thus on
the nerves there may be a  stimulant or sedative action, and on the blood they are
capable of removing substances  from it, and of enabling them to be absorbed into it.
These modes of action depend on the state of the system, the temperature, and the
substances which are dissolved in the bath. (pp. 41, ii.)
  "The next point in the treatment that must be attended to is to keep all the uric
acid in the ultimate textures in  solution.  This  may perhaps be effected by water
and alkalies.  When these or  their  carbonates  are given, they should be taken at
least an  hour before  food in order that they may not interfere with digestion;  but
though these medicines may relieve the complaint, they never can cure it. * * * I
believe these medicines are the least necessary part of the treatment I have laid
down, and it would be well for all to try what may be effected by diet and exercise,
before they resort to alkalies, which may in some cases, perhaps, be the cause of an
increase in the quantity of uric acid.   This appears to be the opinion of Pelouze, in
his last report." (p. 45.)]

   2013. Gravel which is formed of cystic oxide requires the same treat-
ment as  uric  acid, especially in  reference  to  dietetics (1).   In oxalate
of lime gravel  all  vegetable food  should be  withheld,  according to
Magendie, but  according to Prout the treatment must agree  with that
for uric acid  gravel.   After what has been already said (par. 1993) of
the origin of gravel  from oxalate  of lime, both  modes of treatment may
be proper (2.)   In phosphate of lime gravel the increased constitutional
irritability in  general, and that of the urinary organs in  particular,  must
be diminished by opium, by hyoscyamus, and  the like, in  combination
with tonic remedies.  At the same time acids, especially the hydrochloric,
must be used, and if that cannot  be borne, citric or carbonic acid.   Much
drinking, which is  usually recommended  to favour  the  solution of the
phosphates,  is in reality hurtful,  and increases the already too great irri-
tability of  the kidneys and bladder.  In  the  use  of acids, however, it
must be remembered that if the patient use more than is  necessary for
neutralizing the alkaline condition  of the urine, and for dissolving the
earthy salts which are deposited, the white  gravel indeed disappears, but,
in its stead, uric acid gravel is formed from the  precipitation of the uric
acid, in consequence of the acid state of the urine.   The bowels should
be kept open with gentle, but not saline medicines ; the living should be
strictly attended to: the patient  should take easily digestible meat, light
puddings, which seem  more proper than the use of vegetables, and food
destitute of azote, although, according to Magendie and  Chevreuil,
the phosphates  are  diminished  in the urine of camivora  by such diet.
If any organic  disease of the  urinary  passages or  of the spinal mar-
row accompany phosphatic  gravel,  a proper  treatment  should be had
recourse to.
   [(1) With Tegard to the medical treatment of the sediment from cystic oxide,
Prout observes, that it " will depend on circumstances.  In the first place, great
care should be paid to the digestive functions, and if the urine be acid, the alkalies
maybe taken with advantage ;  on the contrary, if alkaline, the muriatic acid, indeed
the latter, if the irritation present would  permit it, might, perhaps, in all cases be 
TREATMENT  OF.                         263
employed advantageously, not only with the view of retaining the cystic oxide  in
solution, but of inducing the lithic (uric) acid diathesis.  From the diseased state of
the kidney, also, with which this  diathesis  seems to be so frequently associated,
local counter-stimuli will be likely  to be serviceable." (p. 169.)
  (2) "The absence of urinary sediment, &c." in the oxalate of lime  diathesis, says
Prout, " are  of a negative character, and lead to no inference where other circum-
stances are wanting, as is most  generally the case.   But if there be pain in the
region of the kidney, and  other symptoms  of gravel, without  any  appearance of
sediment, and  if the urine  be acid and of the yellow tinge above alluded to, the
stomach deranged, and an inflammatory diathesis, either general or local (i. e. about
the urinary organs,) be present, and if all these are associated with suppressed gout,
or tendency to cutaneous disease, the existence of this form of the disease may be
suspected, and means immediately taken to counteract  it.   Besides the  general
principles of treatment above mentioned, I  have lately adopted another  principle,
very different indeed from  these, but which I  think I  have seen of considerable
utility in two or three instances.   This has been to endeavour to change the diathesis
from  that of the oxalate of  lime  to ihe lithic acid.  It struck me that, as these two
diatheses never appear to exist at the same time, if the former could be  converted into
the latter, that a very obscure disease would thus at least be exchanged for one of a
more open  character.   The muriatic (hydrochloric) acid was chosen to  effect this
purpose, (though in some instances it is probable that the  vegetable acids would
answer as well,) and  its use was continued till  the lithic (uric) acid began to be
deposited plentifully on the cooling of the urine.   The muriatic (hydrochloric) acid
is sometimes apt at first to derange the stomach, but notwithstanding this,  in the few
instances in which I have  had  an opportunity  of adopting  this plan,  it has been
always ultimately followed with very considerable relief to the patient's sufferings,
both  constitutional and local. *  *  * It need scarcely be mentioned that this plan of
treatment requires some judgment and care  in its management, and  that it should
hardly in any case be adopted when disorganization or calculus is already supposed
 to  exist in the kidney or bladder, or perhaps in  very young or very old  subjects."
(p. 160-62.)
   " In the oxalic acid diathesis," observes Jones, "the oxydizing process is carried
a step further than it is when the uric acid  diathesis exists; but  it is still stopped
short of the extent to which it is  carried in the state of health. *  * * It is possible
that sugar and perhaps other substances  of the non-nitrogenous class, may, by im-
perfectly  combining  with  oxygen  in the body,  give rise to oxalic acid  ; still  the
oxygen has evidently  a much stronger affinity for the non-nitrogenous than for  the
nitrogenous substances in the body, and thus the process of oxydation is far  more
frequently incomplete in the latter than  in  the  former;  so  that we should expect
oxalic acid  generally to arise from the insufficient oxidation of the uric  acid, and
much more, rarely from sugar ; and  the alternation of this substance with uric acid in
calculi, and the ease with which  it  is formed from uric acid,  leads to the belief that
this is the usual origin of oxalic  acid.  The free oxalic acid passing  off by the
kidneys, meeting with the phosphate of lime, which is secreted both by them and
by the mucous membrane  of the urinary passages, decomposes  it, and   oxalate of
lime  is the result.  The same thing happens when oxalic acid is taken, as such, in
the food; if free, like tartaric acid, it passes  off at the kidneys, and combines with
the lime which it afterwards meets with.   If taken  in combination  with alkalies,
like tartaric  acid, it would  probably be decomposed.  The causes,  then, of this
disease are  in most cases similar to the causes of the uric acid diathesis ,- both dis-
eases may be referred to insufficient oxidation, and the treatment must consequently
be the same in both." (p. 71-3.)
   " It is highly probable that an excess of lime in the system may induce  the forma-
tion of oxalic acid, but some lime is necessary for the bones and the membranes,
and it is taken into the system in all solid and liquid food.  Now, though it  is im-
possible to obtain food absolutely  free from it, and thus  to  hinder all formation of
fresh oxalate of lime, still by rendering it as free as possible, the rapid increase of a
calculus may be prevented.   Perhaps of all substances, water is the easiest to render
pure, and it is that which usually contains most lime.  On this account, in the oxalic
acid diathesis, distilled water should always  be used  in every thing for which com-
mon water  is  employed in the state of health.   When  distilled water  cannot  be
obtained  rain water would be the best substitute; and when this is not  to be had, 
 264             CYSTIC OXIDE GRAVEL, TREATMENT OF.

 then that which has been purified as  already mentioned.  *' *  * This treatment is
 merely palliative, and the curative treatment must be directed to the oxalic acid and
 not to the lime."  (p. 74.)
   (3)  "The principles of treatment in both  forms  of the phosphatic deposit are,"
 says Prout, " the same, and  differ only in  degree.  The particular  indications of
 cure seem to be to diminish the unnatural  irritability of the system,  and to restore
 the state of the general health, and particularly of the urinary organs,  by  tonics, and
 other appropriate remedies.  In severe affections,  especially of the amorphous class,
 opium, as far as my experience has hitherto extended,  is  the only remedy that can
 be employed with much advantage to fulfil  the first  indication.   This  must be given
 in large and repeated doses, such as from gr. i. to gr. v., or more, two  or three times
 a day.  Under this plan the more distressing symptoms will commonly be speedily
 relieved ; and  now,  in conjunction with opium, (in  more moderate doses  if the state
 of the disease  will permit,) the mineral acids, cinchona, uva ursi,  different prepara-
 tions of iron and other tonics may be had recourse to; or if the  mineral acid should
 disagree, the citric acid may be taken instead.   There may be also  applied  to the
 region of the loins, a large pitch, soap, or galbanum  plaster, which frequently seems
 to afford considerable relief to the  distressing pain  there felt;  or  if the  symptoms
 are unusually  severe, and connected with  manifest local  injury, setons,  or issues,
 may be instituted in  the back. * * * rJ he bowels are most frequently constipated ;
 but purgatives of the more active class must  be given with caution.   Saline purga-
 tives, more especially those containing a vegetable  acid, as the Rochelle salts, the
 Seidlitz powders, &c, must be avoided, and recourse had to small doses of castor oil
 or laxative  injections.  Mercury, in all its  forms, and particularly when  pushed  so
 far as  to produce its specific effects on the constitution, seems  capable of doing a
 great deal of mischief,  when the phosphates  are  concerned, more especially in the
 severer forms  of the affection; and if from  other  causes it be  judged  proper  or
 necessary, as the least  of two  evils, to administer this remedy, its exhibition must
 be managed with caution, and its effects closely watched.  Perhaps the  best mode
 of exhibiting it in such cases is to combine it with  opium, or  with a purgative, in
 some instances.   I cannot help thinking, however, that  in very severe forms of the
 affection, its use had better be omitted altogether, till  the more distressing symp-
 toms have somewhat yielded, and the  patient has  recovered a little strength.  Alka-
 line remedies  of every description  must be  most  carefully avoided, their use, in
 every point of view, being most mischievous, when the phosphates are concerned.
 Indeed, all  remedies that act as diureties, should, in general, be shunned, and the
 patient should  be prohibited from  drinking too much.  With  respect to drinks  in
 general, they should  be of a soothing demulcent  character, and  prepared  with dis-
 tilled or the softest water that can be procured, as  hard waters are literally poison in
 this form of disease.   In less severe  cases, where the  source of irritation is chiefly
 confined to the urinary organs, and where the constitution is sound, and the strength
 not remarkably reduced,  similar means may  be had recourse to: though opium, to
 the  above extent, is seldom necessary or  proper.  In  such cases, the hyoscyamus
 is an excellent remedy, especially when combined with the extract of uva  ursi; and
 more or less, according to circumstances, of the  extr. opii ; the same  is true of the
 alchemilla arvensis, a strong infusion of which taken frequently, sometimes gives
 great relief.  In such cases, also,  occasional purgatives, especially of the milder
 class, may be employed with safety and advantage,  (p. 182-86.)
   " The diet in severe cases should be of the  mildest and most  nutritious  kind, and
 taken in very moderate quantities at a time.   From what I have  seen I am certainly
 inclined to advise an  animal diet in preference to an acescent vegetable  diet, com-
 monly recommended ; but I wish it to  be understood that no positive directions  are
 given on this point;  *  * * for I am disposed to believe, that in all instances, that
 diet is  most proper for a patient, which agrees best  with  him, and which, in many
 instances oan be only known by actual  trial; I may give it,  however, as my opinion,
 that all watery  diet, as soups, &c, should be taken very moderately.   If the patient
 has been accustomed to wine, the Rhine or  some of  the lighter  varieties of French
wines will be preferable.   Cider and perry  may be  also taken,  if they do not disa-
 gree.  I wish it to be understood, however, that the  use of these is not particularly
 recommended.  But these and  every thing else that can  be  done  for a patient in this
 state, are of very little use, if the mind  cannot  be set  at rest.   The influence of men-
tal anxiety is really astonishing in this disease; and absence from care, the exhila- 
STONE IN THE KIDNEYS.
265
rating air of the country, and such exercises as are consistent with the patient's con-
dition, will, perhaps, more  than any thing else, contribute to the cure, particularly
in the slighter cases, and when the cause is not local injury." (pp. 186, 87.)  Jones
observes that, in the palliative treatment of these complaints, "the first object must
be to cause the phosphates  to be retained in solution:  this is effected by rendering
the urine acid, which  is most easily done  by any vegetable  acid, as tartaric, citric,
acetic acids.   It was found by the experiments of Woehler on men and dogs, that
if any of these acids are taken in a free state, that is not in combination with an al-
kali, they pass through the blood unchanged, and  appear as acids in the urine.  Why
they should not be  oxidized, as they are when in combination with alkalies, is  at
present unknown. *  *  * The dose of these acids  should be  gradually increased
till the urine becomes again acid to test  paper, when  great care must be taken not to
render it so much so as to cause precipitation of  uric acid.  * * * It has also been
found, by experiment (a), that the strong mineral acids possess no power to render
the urine acid ; probably their strong affinity for the soda in the blood causes it  to
leave  its combination  with the albumen ; and thereby salts of soda would be formed,
and the acids would pass off by the kidneys as neutral salts. * * * Our chief at-
tention must be directed to the removal, if possible, of the cause of the alkalescence
which constitutes the  curative treatment; this may be most beneficially joined with
palliative measures.   If the alkalescence arises from the altered mucus thrown out
by an inflamed bladder, when the inflammation is  cured, the  acidity will return,
the deposit cease.  If the irritation  of a  stone causes the  secretion of  mucus  or
hinders  the emptying of the bladder,  the stone must be  removed.   If the  alka-
lescence proceeds from weakness, it is only by restoring the  general health that
the urine will permanently regain its  natural condition; though for a  time, and
for a  time  only, much evil may be hindered by the use of vegetable acids."  (p.
86-8.)
                  II.—OF STONE IN  THE  KIDNEYS.

          (Calculus Renalis, Lat.; Nierenstein, Germ.; Calcul Renal, Fr.)

  Hevin, Recherches historiques et critiques sur la Nephrotomie; inMem.def'Acad.
de Chirurgie, vol.  iii. p. 238.
  Troja, Ueber die Crankheiten der Nieren und der ubrigen Harnorgane.  Leipzig,
1788.
  Combaire, J. N., Dissertat. sur l'Extirpation des Reins.  Paris, 1804.  4to.
  Earle, Henry,  On Renal Calculi; in Med.-Chir. Trans., vol. xi. p. 211-18.
   2014. In the  calices  and pelvis of the kidney, stones  may be formed
of  different shape  and  nature, singly, crowded together, or as one very
large mass, distending the cavities of the organ, in which case the sub-
stance  of the kidney is diminished by absorption.    The chemical nature
of  renal stones varies; they  most frequently, however, are composed of
uric acid.
  [In rare cases, a stone in the kidney, if very large, may be felt through the loins.
A case of this kind occurred to the elder Cline, who would have operated had the
patient's health permitted (by
  Prout accounts for the formation of uric acid stones in the kidney in the follow-
ing way:—" The kidney is made up of a congeries of similar parts, or little kid-
neys, if we may use the expression, each one of which is independent of the others in
its structure, and may therefore, probably, independently of the others, become more
or less deranged in its functions.  Let us suppose  one or more of these little kid-
neys similarly deranged to the others, but in a greater degree, so as to secrete very
little water, but a large proportion  of lithic  (uric) acid.   In such a case, the
lithic (uric) acid must be obviously separated  in  that peculiar semifluid condition,

  (a) Berzelius's Handbook, p. 467.          (b) A. Cooper's Lectures, vol. ii. p. 222.
                                    23* 
 266             STONE  IN THE KIDNEYS, DIAGNOSIS

 or state of hydrate, which it is well known to be readily capable of assumrog.  In
 this state it is bulky, and may thus occupy the whole of the infundibulum in which
 it has been deposited ; or the quantity may be supposed to be sometimes so great as
 to be partly protruded, in a  similar state, into the common receptacle or pelvis of the
 kidney.   After remaining in this state for a greater or less time, crystallization may
 be supposed  to take place ;  the  semifluid  mass will now be much diminished in
 bulk, and perhaps reduced  to the form of  a congeries of crystals  easily separable
 from one  another, and thus  pass off in the form of gravel; or what may easily be
 supposed to take place, (especially when the  lithic aeid is very impure, and com-
 bined with a larger portion of  the other matters  than usual,) it  may assume the
 form of an imperfectly crystallized or amorphous mass, and thus constitute a nu-
 cleus possessing these characters: or something between the two extremes may take
 place—the plastic mass may separate partly into crystals, and partly remain an
 amorphous mass, enveloping these erystals; in which ease, a mixed kind of nucleus
 will be formed." (pp. 207, 208.)
  Brodie (a) observes, that uric acid stones oecur "most frequently in those who
 have led luxurious and indolent lives; and  who previously have been subject to de-
 posits of lithate of ammonia, or of lithic aeid sand, in the urine.  It is  this class of
 individuals that is especially liable to gout, and  there is an evident connexion be-
 tween these two  diseases.   A patient may have been in the habit of voiding lithic
 (uric) acid calculi ; he becomes affected with the gout, and the formation of the cal-
 culi ceases.   In a few cases the two diseases go on together.  Some persons void a
 great number of this kind of lithic acid calculi. I am almost afraid to say how many
 I have known to be voided by one individual—probably some hundreds, of all varieties
 of size."  (pp. 224,25.)
  "I have had fewer  opportunities of examining renal calculi composed  of oxa-
 late of lime," says Prout, " from their being comparatively more rare.  Sometimes
 they are formed on a primary nucleus of lithic (uric) acid.   In one or two  instances,
 I have seen them contain in their centre an  irregular cavity, formed apparently by
 the agglutination of several imperfectly globular-shaped plastic masses round a sub-
 stance which had subsequently been entirely remo ved,or had disappeared by drying; the
 whole being  afterwards surrounded by concentric laminae of the same substance. It
 may, perhaps, appear difficult to conceive  how a substance so insoluble as  oxalate
 of lime can exist in a plastic state, or form  a calculus at all;  since, in our hands this
 salt occurs only in the  state of a powder, and seems incapable of concreting or as-
 suming the crystallized form. Perhaps the circumstance may admit of an explana-
 tion, by supposing that a solution of oxalic acid, nearly in a saturated state, and in
 union with a little lime, is  secreted by a portion of one of the kidneys,  instead of
 the  lithic (uric) acid in  the former  case;  that this, enveloped in  the usual  ani-
 mal  matters,  passes from the infundibulum  into the pelvis of the kidney,  and there
 meeting with the lime naturally contained  in  the  urine seereted by the other parts
 of the kidney, instantly combines with it, and forms the compound in question; and
 that from the peculiar manner in which it is formed, and the abundance of animal
 matters present, it may be able to exist for some time at the temperature of the hu-
 man, body in  a plastic semifluid state, before the whole concretes into a solid mass.
 Whether  this supposition be admitted or not, which is a matter of no importance,
 the  facts are certain, that oxalate of lime not only does sometimes exist as an amor-
phous mass in renal calculi,  but occasionally in the form of crystals  also ;  a circum-
stance still more difficult to  explain, except on some such supposition as the above."
 (pp. 209, 210.)
  Brodie also observes :—" Calculi of oxalate of lime are much more rare than those
of lithic (uric) acid.  It is   not merely that the disposition to form them exists in
fewer individuals, bat that where it does exist they are not generated in  the same
number as the lithic (uric) acid calculi.   A patient may void one of these calculi, and
never void another, or he may void a second after the lapse of many years.   In one
instance, however, in examining  a body after death, I  discovered as many as five
or six in one  kidney : extensive  suppuration and complete  disorganization  of the
glandular structure of the kidney ; and this local  disease was  the immediate cause
of death." (p. 225.)
(a) Above cited. 
AND TREATMENT.
267
  "Calculi of cystic oxide," Prout states, "are extremely rare.   From what has
been already quoted on this subject, there is  reason to conclude that they generally
originate in the kidneys.  I have only had an opportunity of examining two speci-
mens of this species of calculi, with reference to their primary nuclei; in one of these
the nucleus consisted of a small triangular amorphous mass, apparently of the same
matter as the rest of the calculus, though a little deeper coloured.  In the  other, no
distinct nucleus could be discovered." (p. 210.)
  The rarity of  renal stones  composed of the  phosphates, Prout considers as  de-
pending "on various circumstances.  In the first place, this form of the disease is
seldom original, but  consequent to others; and the  system appears to  be affected
generally,  rather than the kidney locally, as in the other forms of the disease.  In
the second place, the large flow of urine, and the consequent hurried state of action
to which the kidneys are necessarily subject, may be justly considered as unfavour-
able  to the formation of renal calculi.  In some instances, however, as before stated,
calculi composed of the phosphates are actually formed in the kidney; but in every
instance of this description, the particulars of which I can trace, it has occurred only
in very severe and  obstinate cases  of the phosphatic diathesis." (p. 211.)

   2015.  The diagnosis of renal stones is for  the  most part doubtful, as
the  symptoms which  they produce are very  various.   Sometimes they
cause  no pain; often (he  patient feels an oppressive, dull, straining pain
in the region of  the kidney, which sometimes ceases and then recurs, is
diminished  by rest,  and  increased by jolting movements of the body.
With pointed, angular stones,  the pain  is severe and tearing,  extending
towards  the groins and testicles.  Not  unfrequently inflammation of the
kidneys occurs with all its symptoms.   The  urine is  often mixed with
blood, mucus, pus, and sand.
   ["Sometimes,"  says Brodie, "calculus in the kidney  may be  said  to cause no
inconvenience at all, so that  calculi are found in the kidney after death, the exist-
ence of which had never been suspected during the patient's lifetime.   In other
cases,  the patient  complains  of pain in the loins,  and  the urine is occasionally
tinged  with  blood, especially after any jolting exercise, such  as  riding on horse-
back."  (p. 233.)
   Astlev Cooper  observes, that "the presence of a stone in the kidney is some-
times manifested by extreme irritability of the bladder,"  of which he mentions an
instance, in a male, that had existed for a great length of time without being relieved
by treatment.  After death, "no disease of the bladder or urethra was found, but a
large stone was discovered in the kidney." (p. 221.)  Brodie relates a similar ex-
ample in a female, but in this case, "the urine deposited  what  appeared at first to
be a muco-purulent secretion, but afterwards had all the characters of true pus, like
that from an abscess."   After two  or three years,  symptoms  of a stone passing
through the ureter came on; a large stone was voided by the urethra, and the origi-
nal symptoms were relieved, (p. 68.)]
   2016. Stone in the kidney is a tedious and painful disease.   If only
one kidney be affected, there is less danger to life  than if stone  exist  in
both kidneys.   If inflammation of  the  kidneys arise, it may cause death
by its severity, and by the complete  suppression of the urine, or it may
go on to  suppuration, and the pus may be discharged either by the ureter,
or it may form a fluctuating tumour in the loins.

   ["In the majority of cases," says Brodie, "a calculus of the kidney finds its way
into  the bladder soon after its first formation;  but  in other cases it remains for a
considerable time in the kidney, being at last dislodged by some accidental circum-
stance;" of which  he mentions a  good  example, of a gentleman  whose urine had
been occasionally tinged with blood; having been overturned in a carriage, he soon
after found himself unable to make water, but after some straining, a renal calculus
which seemed to have the form of one of the infundibula of the  kidney, was pro-
jected with no small degree of force, and the urine flowed in a full stream " (n
233.)                                                                   ^' 
268          STONE  IN  THE  KIDNEYS;  TREATMENT.
  Instances of abscesses in the loins, by which stones from the kidney have been
either extracted or discharged, are mentioned by Hevin (a), and Astley Cooper,
in whose patient they were  composed of the ammonia-magnesian  phosphate (b).
Brodie also mentions the case of a woman who had abscess in the loin, which after
death was found communicating with a large collection of irregular-shaped stones
in the kidney (c).
  A stone remaining in the kidney may be snapped in two by the person making
use of any unaccustomed exertion, of which my friend Crisp has mentioned to me
the  following example:—A medical man whilst jumping over a flower bed, dropped
down suddenly with intense pain in the loin, which continued for two or three hours.
He  died a few months after of heart disease and other lesions, and  on examination
of his body, a stone was found in the kidney of  irregular oblong form, which was
separated transversely into two nearly equal halves.—j. f. s.]
  2017.  The treatment, when the object is  the solution of the renal stone,
or the getting rid  of the disposition to lithogenesis, must be guided by the
rules already laid down {par. 2011-13.)   It is in general confined only
to lessening  the  symptoms, by blood-letting, mild  mucilaginous drinks,
antispasmodic remedies,  baths, rubbings and the like (1).
  The removal of the stone by cutting (Nephrotomia) can only be under-
taken,  when  an cedematous, or fluctuating  swelling, or  a  fistula  has
formed in  the loins.   Having opened  the abscess, its  bottom  must be
examined with the finger or the probe, and if a stone be met with it must
be  removed, after enlarging the wound, if it be too confined.   If there
be  a fistula leading down to a stone, it  must  be properly enlarged with
sponge tent  or with a bistoury.  If the stone be fixed, its extraction must
be postponed till it has become somewhat loose.  Oftentimes a superficial
suppurating cavity is found between the  muscles and the skin, from which
an  opening leads to the abscess in the kidney.   The wound, whether or
not  a stone be found, should be kept  open with wads of lint attached to
a thread, as  long  as stones  are formed  in the kidney, or  the  diseased
secretion exists in the urine (2).
  [(1) "If there be symptoms," says Brodie, "which lead you to suspect that a
stone is lodged in the kidney, it is of course desirable that it should be made, if
possible, to pass into the ureter, before it has attained such a size as to be incapa-
ble  of being conveyed along  the canal into the bladder.  Horse exercise, especially
hard trotting, in such a case  generally produces bloody urine.  This shows that the
calculus is made to undergo  some change of  position, and whatever produces this
effect, is, of course,  favourable to its escape from the kidney.—[With due respect
to this high authority, I should hesitate in advising horse exercise, or any other vio-
lent effort to excite change of place in the stone, for fear of setting up active inflam-
mation in  the kidney, already irritated by the pressure of stone, and which might
not  be very easily or certainly repressed.—j. f. s.]—It is reasonable  to suppose, that
medicines which occasion a more abundant flow of urine, combined with diluting
drinks, may also be useful under these circumstances.  Where a calculus retained
in the kidney produces considerable pain in the loins and neighbouring  parts, the
patient will sometimes derive benefit from local blood-letting, by  cupping, or by
leeches.   At other times the application of the belladonna plaster.  You may also
employ setons and issues in  the loins, as recommended by Earle (d).  According
to my experience,  however, the last-mentioned remedies are  seldom very useful,
except in those cases in which disease of the kidneys, and especially abscess of the
kidney, has taken place as a consequence of the lodgment of the  calculus.  That
they are sometimes eminently useful, under these last-named circumstances, I can-
not doubt." (p. 241.)
  "When the inflammation of the kidneys is supposed  to be  connected with  the
  (a) Mem. de l'Acad. de Chirurgie, vol. iii.    (c) Above cited, p. 69.
p. 266.                                  (d) Med.-Chir. Trans^ vol. xi. p. 211.
  (6) Lectures, vol. ii. p. 222. 
STONE  IN THE URETERS.                  269
presence of renal calculi," which is by far the most frequent occurrence, Prout re-
commends, "in connexion with general blood-letting or cupping (if necessary) and
the warm bath, calomel in active doses, which, when the constitution is otherwise
sound, may be employed with great advantage, especially if it be immediately fol-
lowed or accompanied by the use of hyoscyamus in pretty large doses, so  as to insure
the anti-spasmodic effects of the latter on the system;  and when the urine is  high-
coloured and acid, the purgative effects of the calomel may be increased or kept up
by the use of some of the diuretic purgatives, such as the neutral salts, and particu-
larly the tartarized soda. This  plan may be  pursued for a greater or  less  time,
according  to the circumstances  of the patient;  and will, in favourable cases, be
followed by the expulsion  of the  cakulus from  the  kidney, without  the severe
symptoms commonly accompanying its descent down the ureter." (pp. 219, 20.)
  (2) In connexion with the subject of stone in the kidney, the following observa-
tions of Brodie on what he considers to be
  Gouty Inflammation of the Kidney are worthy of particular notice.  "A class of
cases you will  occasionally  meet with," says he, "among the  affluent classes  of
society, the symptoms of which  bear no small  resemblance to those just described,
although they have a very different origin; and the diagnosis of which is of no small
importance in practice.  The persons  liable to be thus affected are those who lead
indolent lives, indulging themselves, at the  same time, in all the luxuries of the
table.   There is pain in the loins,  often very severe, extending downwards  to the
groin; the  urine is  scanty and high coloured, depositing, as  it cools, an abundant
red or yellow sediment (lithate of ammonia.)  So far the symptoms a  good deal
resemble those produced by  the passage of a calculus down the  ureter;  but the ab-
sence or pain in the testicle, of siekness and faintness, and the presence  of no  small
degree of symptomatic fever, enable you to distinguish  the two orders of cases from
each other.  The effect produced by the remedies will assist you  in your diagnosis.
The  symptoms which have  been just described  are  of a gouty origin, and  yield
almost immediately  to a free exhibition of colchicum ,• which, however, it is  gene-
rally more prudent not to administer until after the bowels have been emptied, by
the exhibition of some grains of calomel, followed by a  draught of infusion of senna
with  the sulphate of magnesia, or some other saline aperient." (p. 232.)]
                  III.—OF STONE IN THE  URETERS.

   (Calculus Uretericus, Lat.; Stein in den Harnleiter, Germ.;  Calculengage dans
                                Vurelere, Fr.)

   2018. When a stone descends from the kidney into  the ureter, more
or less violent symptoms arise, in proportion as the passage of the urine
through the ureter is completely or partially prevented.   Pain comes on
which  descends from the kidney to the pelvis, and the  patient often feels
distinctly the  gradual progress of the stone.   The ureter is often consi-
derable distended by the urine collected above the stone.  Symptoms of
stone in the kidney will also have been previously observed.  When the
stone escapes  from  the ureter into  the  bladder,  the  symptoms quickly
subside, and those of stone in the bladder arise (1).
   The  treatment is precisely similar to that for stone in the kidney, and
for ischuria ureterica (2).
  [(1) "The time occupied by the passage of the calculus along the ureters varies
in different cases," says Brodie (a), " according to the dimensions and figure of the
calculus, and the impulse which it receives from the current of urine behind  it.
Sometimes the calculus  may reach  the bladder almost immediately; at other times
it may be lodged in the ureter for many  hours, or even for  two or three days.
Where the passage of it is thus protracted, the parts to which the pain is sympathe-
(a) Lectures in London Med. Gaz., vol. viii. 
270
STONE IN THE  URETERS.
tically referred, become tender to the touch, and the testicle not  unfrequently is
actually inflamed and swollen, the inflammation of it continuing for some time after
the cause which produced it had ceased to operate.  *  *  * The pain is often very
severe, and in that case attended with sickness and vomiting, prostration of strength,
cold extremities, a feeble  pulse, and a pallid countenance; in short the patient is
what is commonly called in a state of collapse.   These symptoms are followed by
pain referred to the inside of the thighs and the testicle;  and frequently the testicle
is drawn upwards to the groin by a spasmodic contraction of the  cremaster muscle;
no relief is experienced until the  calculus has escaped from the lower orifice of the
ureter, and entered the bladder;  but  as soon as  this has happened, the patient's tor-
tures, for  they  truly deserve that  appellation, are at an end. (p. 66.)  It seldom
happens that the excretory duct of the kidney is completely obstructed, but when it
is so the necessary consequence is that the urine becomes accumulated in the infun-
dibula, and that these become dilated to a large  size, forming membranous cysts;
while the glandular structure of the  organ is expanded, and in a  great measure ab-
sorbed from the pressure which is  thus exercised  upon it.  In some cases, you find
at last the kidney converted into a large  membranous bag, on the surface of which
scarcely a vestige of the glandular structure is perceptible, while  the interior  of it is
composed of a  number of cells communicating with each  other, and all containing
urine." (p. 68.)
  "But a calculus (a) maybe of such size as  to be  stopped in  its passage to the
bladder, and  retained in the ureter.   One might suppose, that under these circum-
stances, the  ureter would  become more  and more dilated, and at last burst, as the
urethra bursts  behind  a stricture.  I cannot say this never happens;  and  indeed
Morgagni quotes a case from another writer, in which there is reason to believe that
such an event actually occurred.   However, this is not the constant order of events,
as the following case, which occurred to Brodie, will prove; a  person for several
years had been subject to  the formation of renal calculi, which were passed  by the
urethra.   At last, however, an  attack came on, no  stone passed, and he ceased to
void urine;  a catheter was passed, but no urine flowed ;  the patient became coma-
tose, and died ten or twelve days after."   In one  kidney there were several calculi;
there were none in the other.  In the latter and in the upper part of that canal, there
was a calculus, as it  were  wedged  in, of  about the size of a horse bean.  A patient
died also under Travers's care, with the same symptoms,  having each ureter where
it arises from  the pelvis of the kidney  completely obstructed by a calculus."  (pp.
241, 42.)
  Persons may also  die from suppuration occurring in the kidney, whilst its  escape
is prevented  by a stone blocking up  the  ureter.   A case of this  kind is related by
Astley Cooper (b)  as having occurred  to the elder  Cline; he  had operated on a
boy for stone in the bladder.  "The  boy had recovered from the operation, when he
was seized with rigors, great pain in  the course of the ureter, and  vomiting; a swell-
ing formed just above the seat of the caecum, in the right \\iac fossa, which gradually
increased, and the boy's constitution  quickly gave way.  On examination after death,
the pelvis of the kidney and the ureter were found  distended with matter; and at the
end of the ureter  near the  bladder, a  stone was discovered, which had prevented the
escape of the urine and matter into the bladder, and thus occasioned death." (p. 225.)
He mentions also the case of a woman who "had great  pain in her loins, and ten-
derness in her abdomen, with so much fever, that she did not live long. * * * Upon
making an incision  into the abdomen, there issued a strong urinous smell, and a
watery fluid  mixed with matter.   The intestines were inflamed  and adherent; the
bladder was  small;  one kidney was much enlarged, and  the other unaltered; the
ureter of the enlarged  kidney was greatly increased in size, and full of matter; it
was completely closed at the lower part  by a calculus, and  had given way above, so
as to allow of the escape of the urine and matter  into the abdomen." (p. 226.)  He
also relates one case in which a stone stopped  for some  time in the ureter, and the
latter having become adherent to the colon, ulceration ensued,  and the stone was
discharged by stool; and another where  "an abscess formed near the anterior supe-
rior spinous process  of the  ilium from which a calculus and a quantity of matter were
discharged, and the  patient recovered."   (p. 227.)
   (2)  As to treatment, Astley Cooper recommends large bleeding, warm bath,
(a) Lectures, at the head of this article.
(b) Lectures, vol. ii. 
STONE IN THE BLADDER.                    271
opium, liquor potassae, to allay irritation, and the abdomen to be fomented, and gently
rubbed from above downwards to  assist  mechanically the passage of the calculus.
(p. 227.)]
                  IV.—OF  STONE IN THE BLADDER.

     (Calculus Vesicalis, Lat.; Harnblasenstein, Germ.; Calcule Vesical, Fr.)

  2019.  Stone  in  the urinary bladder is  either primarily formed in the
kidney, and  enlarges in the  bladder,  or it  forms  in  the bladder, as in
incrustations  on foreign  bodies.   The variety  of  stone  in  the  urinary
bladder is very great, as regards shape,  size, number, and position ; and
on these, in part, depends the severity of the symptoms which it excites.

  [" Calculous disorders," observes Brodie, "prevail differently in different classes
of society, among individuals of different ages, and in different climates  and dis-
tricts.   Among the lower classes, children are much more liable to calculi than adult
persons.  You know how  large a  proportion of our hospital  patients admitted for
lithotomy are children.  On  the other hand, in private practice, that is, among the
upper classes of society, very few of our patients are children, and the great majo-
rity are persons above fifty years of  age.  Nor are these things of difficult  explana-
tion.   The great  majority of calculi are originally composed  of  lithic (uric) acid,
that is, have a lithic acid nucleus.  * * *  In all classes, persons of a middle age are
less  frequently affected by stone in the bladder  than those who are younger or
older." (p. 253.)
  These observations are confirmed  by the following analysis of three hundred and
fifty-four cases, between the ages of two and of seventy-nine years, which has been
given  by Smith,  of  Bristol (a), together with the results of the operation, which
was performed on all, seven only of the  number being females, of whom two were
under ten years, three between ten and twenty, one between twenty and thirty, and
one between thirty and forty.

                     Analysis of 354 Cases of Lithotomy.
" 135 from  2 years to 10; Cured, 106;  Died, 29, or one death in 4£
65	10	20	52	13	5
35	20	30	30	5	7
34	30	40	27	7	5
37	40	50	26	11	H
28	50	60	22	6	41
18	GO	70	11	7	n
2	70	79	1	1	2
354			275	79	H
  Smith estimates the number of stone-operations in the  provinces at 90;  in the
London hospitals, at 47; and in London private practice, at  30; making a total  of
167: in the whole of Scotland, at 12; in  Ireland, the same; and that, if we take
the whole in round numbers at 200, we shall have  the very extreme point of cal-
culous cases for our whole population.   He also notices the curious fact, that certain
districts abound  in cases ;  whilst, in others, the disease is scarcely known.   "Let
us instance Norfolk  and Hereford; and again, it is a surprising truth, that in the
hospital at Norwich alone, the numbers  are  as great as either in  all Ireland  or
Scotland." (p. 50-2.)  Whilst in the  County Hospital at Hereford  there had not
been a single stone-patient in the course of forty-five years.   Sailors  appear  to be
remarkably free from stone in the bladder, as  from A. Copland Hutchinson's (6)

  (q) A Statistical Inquiry  into the fre-    (b) On the Comparative  Infrequency  of
quency  of Stone  in the Bladder in Great  Urinary Calculi among Seafaring People;
Britain and Ireland;  in Med.-Chir. Trans.,  in Med-Chir. Trans., vol. ix.   1818.
vol. xi. p. 1. 1820. 
272
STONE IN  THE  BLADDER;
 account, only eight cases occurred in the course of fifteen years in the navy, during
 which period the average annual number of men in the service was 132,000.  And
 he asks two questions—-first, that it appearing "seamen, who have rarely oppor-
 tunities of indulging in the use of malt iiquors, are, in great measure, exempt from
 urinary concretions, whether all  kinds of fermented liquors be not favourable to
 the production and accretions of such disorders!" second, "may it not, therefore,
 happen, in the instance of seafaring men, that the peculiarities of their regimen, and
 especially the great quantities of muriate of soda they  habitually take with  their
 food,  contribute to produce this effect?" (p. 453.)]
   2020.  In regard  to the form  of  stone  in the  urinary bladder, what
 has been  already stated  in general  {par.  2005) applies here also.   In
 most cases, especially when   there is but a single stone, it is oval,  and
 somewhat flattened on both sides; its surface smooth, bossed, or angular,
 and often wish  facettes of various forms (1.)   Its size usually varies be-
 tween that of an  almond and  of a hen's egg;  it may, however, be much
 larger (2).   In general, there is only one stone in the  bladder; but,
 sometimes,  several, even as many  as a  hundred,  exist  at  the same
 time  (3).   In  such cases, the stones, as  already remarked, are,  in some
 places, smooth, ground  away, and  variously  formed,  by  lying  against
 each  other.  According  to  their  chemical  composition,  they  vary in
 reference to  their firmness,  colour,  and the like.   In most  instances,
 the stone  lies  loosely at the bottom  of the  bladder; but not unfre-
 quently it is attached at one  place,  which may occur in different ways.
 First. The stone sticks in the orifice of the  ureter, or, in escaping from
 the ureter, it  slips  between  the membranes  of  the bladder, and  en-
 larges, so  that  it lies  in a cavity of  its own, which communicates with
 the bladder itself by a roundish opening.   Second. It lies  in a diverticu-
 lum of the  bladder, or in a hernia of the bladder  (4.)   Third. In many
 persons the inner surface of  the  bladder has a peculiar net-like disposi-
 tion,  by which  fan-shaped  hollows are formed; and if  the  formation of
 a  stone begin  in one of these,  the  hollow  is gradually enlarged, and
 the stone  is, for  the  most part,  overspread by the internal coat of the
 bladder.   In proportion  as   the  stone increases, the  enclosing mem-
 brane stretches, so  that it is   connected to the  other part of the  bladder
 merely by  a neck (5).  Fourth.  Stones, which   form  in  the prostate
 gland, may partially project into  the  bladder.   Fifth. In consequence of
 the irritation of the stone, and the inflammation depending thereon, false
 membranes are  formed by the  exudation of plastic lymph, which partially
 cover the stone.
   Stones which are  enclosed and  held fast  in one of the above ways
 {Calculi saccati, Lat.; Umschlossenen und festgehallenen Steine,  Germ.;
 Calculs enchatonnes, Fr.,) must be distinguished from the so-called adhe-
 rent  stones, (Calculi adherentes,  Lat.; Angewachsenen Steine,  Germ.;
 Calculs adherens, Fr.,) a  term which can  only apply to those cases in
 which excrescences, fungus,  and polypi of the bladder become incrust-
 ed (a).
   [(1) In reference to  those stones occasionally mpt with, and which  being con-
 tracted in their middle, have somewhat the shape  of an hour-glass, Taylor (b) ob-
 serves:—"It has  been conjectured that in  such cases they have been partly lodged

  (a) Houstet, Observations sur les Pierres   —Deschamps, above cited, vol. i. p. 59-77.—
enskystees et adherentes  a la vessie;  in   Walther, above cited, p. 424.
Mem. de l'Acad. de Chirurgie, vol. i. p. 395.    (b) College Catalogue, part i. 
FORM  AND  SITUATION.
273
in the orifice of the ureter or in a pouch of the bladder, and that the growth of the
calculus has continued  unobstructed at the  two extremities, while it has been pre-
vented in the middle by the constriction of the orifice.  But the deposition of qrys-
tals, even on the constricted portion, seems scarcely consistent with this explanation,
unless it is conceived  that they were deposited after the calculus had escaped into
the cavity of the bladder." (p. 83.)
  (2) The size of stones is very variable.  The largest stone is, I believe, that from
Sir Walter Ogilvie, which is in the College  Museum H 2,  consisting of mixed
phosphates; it weighs  forty-four ounces, measures sixteen inches around its  long
axis, and fourteen around its short axis.  Its origin seems to have been traced to his
having received  a blow in his back from the boom of a vessel, when twenty-three
years of age;  in consequence of which it was necessary to draw off his water with
a catheter for  two months; and  for a twelvemonth after he was obliged to keep in
bed, in a horizontal posture; his bladder, however, recovered its powers.  Twenty
years after, symptoms  of stone having appeared, and sounding having led  to the
belief in the existence  of a large stone, the operation was advised, but not assented
to.   He continued to become worse, and towards  the latter end of his life he could
"make no water, without standing almost on his head, so as to  cause the upper part
of his bladder to become the lower, and this he was obliged to do frequently, some-
times every ten minutes, as the quantity voided each time was less than the measure
of a wine-glass.  At last, however, thirty years after the accident, he was so worn
out, he was determined to have the stone removed, which could now be felt above
the pubes, forming a large prominent tumour, and below it prevented the entrance of
a sound into the  bladder.  The operation was attempted  by Cline, but no kind of
forceps could  be introduced till a soft part of the stone having  been found, some of
it was broken away with the finger, and then  the forceps broke away more, till,
with  the aid  of the scoop,  about a  teacupful of fragments was removed; but the
greater part of the stone remaining hard and impenetrable, and Sir Walter being
much exhausted, the operation was given up: he died on the tenth day.   The stone
appeared moulded by the bladder; the lower part confined by the bony  pelvis,  with
its  impression, and  was smaller  than the upper part, which had  projected so as to
lie on the pubes (a).
   Of stones which  have been removed, Astley  Cooper mentions one in Trinity
College, Cambridge, which weighs thirty-two ounces and seven drams ;  a cast in
St. Thomas's  Museum  of one which weighed twenty-five ounces ; another of sixteen
ounces which he himself removed, but without success; one removed piecemeal, by
Mayo (b), of Winchester, weighing fourteen ounces and  two drams, and measur-
ing eight inches and a half in its smallest, and ten in its largest diameter; one in the
Museum of the Norfolk and  Norwich Hospital, of eight ounces.  The largest stone
removed successfully by Astley Cooper, weighed  near  six  ounces.   Smith (c)
mentions a cast in the Bristol Museum, of a stone which weighed ten ounces and a
half,  and  measured  nearly ten inches in circumference :  the  patient recovered in
eleven weeks.  In the  Museum of the College there is a stone, A c 7, composed of
three large uric acid stones, cemented together with mixed phosphates, which weighs
seventeen ounces: it was removed by  Cheselden, in St. Thomas's Hospital, from a
man fifty years of age, but he died the next day after the operation.
   As to the small size of stones, perhaps that of ten grains from  ± lad of thirteen
years, and  that of a few grains from a boy of sixteen, removed by Martineau (d),
may be considered among the smallest.
   (3) "The greatest number of  stones I ever extracted in the  operation of lithoto-
my," says Astley  Cooper, "was one hundred and forty-two,  many of them about
the size of marbles.  A great number of stones does  not add much to the patient's
danger in the operation ; for it is not the frequent introduction of the forceps, but the
violence which is used in extracting the stone or  stones which produces mischief;
thus the removal of one large stone, is more to be dreaded than that of many small."
(p. 233.)
  (4) In the Museum of the  College of Surgeons, there is a fusible stone which was
removed by Pott (e), from a  vesical rupture in  a boy of thirteen.  " When six

                     (a) Taylor's Catalogue, part i. p. 116-19.
  (b) Med.-Chir. Trans., vol. xi. p. 55.  1820.   (d)  Med.-Chir. Trans., vol. xi. p. 407.
  (c) Ibid., p. 15.                          (e) Chirurgical Works, vol. iii. p. 324.
     Vol. hi.—24 
274
STONE IN THE BLADDER ;
years old he was  seized with  an acute pain about the region of the pubes, which
lasted near an hour and a half, and suddenly ceasing he became easy.   During the
time his pain lasted he could not discharge a drop of water, though he  endeavoured
so to do, but as it ceased he pissed freely.  In a few days after a small tumour was
discovered, about the size of a pea, in the spermatic process just below the groin;
it gave the child no pain, and therefore no notice was taken of it."   When thirteen
years old it became troublesome from its weight, though he had never any pain in
his back and loins, and it was therefore  determined to remove it.  This was done
by a cut through the skin and cellular membrane, the whole length of the process and
scrotum, which exposed a firm white membranous bag or cyst, narrowing upwards,
and being followed was found " dependent from  and continuous with a membra-
nous duct, about the breadth of the largest wheatstraw, or what it was more like to,
a human ureter, which passed out from the abdomen through  the  opening in  the
muscle."   On  dividing this  duct, immediately above the  tumour, four ounces of
a clear fluid issued, and the mouth of the cyst expanding, presented a stone similar
to that found in the human  bladder.  To decide on the connexion of the cyst with
the bladder, the boy was after some time directed to make water, when a large stream
of urine flowed through the wound instead  of  by the urethra.   He recovered.  In
the preparation the stone is  enveloped in the cyst.
   (5) The case related by Brodie of " an elderly person, who for the most part suf-
fered little inconvenience from the disease,  but every now and then was suddenly
seized  with usual symptoms of stone and very  severe ones too," seems to be of this
kind, except, that it does not appear to have had   any neck, which  as far as I have
had opportunity of seeing is very rare.   He lived three or four years after the de-
tection of the disease, and  died of pleurisy.  " On examining the  body, I found,"
says Brodie, " the stone imbedded in a cyst near the fundus of the bladder.  The
cyst was formed in this case, not by the protrusion of the mucous membrane between
the muscular fibres, but by  a dilatation of both tunicles of the bladder, the muscu-
lar as well as the mucous.  It was such a receptacle as would be supposed a large
calculus which had long been resident in the bladder, might gradually have made for
itself.  The stone was  not so closely embraced  by the cyst as to prevent it occasion-
ally slipping out of it, and  I  suspect that this actually happened, and that it was
when the stone lay in the cyst, that the patient was free from the usual symptoms
of calculus, and that his sufferings took place when  the stone  escaped from it into
the general cavity of the bladder." (pp. 258, 59.)
   (6) Wickham (a) relates the case of a boy four years old, on whom he performed
the lateral operation, and met with some difficulty in extracting the  stone; " no un-
toward symptom occurred,  until  about the eighth day, when the water returned to
its accustomed  course, which  was attended  by  severe pain, the boy screaming very
loudly at  each  effort to make water.  This  continued till  the fourteenth day, the
wound having appeared foul and the surrounding parts inflamed for two or three days
previously, when a substance came away from the wound, having the following
appearance.  It is a cyst, apparently of the same structure as the bladder; its size is
sufficient to contain the calculus, which weighed two drams ; the opening into it is
just large enough to admit  of  its exit, and its whole  internal surface is lined with
calculus matter, in fact, studded with large pieces  of calculi. *  * * I have no hesi-
tation," says Wickham, " in pronouncing the substance voided by the  wound to be
a cyst, in which the stone was contained previous to the operation."  (p. 186.)  I
cannot agree with Wickham's conclusion on this point, as  he states (in describing
the operation) that "the stone being completely exposed, he passed in the forcep9
again, and took away the  calculus without  difficulty," though he had done nothing
more than dilating the gorget wound, which he thought had not been made sufficiently
large by a very slight effort with his finger.  I do not think the stone had been en-
cysted, not even by a false  membrane, as here described by Chelius,  but it seems
to me corresponding precisely to the following circumstances mentioned by Brodie:
—" It occasionally happens,  that coagulated  lymph is effused from the inflamed
mucous membrane  of the bladder.  The inflamed mucous membrane also secretes
the adhesive mucus which contains the phosphate  of lime.   A portion of the  phos-
phate of lime thus produced, mixed probably with some of the triple phosphate from
the urine, is deposited on the lymph, and thus the incrustation takes place.   It cor-
(a) London Medical Gazette, vol. iii.  1829. 
FORM AND  SITUATION.
275
responds exactly to the incrustation of the wound of the perinaeum, which occurs
aftsr lithotomy, where the operation is followed by the secretion of the same ropy
mucus from the bladder." (p. 260.)
  Brodie speaks of " a class of cases which, being of rare occurrence, do not seem,
in the present state of our knowledge to be of muchpractical importance," and quotes
from a letter of Heister (a), "the history of a patient who, having for a considerable
time, laboured  under the symptoms of stone in the bladder, began to void by the
urethra what had  all the appearance of portions of a larger calculus, broken down into
fragments of various  shapes and sizes.  The number of these fragments at last
amounted to more than two hundred, and now the discharge  ceased, the symptoms
at the same time having subsided, and the patient being restored to perfect health.
In this instance, the discharge of the fragments of the calculus was attributed to the
use of certain  mineral waters."   Prout mentions a case, in which, however, the
same happened without the patient using mineral waters or any kind of  medicine;
and Cross speaks of numerous fragments which he obtained from a gentleman after
a ride on horseback; as well also " of twenty-two calculi removed after death, from
a patient seventy  years of age, which are  of a very irregular shape, but admit of
being so arranged as to form four regular and well-shaped calculi, each of the size of
a pigeon's egg, which, with the appearance of the different surfaces, proves that the
calculi had broken in  the bladder by knocking against  each  other under certain
movements of the body.  The incrusted state of the fractured surfaces proves, that
the calculi were  broken  some time- before  the  death of the individual." (p. 10.)
Brodie, himself,  has also seen three cases of  the same kind ; in one, evident frag-
ments of a larger  calculus were voided by a young lady; in another, numerous small
calculi were voided next day after a journey, which  had  the appearance of having
been  recently broken, probably from the  concussion of them one against the other
during the journey; and a third, in which  after or whilst drinking some mineral
waters,  "he began to void with his urine broken pieces of calculi of various shapes
and sizes, but generally with one  concave surface, and rough irregular edges, as if
the various laminae of which the calculi were  composed had cracked, and then had
become separated from each other. After  some time a great number of these frag-
ments having come away,  the discharge of them ceased, the patient, being at the
same time, relieved from all the symptoms under which he had formerly laboured."
(p. 269-71.)
  In  the Museum at the Royal College of Surgeons there are  several examples of
similar broken stones.]

   2021. The symptoms of stone in  the bladder are very various.  In
general when the stomach is primarily formed in the kidney, there is more
or less  severe pain  in the kidney, and  running along the ureter.   This is
wanting of the  stone to be first formed  in the bladder itself, and especially
must not be considered as a certain and constant symptom.  The patients
have a  sensation of warmth  or painful tickling in the glans penis, and
they, therefore,  especially if  children, are  continually  pulling  the penis
about and drawing it away from the body.   These sensations show them-
selves  at the beginning  of the disease, but only when the patient exerts
himself violently, or the posture of his body is suddenly changed, or im-
mediately after passing the last drops of urine.   The orifice of the urethra
is inflamed, as  in a clap.   The call to  make water occurs very frequently,
and whilst the water flows, there is a burning pain at the tip of the glans.
The stream of urine is often suddenly  interrupted; the  most insufferable
pain, occurs with severe forcing,  and the urine  only again begins to flow
when the patient changes his posture,  lies ou his back or the like.   The
discharge of the last drop of urine is attended with the most violent pain,
as the bladder then contracts upon the stone.   The call to make water is
accompanied with frequent forcing at stool, and often to such degree  that
(a) Phil. Trans., vol. xxxvii. p. 13.  1731, 32. 
276
STONE IN THE BLADDER J
 the rectum protrudes, and frequently the hsemorrhoidal vessels swell from
 the irritation of the bowel.   The  same  also occurs in women, with the
 vagina, which in a long-continued state  of  irritation and inflammation,
 becomes  the seat of constant mucous discharge,  and  often protrudes.
 The  urine passed is  generally pale, limpid,  and has a peculiar offensive
 smell.  If the patient keep quiet, the symptoms are usually slighter; but
 they  increase on every movement, in walking, riding on horseback, or in
 a carriage, in which latter case the patient often feels as if a foreign body
 fell from  one part of the bladder  to another;  after violent  movements
 some drops of blood frequently flow from  the urethra.  The patient com-
 plains not unfrequently of a painful drawing up of  the testicles, accom-
 panied with  numbness along the inside of the thigh, sometimes running
 down even to the foot.  He also often feels  a tormenting violent pain in
 the sole of the foot, sometimes a slight sensation of numbness, or a trouble-
 some tickling.  As the irritation of the stone on the walls of the bladder
 continues, they are brought into a state of slow inflammation, the urine is
 mingled with much thick mucus;  the walls of the bladder become thick-
 ened, and contract around the stone, so that with diminished capacity,
 and inability of distention, the bladder can  no  longer retain the  urine
 within it, but discharges it every minute.   The inflammation may extend
 to the ureters and kidneys, and it  may eause ulceration and other kinds
 of destruction.  In consequence of these  symptoms, and  of the constant
 pain  which deprives  the  patient of rest  and sleep, the digestive organs
 are sympathetically affected, the powers  sink, and  are at last destroyed
 with  symptoms of hectic fever.
   2022.  These symptoms undergo various modifications according to the
 constitution of the patient, the nature of  the stone,  and the place where
 it is  situated.  The more sensitive the patient  is,  the less regular and
 quiet his  mode of living, the  greater are  his sufferings.   The larger the
 stone is,  the more severe are the symptoms.   With smooth stones, or
 with  such as are enveloped in a sac, the symptoms are less; but with a
 stone lying loose,  of an angular shape, or of  the mulberry kind,  they are
 more violent.  If the  stone be seated at the orifice of the  ureter or in the
 neck  of the bladder, the symptoms are more severe, and in the latter case
 it may hinder or prevent the discharge of urine ; it may, by irritating the
 openings  of the spermatic ducts, produce painful priapism and swelling
 of  the testicles.   A-  stone frequently causes no inconvenience if it  be
 fixed at any one part  of the bladder, and  the pain only comes on when,
 by any movement or exertion, it is brought into another place.  If a large
 stone be constantly at the bottom of the bladder, it may cause ulceration
 of it, and also  of the  corresponding wall of the rectum, and in this way
be discharged.   The  same also may happen in  women by ulceration of
the wall  of the vagina.   Instances have, however, occurred in which
 even  large stones  lying loose in the bladder have  been borne for many
years without having  produced any particular inconvenience.       •
  Each several kind of stone has its own peculiar symptoms (Prout.)  With uric
acid stones  they are generally less severe than with other kinds ; the urine is natural,
but a little  darker in colour; its specific gravity is greater than usual; on cooling,
it leaves a crystalline sediment mixed with mucus, which increases on any accidental
irritation; the  urine, at first turbid, becomes  clear  by standing.   With oxalate of
Ihne stones the symptoms are very violent, (I have, however, several times noticed 
SYMPTOMS.                           277
the reverse,) and the urine is clear, and deposits neither uric acid nor phosphates.
Stones composed of phosphates produce the most severe symptoms; the urine in
this case is quite characteristically curdy, turbid, specifically light, deposits much
phosphate  and mucus, sometimes is alkaline, putrid, stinking, and secreted in large
quantity, and the constitution generally suffers considerably.
   2023.  The  above-mentioned symptoms lead to the supposition merely
of the presence of a stone in the bladder; a certain knowledge of it can
only be obtained by examination with  a sound, by the distinct feel of a
hard  resistance, and by the metallic tinkling.   Examination {searching,
as it wTas  formerly, and sounding, as it is now generally called) even, can
in many cases give only a doubtful result, or none at all; for instance,
with  a  very small stone, such as  are  for the  most part  or completely
covered by the inner membrane  of the bladder, or by a false membrane,
or are enclosed in a diverticulum of the bladder.  As it  depends on the
size,  nature,  and  position of the stone, whether it  be touched by the
beak of  the sound  more readily or with difficulty,  so,  in making  the
examination, the bladder must be  gently felt all  round, and the patient
sounded  with his bladder full and empty, and in different  postures.   Ex-
amination  by introducing the finger into the rectum at  the same time,
may  make easy the finding of the stone; and a large stone which lies in
the bottom of the bladder may often be distinctly felt by the finger in this
way.
   Klein (a) observes that silver sounds, in very sensitive persons, often excite con-
siderable pain, and contraction of the bladder, which interferes with the examination
of the stone; whilst the iron sound, or even  an elastic catheter, causes neither pain
nor contraction, and easily finds the stone.
   [(1) Brodie says :—" In some cases a calculus which has not been discovered by
means of the sound is at  once detected by means of the elastic gum catheter.   This
is an observation made by Sir Everard Home, the correctness of which I have had
frequent opportunity of verifying.  The gum catheter should be introduced without
the iron stilette, while the patient is standing, with his bladder full of urine.  You
allow the  urine  to flow through the catheter, and, as the last portion of it comes
away, the calculus falls down on the extremity of the instrument, in withdrawing
which you feel it quite distinctly." (p. 277.)
   It may be well to observe, that if the patient's symptoms continue it will be right
to sound him again and again at proper intervals, as the  stone may increase  in size
or alter its position, so that at last, after repeated fruitless attempts  during many
months, it may be detected.  This I have known in more than one or two instances.
In rare cases, however, though a stone really exists, it cannot be found by the most
careful sound, which happened to the celebrated French surgeon, La Peyronie, in
whom the stone was only discovered after death.
   " There may be a stone," Brodie  observes, " without the usual symptoms, and
there may be many of the usual symptoms  without a stone  in  the bladder.   In
children especially, the disposition of lithic (uric) acid sand by the urine will not
unfrequently produce not only pain in the glans, but bloody urine, and all the other
symptoms of stone in the bladder."  And  he mentions  the case  of a boy who suf-
fered severely, but no stone could be found after repeated soundings   "I then
inquired more particularly," says he, " into the child's health in other respects, and
the result was,  that I was led to prescribe an occasional dose of calomel and rhubarb,
with  rhubarb and sal polychrestin  the intervals; and under this simple plan of treat-
ment all the symptoms disappeared in the course of a few weeks." (p. 275.)
   I  have  known a similar case as regards the symptoms in a child, of two and a
half years, who suffered  very severely;  a stone was believed to have been felt, and
he was cut, but no stone was found.  No violence was used, nor the bladder irritated
by continued use of the instruments ; but it being soon discovered that there was no

   (a) Praktische Ansichten der bedeutendsten Chirurgischen Operationen, part iii. p. 35
 Stuttgardt., 1819.
                                    24* 
278
STONE IN THE BLADDER ;
stone, he was put to bed, quickly recovered of the operation, and at the same time
lost all symptoms  of stone.
  A polypus in the bladder may sometimes, from its irritation, produce symptoms
of stone,  and, being struck  by the sound,  may lead to the operation.  There is a
case of this kind in the Museum at St. Thomas's; the patient recovered from the
operation, but died some time after, when the nature of the disease was ascertained.
■—J. F. S.] '
  2024. By sounding, information can, to  a certain degree, be obtained
of the size and other conditions of the stone.  If the stone be large, it is
always felt at the point of  the sound, whatever  direction be given to it;
if small, it  frequently slips  away, and is only felt  at  intervals; if it be
bossed,  the  sound  is often  caught.  Hard  stones give a  clear, and soft
ones  a  dull  sound ; but  in  reference to  this point the feel  is often very
deceitful.   When a stone does not lie loose in the bladder, but is lodged
in a sac, the sound, as  it  does not touch it directly,  gives a feel which
cannot decidedly distinguish between a stone and a  fungous growth of
other swelling on the inner surface of the bladder.
  Leroy d'Etoille (a) has invented an instrument for measuring urinary stones;
it is easy, however, with the greatest care, to be deceived by it, as it is difficult to
avoid grasping the stone again and again in the same diameter.  The best lithometer
is, according to the observations of Sanson and Pigne,  the common sound.   When
the stone is found, the beak of the instrument is to be carried to the hind end of the
stone, and then brought gently forwards, moving it at the same  time gently on its
axis.   At each motion the stone is felt, and if it  be noticed how far the sound pro-
jects from the urethra, at the moment it touches the hind end of the stone, and how
much further it projects at the time when the stone can no longer be felt, then the
diameter of the stone from behind forwards may be determined.  For the purpose of
ascertaining the lateral diameter, the sound must be  carried  from one side to the
other, and the extent noted  through which its handle passes, by which means the
lateral diameter ean be measured.  In order to hear distinctly the-stroke of the sound
upon  the stone, and to guard against mistake, if the stone be  covered with mucus,
or if a hard part of the wall of the bladder be touched, it has been proposed to apply
the ear to the pubic region.   Moreau and Berier have added a stethoscope to the
sound.   Pfriem (b) also, and Leroy d'Etiolle  use a long elastic tube, the upper
end of whieh is furnished with a stethoscope.
   [It is often difficult to ascertain the size of a stone, as its position may render it
more or less accessible to the sound, and when its diameters are unequal the sound
may travel upon it in such way as to give a notion of its size very contrary to that it
really has.   The readiness with which the  stone is  struck  immediately  on the
entrance of the sound into the  bladder, and the  less or greater ease with which it
can be displaced are probably among the best means of concluding satisfactorily as
to its bulk;  and more especially if the time during which the patient has had symp-
toms of the disease be taken into the account; as if these have existed long, it may
be expected the stone is large, whilst the contrary may be presumed if the symp-
toms have been recent.—j. f. s.]

   2025. The following are the various modes oftreatment recommended
 and  employed for the removal of stone in  the bladder :—
   First, The internal use  of stone solvents (Lithontriptics.)
   Second, The  injection of stone solvents into the bladder.
    Third, Solution by means of the galvanic pile.
    Fourth, Extraction of the stone through  the urethra.
    Fifth, Breaking up the stone in the bladder (Lithotrity.)
    Sixth, The operation of cutting for the  stone (Lithotomy.)

   (a) Journal general' de Medecine, vol. cix. p. 5. 1829.
   (6)  Das Lithoscop oder  Beschreibung eines instruraentes zur sicheren Diagnose der
 Harnblasen steine.  Wurzburg, 1838. 
CONSTITUTIONAL SOLVENTS.                 279
                   I.—Internal Use of Stone Solvents.

          (Remedia lithontriptica, Lat.; Steinauflbsenden MUtel, Germ.)

  2026.  The stone-solvents, which in former times were used in so great
number,  although without any knowledge of their possible operation,
can only by the advance  of chemistry^and by a  precise knowledge of
the constituents of  stone  in the bladder, attain their proper application
and efficiency.   The circumstances  which  have been considered in  the
treatment of gravel  also apply here. {par. 2011-2013.)   For stones con-
sisting of uric  acid, alkalies, for those of phosphates, the use  of acids
have   been  recommended,  with  corresponding dietetic  treatment.   In
regard to acids, it must also be added, that they operate  only against the
phosphatic  diathesis, and probably have no  effect in  dissolving stones,
except by injection.
   Many empirical remedies consist principally of alkalies, as Stephens's remedy?
and others.   Some, as so many of the vegetable remedies, operate only by allevia-
tion, through the large quantity of drink combined with their use.  Many mineral
waters operate both ways.
   2027. The efficacy  of  these  remedies has been  too highly valued by
many practitioners, and  by others  too  much decried.    If  we cannot
expect  by the  use  of  these remedies to dissolve large stones, yet, how-
ever,  their increase may be prevented, the symptoms caused by  the stone
diminished, and small stones  perhaps got  rid  of.  Under circumstances
which forbid the removal of a large  stone  by operation,  or after the  per-
formance of an operation  to get rid of the diathesis producing stone, their
 employment is always very advantageous.
   Upon the  effect of pure  water see Littre  (a);  of  Stephens's  remedy, see
 Morand (6), Baume  (c) ; of lime water, see White-. R. (d), Burlet  (e), Sega-
 las (/), Lancier (g); of magnesia, see  Brande (h), Hoffmann (i); of carbonate
 of soda, see Mascagni (j),  Magendie (k), Leroy (I) ;  of bicarbonate of soda, see
 Genois (m); of the mineral  waters of Vichy see Charles Petit (n).
   Upon the  operation of these different  remedies, various experiments have been
 made, and especially the efficacy of the waters of Vichy proved by A. Chevalier (o).
   Even when, by the continued use of alkalies, the inconvenience of stone in the
 bladder are arrested ; there is, according to Howship (p),.no proof that it is dissolved;
 for, by the specific effect  of the alkalies on the bladder, its coats are relaxed, and so
 a sac is formed by the weight of the stone.  If,  then, the  disturbance of the diges-
 tion,  which has followed the use  of alkalies, render the employment of  tonic

   (a)  Mem. de l'Acad. des Sciences. 1720.     (k)  Above cited.
 p. 436.                                  (I) Expose des divers procedes employes
   (b)  Ibid., 1740. p. 177.                 jusqu'a ce jour pourguerir de la  Pierre sans
   (c)  Elns6ns de Pharmacie, p. 200.         avoir recours a l'operation de Taille,  p. 59.
   (d) An Essay on the virtues of Lime, in  Paris, 1825.
 the Cure of the Stone.  Edinburgh, 1755.      (m)  Revue Medicale, 1826. vol. iii. p. 515.
   (e) Recueil de l'Acad. des Sc. pour 1700.     (n) Du Traitement medicale  des Calculs
   (f) Essai sur la Gravelle, p. 59.          Urinaires et particulierement de leur riisso-
   (g) M6m.  de l'Acad. de Medecine, vol. i.  lution par les eaux de Vichy.  Paris,  1834.
 p. 405.                                Nouvelles Observations gnerisons dans les
   (h)  Philosophical Transactions. 1810.  p.  calculs urinaires an moven des eaux ther-
 186.                                   males de Vichy.  Paris,")837.
   (i) Observations et Annotationes, cent. i.    (o)  Essai sur la dissolution de la Gravelle
 cap. v.                                 et des Calculs de la Vessie.  Paris, 1837.—
   (j)  Memorie della Societa  Italiana, vol.  See also Willis, above cited.
 xi. No. 34.                               (p)  Above cited, p. 102. 
280                   STONE IN THE BLADDER;
remedies necessary, whereby the muscular activity of the bladder is again excited,
the bladder contracts completely around the stone, and encloses it in a blind pouch.
Others have imagined, that by the alkalescence of the urine thus produced, a deposit
of phosphates upon the stone takes place, by which the irritating effect upon the
bladder is  lessened.
   [The best instance of a stone having undergone partial solution whilst in the blad-
der is Liston's case, C. f. 8, in  the Museum of the Royal College of Surgeons.  It
was removed by operation.   "The external surface of the calculus is very rough and
uneven, and in some places is eaten i§to small holes, which are excavated, or, as it
were, undermined at their sides.  Its  section shows that the concentric layers of
uric acid, of which the calculus is composed, are not continued entirely round  it, but
terminate abruptly at those parts  which correspond to the excavations on the surface,
as if a portion of the  calculus at these points had been either broken away or dis-
solved.  That these effects, however produced, must have taken place whilst the
calculus was in the bladder,  is shown by the layer of the earthy phosphates covering
all its irregularities" (a).]
               II.—Injection of Solvents into the Bladder.

  2028. Injections into the urinary bladder, which had long been recom-
mended and employed for the  solution of stone, were first subjected to
definite  rules by Fourcroy and Vauquelin (6).   The  solution  of uric
acid and urate of ammonia was to be effected by diluted alkalies; those
composed  of phosphates,  by dilute hydrochloric acid; and those  of oxa-
late of lime, by dilute nitric acid.   With the view of acting more power-
fully upon  the stone, without subjecting the bladder itself to the irritating
and solvent materials, it has been endeavoured to enclose the stone in a
bag which  could withstand the effect of the injection; for which purpose
Percy, Civiale, and Leroy (c) have made  some proposals, and Robi-
net {d) has recommended a peculiar apparatus, by which  the stone may
be enclosed in a bag made of intestine, and the injection made by means
of a catheter with a double passage.
  Phosphatic stones of triple phosphate and lime, are said not  to be dissolved by
solutions of alkaline bicarbonates, but broken up and converted into powder.  Oxa-
late of lime  stones  are liable to the same change.  (Willis.)  A. Ure recommends
the use of hippuric acid, (carbonate of lithia,) from which, however, according to
Garrod's and Keller's experiments, but little advantage can be expected.  Berze-
lius, who has expressed himself favourably as to the possibility of the success of
injections, and has recommended frequent  trials, proposes  a lukewarm mixture, of
one part of carbonate of potash and nine hundred parts of water, with some muci-
lage; and in cases where the stone consists of uric acid, a solution of borax.
  [Dorsey, On  the  Lithontriptic Virtues of  the Gastric Liquor.   Phila-
delphia, 1802.—g. w. N.]
  2029. With  the purpose  of  effecting the  solution of the stone by the
continued  flow of  a  lage  quantity of water,  of some  chemical solvent,
Gruithuisen (e) has proposed  an  apparatus, and  Cloquet (/) has
recommended again  the double-passaged catheter previously proposed by
Hales.
  2030. Opinions as to these modes of treatment differ as  much as those
  (a) Taylor's Catalogue, part i. p. 92.       (d) Repert. gen. d'Anat. et Physiol pathol.
  (b) Memoires de la Soc. d'Emulat, vol. ii.  et de Clin. Chir., vol. i.  Paris, 1826.
p. 76.                                   (e) Salb. Med.-Chir. Zeit, vol. i. p. 289.
  (c) Aboved cited, p. 88.                1813—Textor; in same, vol. ii. p. 94.
                      (/) In Leroy, above cited, pi. ii. f. 7. 
INJECTED SOLVENTS.
281
upon internal treatment.   There are  still but few facts which prove the
efficacy of this plan of proceeding.   The frequent variety in the layers
of the  stone  must not indeed be considered as a very great obstacle to
this treatment,  as partly by the  nature of the urine, by the result of the
injections, by the modes of treatment, to be  mentioned when crushing
the stone is treated of, by the extraction of single fragments of stone, its
character at different periods  can be  ascertained.   Stones of oxalate of
lime would be  dissolved with most difficulty (a).
  The most recent experiments made on this subject are those of Pelouze (6), from
which it appears—First, that the effect of different agents upon urinary stones is less
upon the substances of which they consist, than upon the animal matter.  The ope-
ration proceeds very slowly, even  out of the bladder.  Second, that by drinks and
baths a cure is scarcely ever effected.  Third, that the result of injections, although
they act  more powerfully, is problematical, and the danger of inflammation is not
counterbalanced, as in lithotrity, by a quick destruction of the stone.  Fourth, that
although  the combination of lithotrity with  injections increases the probability of
success,  yet it is most advisable to proceed with lithotrity  (c).
  Prout observes :—"When the very weak state of the solvent that can be injected
into the bladder is taken into account, the consequent length of time necessary for
continuing the experiment, and above all the refractory nature of certain calculi, I
confess I am very much disposed to doubt if any solvent at present known can, in
the great majority of instances, be ever so administered as  to produce the desired
effect; and this, I believe, is the general opinion on the subject." (p. 284.)]
  " It has been observed by chemists,"  says Brodie,  " that lithic acid admits of
being dissolved by a strong solution of pure or caustic alkali. It  has been  also,
observed that calculi composed of the phosphates are acted  on by the mineral acids,
and  it may not unreasonably be entertained as a question, how far those changes,
which take place out of the body, may be produced while the calculus is still in the
bladder of a living person. * * *  I fear those who have expected by these methods
to relieve patients of lithic acid calculi, have much overrated the effects of alkaline
lixivia on them.   The fact is, that although alkalies certainly are capable of acting
on this kind of calculus, their action, except when employed in a very concentrated
form, is so inconsiderable, as to amount almost to nothing.  Neither  the  stomach
nor the bladder is capable  of bearing  the quantity of alkali which is  necessary to the
production of the desired effect; and even if they were, it would be impossible to
maintain so constant a supply of the alkali as would be necessary to the destruction
of a calculus of even moderate dimensions.  Mr. Brande, moreover, has observed,
that the  carbonate of potass  and soda have  no  action on lithic acid;  that they are
incapable of dissolving it; and that if the pure alkali be taken by the mouth, it
never reaches the bladder in this state, but only in that of a carbonate; and here then
is an insuperable objection to all attempts  to dissolve lithic (uric) acid calculi by
means of alkalies taken into the stomach.  When there is a lithic (uric) acid calculus
in the bladder, and the lithic acid diathesis prevails in the  system, the first effect of
alkalies taken into the stomach is to render  the urine neutral; thus preventing the
further increase of the calculus.  So  far, then, alkalies are useful.   But if they are
administered in still larger quantity, so as to render the urine alkaline, the phosphates
begin to be deposited.   The calculus  then continues  to grow even more rapidly than
before; but its composition is altered, and layers  of the triple phosphate are deposited
on the lithic acid nucleus.   Such is the view of the subject taken by Mr. Brande."
(p. 290-92.)
  Brodie shows the fallacy of the statements in reference to the presumed solution
of stone, by observing that the fragments occasionally passing, are to be referred to
fracture  of the stone from mechanical causes, as already mentioned ; or that the sup-
posed fragments are in reality new formations, and the result of the medicines em-

  (a) In the British and Foreign Quarterly     (6) Comptes-rendus de l'Acad.  des  Sci-
Medical Review, vol. xii. p. 398; and also in  ences, vol. xiv. p. 429.  1842.
Jones, p.  118, all has  been  collected in     (c)  Willis and Jones, above cited.
reference to the effects of Injections upon
Stones. 
282                   SOLUTION BY GALVANISM.
ployed.   As to the cessation of the symptoms, it is no proof the solution of the
stone, as by the use of medicine, a fresh coating may be given to it of a less irritating
character, and the stone still exist, as in the case of Admiral Douglas mentioned by
Astley Cooper (a).
  Brodie, however, considers that " the mineral acids undoubtedly exercise a greater
chemical action on calculi composed of the phosphates than alkalies do on those
which are composed of lithic (uric) acid.  * * *  I found that where the mucous
membrane of the bladder was not inflamed at all, or inflamed only in a slight degree,
the proportion  of nitrip acid might be increased  to two minims or two  minims and a
half  of the concentrated acid to an  ounce of distilled water, without  any ill conse-
quence or even inconvenience arising from  it.  I next endeavoured to ascertain to
what extent a  solution  of this strength was capable of acting on a calculus of the
mixed phosphates.  The change produced was  sufficiently obvious, especially when
the solution was made to pass over the calculus in a stream for a considerable time.
It gradually diminished in  size,  and at last began to be broken down into minute
fragments." For this purpose he at first used  a gold catheter with a double chan-
nel,  through which a constant current was kept up; but afterwards found an elastic
gum bottle  with a stop-cock, and elastic gum tube attached to it.  He first washed
out the bladder with distilled water to get rid  of the mucus lodged in it, and then
injected the solution of nitric acid very slowly,  using the same liquid  over and over
again several times.  The liquid was afterwards tested  with a highly concentrated
solution of pure ammonia, and it was found  that if the ammonia was added in suffi-
cient, but not too large quantity, the phosphates were  precipitated in abundance.
Hence he concludes,  '■'■first, that a calculus, composed externally of the phosphates,
may be acted on by this injection, so as to become gradually reduced  in size, while
it is  still in the bladder of a living person; second, that there is reason to believe that
small calculi, composed throughout of the mixed phosphates, such as  one met with
in some cases of diseased prostate gland and bladder, are capable of being entirely
dissolved under this mode of treatment, and that it is probable  that it  may therefore
be applied with advantage  to some of these cases, in which, from the  contracted
state of  the bladder, or from other circumstances, the extraction of such calculi by
means of the urethra-forceps, cannot be accomplished,"  (p. 292-99.)]
         III.—Of Dissolving Stone by means of the Galvanic Pile.

   2031.  Gruithuisen (b) rests his proposal of dissolving urinary stone
by the action  of the  galvanic pile, upon  Desmortier's experiments.
Prevost  and Dumas (c) haye  made  experiments both out of the body
and upon animals.   The apparatus consists of an elastic catheter, con-
taining two platina conductors, covered with silk throughout their whole
length, except  at their  ends, which are  kept apart by a spring,  and
attached  to  an ivory knob, wdiich closes the  opening  of the  catheter.
This knob is composed of two hemispheres, each of which is  attached to
a conductor, so that the flat surfaces where the platina is exposed, comes
in contact with the stone.   An injection of  diluted nitric  acid renders
the galvanic  pile more active  than water alone.   With this treatment,
no experiments have yet been made on men.
   [In 1844 an American named Hull, in London, attempted to dissolve stone in
the bladder by galvanism, but I do not  know with what success.  The patient had
stone, for I sounded and felt it.-—j. f. s.]

  (a) Lectures on  Surgery, vol. ii. p. 241.    xxiii.  p. 202.  1823.—Leroy, Alteration of
  lb) Above cited.                       the Apparatus, in his  work  above cited, p.
  (c) Annales de Chimie et de Physique, vol.   102. 
EXTRACTION BY URETHRA.
283
       IV.—Of the Extraction of the Stone through the Urethra.

  2032. The  shortness and extensibility of  the urethra  in females, and
the not unfrequent spontaneous passage of stones of considerable size,
have  led to the extraction of stones in women, by dilating the urethra.
Circumstances are less favourable in men, and the instances of voidance
of large stones by them are  much  rarer.   According to Prosper Alpi-
nus (a), the dilatation  was specially suited to men,  and was  performed
among the Egyptians by blowing  air  into  the urethra through tubes of
increasing size, after which the stone was pressed into the neck of the
bladder by the finger  introduced  into the  rectum, (in women the finger
was placed in  the vagina,) and then  the stone was brought out by sucking
vigorously at the penis.   Enlargement of the diameter of the  urethra to
five lines can  be effected in men only with much trouble;  in most cases
such  extension is unbearable.   Small stones, therefore,  can alone be
extracted in this way from men,  and the enlargement of the urethra is
best  effected  by increasingly thick  elastic sounds.   When the urethra
has been sufficiently  enlarged, the patient  must  hold his water, bend
himself forwards, and  as the sound is withdrawn quickly, the small stone
escapes with  the  stream of urine,  or is extracted by a peculiar pair of
forceps  (1).    For  enlarging  the  female urethra,  Weiss's  dilator is
used (2).

  Forceps of this kind had been formerly proposed by Sanctorius and Severinus,
and Hunter's  forceps had been employed for  the same  purpose (b).  Astley
Cooper's forceps (c) are especially applicable.   According to him such little stones
are always lodged in a sac of the bladder behind the enlarged prostate gland, and
are frequently not discovered, if in sounding,  the point  of  the instrument be not
directed towards the  rectum, or the front of the rectum pushed up by the finger intro-
duced into it (3).
   [(1) Brodie, for this purpose, directs the introduction of "a bougie, or a metallic
sound, of such a size as the urethra will admit without inflammation being induced.
Every day, or every other day, according to circumstances,  introduce  one a little
larger, and thus you may dilate the urethra gradually, until it is a good deal larger
than its natural  size. * * * When this process has been carried as far as it can be,
let the patient drink plentifully of diluting drinks.  It may be worth while even to
give some of the compound spirit of juniper or other diuretic, at the same time, and
the calculus will probably, some time or other, be carried by the current of urine into
the dilated urethra;" or, "once daily introduce a large bougie into the urethra and
bladder,  and there let it remain; then  let the patient drink plentifully of barley
water, or toast and water, or weak tea, so that the bladder may become loaded with
urine.  When  the patient can bear the  distention  of it no longer, let him place a
vessel on a chair, standing, and leaning forward over it;  on the bougie being with-
drawn, the urine will follow in a full stream, and the calculus may probably accom-
pany  it." (pp. 281, 82.)
   (2) In the female the urethra being short will easily dilate of itself, and even
permit the passage of a stone weighing an ounce, as in a case mentioned by Astley
Cooper ; and, " unless a stone be extremely large," he says, " it should be removed
by dilatation of the urethra, which may, by a speculum or  pair of forceps, be opened
sufficiently in a few minutes for this purpose.  The advantage attending this* mode
of extracting a stone is, that the passage  again contracts, and the urine is afterwards

  (a)  De Medicina iEgypt., p. 224.  Lugd.    (c) Mrdico-Chirurg. Trans., vol. xi. p. 359,
Batav., 1719.                           pi. vi. 1820.
   (6)  Leroy, above cited. 
284
STONE IN THE BLADDER ;
 retained.  In the first case in which I performed this operation in Guy's Hospital,
 having used sponge tent, the  patient perfectly recovered in a very few days." (pp.
 301, 302.)   This is not, however, always the case, for sometimes the urethra is long
 before it recovers its tone, and consequently during that period there  is a tiresome
 incontinence of urine.—j. f. s.]
   Liston (a) says:—"The best mode of extracting foreign bodies from the female
 bladder is to widen the urethra gradually by means of the screw dilator, then, by the
 induction of a straight blunt-pointed knife, to notch  the neck of the bladder slightly
 towards each ramus of the pubes, so as to divide the dense fibrous band encircling
 it; the dilatation is  continued, and in a few minutes the finger can be admitted, the
 stone  then  can  be readily grasped by  a pair of forceps; and it is astonishing how
 large a body may be removed by these means."  (p. 525.)
   (3) The  urethra forceps, commonly called Cooper's, were the invention of Weiss,
 the  instrument-maker, which  Brodie  considers objectionable, as  "it  is difficult to
 explore with it every part of the bladder, and in opening the blades the neck of the
 bladder is always painfully dilated ;•" and he prefers another instrument afterwards
 invented by the  same maker, and "composed of two pieces of steel, one sliding
 longitudinally in a groove of the other.  The extremity which enters the bladder is
 curved, but not in the manner of the common catheter,  the curve being more abrupt
 and the curved part considerably shorter.  When the forceps is to be opened the sliding
 piece is drawn towards the handle, and thus  the blades, in being separated, are still
 kept parallel to each other; they are closed by an opposite movement. *  * * The
 patient should be laid on his back, and it is generally better that his pelvis should be
 supported by a thick  cushion, so that it  may be higher than his shoulders.  The first
 step of the  operation is to introduce a silver  catheter, and thus empty  its  contents.
 From five to six ounces of tepid  water are then to be injected into the bladder, so as
 to distend it moderately.   If  any considerable portion of the  water  should escape,
 the injection should be repeated, it being absolutely necessary that the operation should
 never be attempted on an  empty  bladder.  The forceps is next introduced, and, of
 course, with the blades closed.   It is  first to be used as a sound, so as to ascertain
 the exact situation of the  calculus.  If  this be not readily  detected, the patient may
 be directed  to turn on one  side,  placing himself  on  his back again afterwards, by
 which change of position  the calculus may probably be made to roll into some more
 convenient place within reach  of the forceps.  The blades of the forceps are then to
 be cautiously opened over the  calculus, and afterwards closed upon  it.  By this
 simple management, with a light hand, the calculus  is seized with facility in many
 cases, otherwise you may adopt  the following method, which rarely fails:—Let the
 forceps be opened with the convexity  of its blades pressed against that part of the
 bladder which is towards  the rectum, so as to make it the lowest or most depending
 situation.  Then, by a slight motion given to the handle of the instrument, the cal-
 culus is made to roll into its  grasp, and thus 1 have often been enabled to remove
 several small stones at once. *  * * When the calculus is grasped you may know
 exactly its diameter  by means of a  scale fixed to the  handle of the forceps."  If
 small, Brodie says,  forceps and  stone may be withdrawn at once; if very large, so
 that  it will not enter the urethra,  it may be dropped at once, and other means resorted
 to; but if of intermediate size, and capable of entering the urethra, from the easy
 dilatability of the neck of the bladder, so as to be "drawn into that portion of the
 canal which lies in  the perinaeum, and there stops, it may then be very distinctly
 felt through the  integuments behind the scrotum;  and if a small incision be made on
 it  in this situation, it is easily extracted, the forceps, after the  removal  of the stone,
 being closed and withdrawn in  the usual manner."  An elastic catheter must be
 left in to draw off the water and prevent dribbling through the wound.   If the forceps
and stone can be brought  forward and only "meet an  impediment in  the anterior
 part  of the canal, that is, at the external orifice or exactly at the anterior part of the
scrotum, or somewhere in  the intermediate space;  if the impediment  be close to the
 orifice that part is easily dilated  by means of a probe-pointed bistoury; and if it be
 in another part  of the  canal, you  may  remove  it by means  of an  incision made
through the  skin, corpus spongiosum, and membrane of the urethra.   Let me caution
you, however, never to make such an incision into the urethra immediately in front of
(a) Practical Surgery. 
CRUSHING, OR LITHOTRITY.                 285
the scrotum.  It is difficult when you do so, even by the constant retention of an
elastic gum catheter, to prevent a small quantity of urine finding its way into the
loose cellular texture of the scrotum, and this may be productive of a succession of
troublesome abscesses, or even of dangerous consequences."  (p. 283-87.)]
                       V.—Of Crushing the Stone.

  (Lithotritia, Lithotripsia, Lat.; Zertriimmerung des Steines, Germ.; Lithotritie,
                              Lithotripsie, Fr.)
  Leroy d'Etiolle, Expose des diverses  precedes pour guerir de la  Pierre sans
l'Operation de la Taille.   Paris, 1825.
  Civiale, Destruction des Calculs sans avoir recours a la Taille.  Paris, 1823.
  ----, De la Lithotritie, ou Broiement de la Pierre dans la Vessie.  Paris, 1826.
8vo.
  Bancal, Manuel pratique de la Lithotritie.  Paris, 1829.
  Tanchon, Nouvelle Methode pour detruire la Pierre dans la Vessie sans operation
sanglante.  Paris, 1830.
  Heurteloup, Lettre a  l'Acad. des Sciences.   Examen critique de l'Ouvrage de
M.  le Dr.  Civiale, intitule, de la Lithotritie, Broiement de la Pierre dans la Vessie,
&c.  Paris 1827.  8vo.
  ----, Principles of Lithotrity, or a Treatise on the Art of extracting the Stone
without incision.  London, 1831.  8vo.
  ----, Cases of Lithotrity.  London, 1831.  8vo.
  Leroy d'Etiolle, De  la Lithotripsie.   Paris, 1836.
  Civiale, Parallele des divers Moyens de traiter les Calculeux.   Paris, 1836.
  ----, Traite de l'Affection Calculeuse.  Paris, 1838.
  Schleiss von Lowenfeld, Die Lithotripsie in Bezug auf Geschichte, Theorie
und Praxis derselben unter Benutzung der neuesten Erfahrungen der Franzosischen
Aerzte hieriiber.   Miinchen, 1839 ;  with eight plates.
  Ivanchich, V., Kritische Beleuchtung der Blasenstein-Zertrummerung, wie  sie
heute dasteht.  Wien, 1842.
  2033.  Although hints about the extraction of an urinary stone after
previously crushing it in the bladder, are found in Celsus (1)  and Al-
bucasis (2), and the successful experiments of two  persons upon them-
selves have been recorded  (3), yet Gruithuisen  {a) made the first actual
proposal,  in  which, by means  of a straight tube introduced into  the
bladder,  and a wire loop projected  out of it,  the stone being held fast,
was penetrated  by a borer  or  trepan passed through the tube, and  the
crushing  of  the small  pieces  effected by the  introduction of forceps
through the tube; this was not thought any thing of, and partly because
the proposed method was considered impracticable. Even Elderton's (b)
instrument, curved like the  common  catheter, and with two opening arms,
by  which the stone might be grasped and destroyed  by means of a file,
was not much  regarded.
  (1) Celsus (c) says:—"Calculus fendendus est.  Id hoc modo fit.  Uncus inji-
citur calculo, ut facile eum concussum teneat, ne is retro revolvatur: turn ferramentum
adhibitur crassitudinis modicae, prima parte  tenui, sed retusa, quodadmodum calcu-
lum ex altera parte ictum fendit."
  (2) Albucasis (d):—" Let a slender instrument be taken  * * * and gently intro-
duced into the penis;  roll the stone into the middle of the bladder, and if it be soft,
let it be broken and discharged."
  According to Haller (e), Sanctorius described a three-armed catheter, through
  (a) Salzburg Med.-Chir. Zeitung, vol. i. p.    (c) De Medicina, book vii. chap. iii. sect. iii.
289, f. 1-9.  1813.                         (d) Liber Theories necnon Practical Vol.
  (b) Edinb. Med. and Surg. Journ., vol. xv.  Aug. Vind., 1519, p. 94.
p. 261, f. 1, 2, 3.   1819.                    (e) Biblioth. Chirurg., vol. i. p. 313.
  Vol. hi.—25 
286
STOXE IX THE BLADDER ;
 which a stilette with a file end was passed, and the stone broken up, and the pieces
 having been seized by the branches of the catheter, were removed.
   (3) The former of these persons introduced, by means of a flexible sound passed
 into the bladder a straight steel rod with its extremity ground to a point, down to
 the stone, and struck upon the  outer end of the  rod, in consequence of which little
 pieces were separated from the stone and voided with the urine (4).   The latter, by
 means of an elastic sound, carried down  a fine file, about thrice in every twenty-four
 hours, between the stone and the bladder, and used it as a file upon the stone, which
 he endeavoured to bring near the neck of the bladder (5).
  (4) This (a) the celebrated case ("if well proved," as Chaussier and Percy
 observe) of the Monk of Citeaux, and to the notice above given may be added, that
 having introduced the rod, he struck its  end with a hammer with some little sharp
 sudden strokes, sufficient to detach some little pieces and splinters, which were car-
 ried off by the urine, and with which in  the course of a year he filled a  little box.
  (5) This person was General Martin  (b), who gives the following account of his
 proceedings :—" As I generally found the stones by the neck of the bladder, it sug-
 gested to me that by making a catheter with small holes on the side, I perhaps could
 break the sharp points of the stones by passing the catheter between the stones and
 bladder;  this by a small catheter I could introduce between the stones and  bladder,
and I succeeded in bringing many small pieces away, and after no more.  But as I
constantly found  the stones, my good genius  suggested  me to make  files, and by
introducing them on  the catheter, and with small motion, I either filed or scraped
the whole stones out during about nine months.   When I could not get at the stones,
I injected warm water in the bladder, which I rejetted or urined out with force, and
large  stream, and  mostly always the  stone came to the neck of the  bladder and
stopped the water, then it was my time to file again, which I did, inclining my body
against the wall for to be able to keep the stones as much as I could in position to be
able to fill it often. * * * As I saw my progress by many small pieces which I still
have,  besides the sand, or fine  sandy part, it made me persevere in that mode till I
brought every piece out, and then, afterwards, I found myself able to walk, ride, &c,
as every body else, which I had not done for many years;  and  I made water very
well, though still always a little matter preceded the urine, and  also by straining,
some  few drops came out after the urine." (pp. 251, 252.)  How long time was
occupied in this process is not mentioned, nor does it-appear how long he lived after
having, as he stated, thus relieved himself.  He  died in 1800, and  in  the note
appended to the letter, Everard  Home  says:—" There  can be  no  doubt, but the
diseased state of the prostate gland  was the cause of his death, since  the pain of the
urine passing over its surface was greater than he could well.bear.   From his own
confession of having a fit of the gravel, after he  had brought the stones away, and
being obliged to tickle the head of  the penis before he could make a  drop of water,
I am strongly disposed to believe, that had  the body been inspected, more than one
 stone  would  have been found in the bladder." (p. 259.)]
   2034. The path first  cleared by  Gruithuisen has been retrodden  by
 Civiale, Leroy D'Etiolle  and Amussat, and  the  instruments they
 have advised, which  correspond with those proposed  by Gruithuisen,
 are to a certain extent to be considered merely modifications of his.  For
 this reason the contention  between Civiale and Leroy D'Etiolle is of
 less consequence, as  even the straightness  of the instrument, the result of
 Amussat's observations,  had  been already proposed  by Gruithuisen.
 In  other  respects,  however,   the   merits  of these  surgeon's are  not
 diminished,  as by their emulation this operation has been perfected and
 subjected to  definitive rules ; and  as also it  was  first  performed   by
 Civiale on living persons, and not merely brought  into practice but its
 permanence ensured.   Besides Civiale, Leroy D'Etiolle and Amussat
 have  most contributed  to the improvement of the instruments, Jacobson,

   (a) Rapport fait a l'Academie Royale des   (b) Home, Practical Observations on  the
 Sciences, par Chaussier  et Percy,  sur le  Treatment of Diseases of the Prostate Gland,
 nouveau  moyen du  Dr.  Civiale, p. 171.  vol. ii,  1818,
 Paris, 1824. 
CRUSHING, OR LITHOTRITY.
257
Heurteloup and Charriere's  inventions  especially, to the simplifica-
tion and greater certainty of the practice, so that of late years this opera-
tion has been brought to a great degree of simplicity and perfection.
   2035. The  numerous instruments  recommended  for the  practice of
lithotrity have this in common, that having  been introduced through the
urethra into the  bladder, they grasp  and fix the stone, and by a force
exerted upon it, break the  stone into so small pieces, that they can pass
through  the urethra.   All these  instruments may be most  conveniently
arranged  under  three  classes:—First, the  stone being grasped  by  its
periphery,  is gradually destroyed towards its centre; second, it  is per-
foratedy to render it breakable, so that it may then be crushed ; third, it is
then crushed by pressure from its periphery, towards the  centre.
   To theirs/ class of these instruments, which effect the gradual destruction of the
surface of the stone, belong the instruments of Elderton (1819,) of Meyrieu, made
public by Tanchou, (1830,) of Recamier, (1830,) which fix the stone with forceps,
and act upon it with the file ; Rigal's (1830) instrument, which fixes the stone with
a perforator, for the purpose of moving it upon the file-like surfaces of the arms of
the forceps  (foret a chemise.)
   To the second class belong the instruments  of Gruithuisen, (1812,) of Civiale
and Leroy D'Etiolle,  (1823,) with the modifications of Griffiths, Luckens,
 Scheinlein; of  Heurteloup, (1828,) and of Rigal,  (1830,)  for  the purpose of
breaking the stone  by an eccentric power; of Pravaz, (1830.) curved like a com-
 mon catheter, and similar to that of Benvenuti (1830.)  The form  of perforator as
 given by Civiale, Leroy, Amussat, Greiling, Charriere, and others, varies very
 much.
   In the third class are Amussat's instrument, (1832,) Heurteloup's brise-coque,
 (1828,) Jacobson's instrument, (1830,) with its modification by Dupuytren, who
 increased the number of limbs for the purpose of getting rid of the angles, which
 the grasp forms;  Leroy and Greiling's instruments; the  percuteur of Heurte-
 loup, (1832,) with the alterations of Segalas, Bancal, Amussat, Weiss, Civiale,
 Leroy, Benique,  Charriere, and  others; Charriere's percuteur  a pignon.
 Schleiss has attached  a perforator to the percuteur so as to act in  two ways upon
 the stone.  The  description  of these instruments, which would be insufficient, is
 omitted, and the  reader is referred for their complete  description and engravings of
them to the works of  Leroy D'Etiolle,  and others, and especially to those of
 Schleiss, von Lowenfeld, and others (a).
    2036.  The  history  of lithotrity affords  a  sufficient opportunity  for
 deciding  on the fitness of these various instruments.   Those which effect
 a  gradual rubbing away of the surface of the  stone  have never enjoyed
 any particular  favour.  The perforating instruments, although  they  led
 to the direct introduction of lithotrity, have been set aside by Jacobson's
 lithoclast; and   both have been, to  a  certain degree,  supplanted  by
 Heurteloup's percuteur.   From a close examination of the three-limbed
 perforating forceps of Civiale, and Leroy, of Jacobson's instrument, of
 Heurteloup's percuteur,  with  screw and  hammer, or a pignon, there
 seem to be good grounds for their employment and effect.
    2037.  The tha\>.-limbed perforating forceps are indeed generally intro-
 duced with ease ; but there are  circumstances in reference to the state
 of the  prostate,  which may render their introduction difficult,  and even
 impossible.  In  general  they  readily grasp  a large  stone; but  the  en-
 trance of  a large stone between  their branches  may be difficult, and it
 may also  be  exceedingly  troublesome  to  grasp a  small  stone; their
expanded branches  may also injure a corresponding number of points on
(a) Above cited. 
288
STONE IN THE BLADDER ;
 the walls of the  bladder.   When the stone is grasped it cannot easily
 escape, its rubbing into fine powder is very favourable for its discharge;
 but at its final breaking up, there still remain fragments, the grasping and
 crushing of which is very difficult.   Hence arises the tediousness of this
 method;  the stone must  be grasped, bored and let go,  must be again
 grasped and bored, till it can at last be broken up.   These manoeuvres
 are difficult, tedious  and  painful, to both  patient and operator.  One
 limb of the forceps may get into one of the bored holes, from which it is
 freed with difficulty ; the perforator itself, if it operate on an irregularly
 shaped stone, and which is perforated at one part, may act upon one arm
 of the forceps, and injure, or even break it.
   2038.  Jacobson's instrument is easily introduced;  searching for and
 grasping the stone with  it is less dangerous, as  when it  is opened, the
 stone almost of itself gets into it; on  account of its curve, however, it is
 difficult to sound certain parts of the bladder—for instance, near its neck.
 Flat stones are always seized with more difficulty by it than by the three-
 limbed forceps, and not always  easily fixed.  The stone is sometimes
 broken slowly, without pain, and without the pieces striking injuriously
 against the walls  of the bladder.  No stone can resist its action (Dupuy-
 tren Pigne) ; and if the instrument should break, its pieces remain con-
 nected with the body of the  instrument, and by giving  it the  proper
 direction, may be withdrawn with it, without danger or difficulty.  The
 dimensions  of the instrument, however, may be  so  large that  it  cannot
 grasp a large stone; it is, therefore, suitable  only for  small stones.  It
 is, above  all, necessary that the stone should  be caught in the middle,
 as otherwise it is difficult to fix, and easily escapes.   Lastly, the re-
 mainder  of the stone may continue attached to the  branches of the
 instrument, and render its withdrawal difficult, or even impossible; this
 awkward  circumstance is, however, prevented by Leroy's modification.
  2039.  Heurteloup's percuteur is  most easily of all introduced into,
 and managed when in, the bladder.  Stones of every shape and size can
 be firmly grasped  by it, and their escape is less to be  feared than from
 any other instrument.   The position of the stone when  seized, can be
 more easily changed, its size measured, and every part of the bladder
 more  readily examined,  by the angular curve of the instrument.  Its
 operation  is powerful and quick; large  stones can  be crushed with it
 more  quickly and with  less effort, and  are converted  into a coarse soft
powder;  but the  fragments of hard stones are very angular and  sharp-
edged, and  produce,  by irritating the bladder, pain,  difficulty in their
passage through the urethra, and frequently their lodgement there.   The
strength of the instrument, notwithstanding its small size, in  comparison
 with others, is, when properly used, so great that there is no fear of its
 breaking.   To this may be added, that it is by far the least costly instru-
 ment.  The percuteur, therefore, possesses all the advantages of the other
instruments, without any  of their disadvantages,  and it  may  be with
certainty presumed that it will supersede them all.
  2040.  Before  proceeding to the operation, the  most perfect  informa-
tion must be obtained, by examination of the position, form, size, and
consistence of the stone and of the state of the urinary organs.   For this 
CRUSHING, OR LITHOTRITY.
289
 purpose a common catheter may be made use of as already directed {a).
 If there be no circumstances contra-indicating lithotrity, if no further
 preparation of the patient be requisite, or it have been already made,
 the rectum  must be emptied with a  clyster some hours previous to the
 operation.
   Previous to the introduction of the straight perforator, Civiale and others have for
 the space of a fortnight, in addition to very strict diet and lukewarm bathing, enlarged
 the canal of the urethra, by the daily use of elastic  bougies, to  such  extent  as to
 render the introduction of the instrument easy.  The patient is thus at the same time
 accustomed to the irritation of a foreign body, on which account Civiale also uses
 bougies, even when the passage of the urethra is sufficiently wide.
   2041.  The patient  should lie upon a common bed, or upon a table
 covered with  a mattress, both of which should be sufficiently high, that
 the operator have not to stop.  It should also be narrow, and the mattress
 firm.   The buttocks  are to  be raised on  pillows, the  back fiat, the
 shoulders and head a  little raised.   The patient should either lie length-
 ways and" the operator standing on his right side, or obliquely, with his
 rump on the edge of the  bed, in which position his feet are either to rest
 on a stool, or to  be  supported by  assistants, and the operator stands
 between his thighs.
   The beds specially for this purpose, as recommended by Heurteloup, Bancal,
 and Tanchou, are thus rendered superfluous, although they are  advantageous, by
 placing the patient easily and quickly in the fitting posture, and giving the operator
 more facility and security.  Rigal's  chest-like contrivance, which contains all the
 lithotriptic instruments, may also be  placed on a table to give  the patient a proper
 position.  The apparatus  used for firmly fixing the instrument to the bed, when the
 stone is crushed with the hammer, is not necessary; for, even if the hammer be
 used, the instrument can be fixed by the hand alone, or by a moveable holder, as the
 crushing of the stone must only be  attempted by light short  strokes, and an im-
 moveable fixing of the instrument may, if the patient move, cause mischief.
   2042.  After voidance of the urine, a quantity of lukewarm water,  cor-
 responding to the capacity of the bladder, is  to  be  injected through a
 silver catheter, till a visible or sensible enlargement of  the region of the
 bladder is produced, or the patient  has an urging to make water.   The
 aperture of the catheter is then stopped with the thumb,  and the existence
 and position of the stone once  more examined ; after which the catheter
 having been withdrawn, the lithotriptor is introduced.
   If the orifice of the urethra be very narrow, it must be enlarged downwards  with
 Civiale's bistoury, or with a narrow  button-ended bistoury, to  the extent of a line
 or two.
   2043. In using the three-limbed perforating forceps of Civiale  and
 Leroy, the instrument, closed and properly oiled, must be held with the
 fingers, of the right hand,  and the penis with those of the left, so directed
 that it occupies a middle position between erection and relaxation ; con-
 sequently almost at a right angle with the body, but forming towards the
 belly a somewhat obtuse angle.  The same direction being given to the
 instrument, it  is introduced into  the urethra, and with gentle twirling  and
 pushing alternately, carried on till it come to the under part of the pubic
 arch, without  changing its direction, or that of the penis.  The  instru-
 ment and the penis are now gradually sunk down, at first parallel to the
horizon, and then brought so far below it as  can be done without  any
  (a) Catheters specially for examination, and of similar construction to that of Heurte-
loup's percuteur, are given by Schleiss.
                                  25* 
290
STONE IN THE BLADDER J
great difficulty, and then its point gently pushed forwards.   If this can-
not be done, the instrument must be again raised and sunk till the point
get under  the pubic arch; the instrument is  then carried in the same
direction through the prostatic part into the bladder, which  is indicated
by a peculiar feel, by the free movement of the instrument, by the escape
of a few drops of urine, and  by urgency to make water.   If there be still
some resistance before the instrument enter the bladder and  it cannot be
sunk lower, the part of the  instrument projecting from the urethra must
be  gently raised, and the neck  of  the bladder thereby be somewhat
depressed.
  2044.  The stone  is in general found without much difficulty, if not
very small, and if the patient be quiet;  and when found, the instrument
must be drawn a little back,  without causing the least shock, and opened
more or less, according to the size of the stone ;  and then, first the outer
canula, and afterwards  the  borer, are  to  be attached.   At the same
moment that the instrument  is pushed a  little forwards, the opened limbs
of the forceps surround and grasp the stone, then the three-limbed canula
is attached  to it and fastened by the screw.  By means of the scale fixed
on the three-limbed tube, and by pushing the borer towards the stone, it
is ascertained that the latter  is actually  fixed, and its size is made out.
The frequent difficulty of grasping the stone may be rendered more easy
by changing the patient's position, or by pressure on the region of  the
bladder.
  2045.  If the stone be very small, it may be at once pulled out.   If it
be very brittle, it often breaks by the closing of the  forceps.   But when
this does not happen, the instrument should be laid into the hand-vice, and
the  borer moved against the stone by means of the bow, on  which a dull or
clear murmur is perceived.   If the stone be in this way broken to pieces,
all the pieces  rarely fall out of its limbs, and  the measure on the  again
retracted canula shows whether the piece  grasped will pass through the
urethra, or whether it must be still more broken.  In the latter case, after
the  canula has been fixed, with the screw, the borer must be again em-
ployed.  The instrument is  then to be slowly withdrawn by moving it
gently from above downwards, and from right to left, observing the same
direction as on its  introduction.  If in doing  this there be still any
obstacle, which is usually the case at the fossa navicularis, the borer must
be again applied to the stone, to render it still smaller.   The pieces in
the  bladder generally escape with the injected  water, or  with the urine
through the enlarged urethra.   If, however,  the stone be firm, and the
borer merely pierce without breaking it,  the borer must, with certain
intervals, operate only so long on the stone, till there is but  a line from
the  tip of the forceps.  Attempts must  then be made either to give the
stone another position, and operate with the borer on its other side, or if
the  patient be fatigued* the operation must be stopped.
  2046.  Jacobson's instrument is introduced just as a common catheter.
Having reached the bladder, gentle movements are to be made with its
beak to find the stone ; the  instrument can also be twisted to the half of
its long axis, so that its point may be directed  against the back of the
bladder, the handle of the instrument raised, pushed gently forwards and
backwards, to one or other side, so as to sound every part of the bladder. 
CRUSHING, OR LITHOTRITY.                291
When the stone is found, the curved part of the instrument is to be laid
on  its side  upon it, the moveable branch pushed forwards, so that the
loop is formed within the bladder, and then by lateral movements of the
instrument,  or by correspondingly raising and sinking one part  of the
pelvis, attempts  are made to bring the stone  into the loop.  When the
stone is  believed to be  caught in its middle, the moveable  branch is
drawn somewhat back, so as to diminish the size of the loop.   In order
to break the stone now grasped, the screw is to be turned from  left to
right, as  far as its length allows.   If the stone be broken, the loop is to
be  again opened, and it is again attempted in the same way as at first, to
grasp the single fragments,  and to crush them, which must be repeated
as often  as  any fragments are to be found for crushing, and the patient
does not express any considerable pain.  When the  instrument is with-
drawn, its moveable branch must be pushed sufficiently forward till it be
completely closed, and if this be prevented by any fragment, the loop is
to be repeatedly opened, and the  instrument  made to move in different
directions, for the' purpose of getting rid of the fragments from the loop ;
and then when the instrument is completely closed, it may be withdrawn
like a catheter.  The instrument is used in the same way for repeatedly
crushing the stone fragments.
   2047.  Heurteloup's percuteur is introduced into  the bladder like a
catheter, and  the  stone  searched for with it.   The  instrument is  then
opened by withdrawing its male branch, as much as the size of the stone
requires, which then falls into the concavity of the female branch, almost
of  itself, or  by  some special movement, and is  then  caught by pushing
down the male branch.   The beak of the instrument is now brought into
the middle of the bladder, the female branch held with the left  hand, and
a slowly increasing constant pressure made upon  the end of the male
branch with the right hand.  The gradual driving forwards of the male
branch, the  sensation of  crushing and the noise  often accompanying the
breaking up of the stone, as well as  the sudden driving forwards of the
male branch and the complete closure of the instrument, show the escape
of the stone.  If the pressure of the hand be insufficient for crushing the
 stone, more force by means of machinery, is employed,  by  which the
results just mentioned are produced.  If pressure with the hand be in-
sufficient to break up the stone, the female branch of the instrument must
be fixed  with the hand-vice already mentioned, or to the proper apparatus
 on the bed, and the extremity of the male branch struck with light, equal,
 quick, and  short blows of a hammer, so that the stone is gradually split
 and at last .completely smashed in pieces.  When  the male branch has
 been driven some way down, the  hammering may be given up, and the
further crushing effected by the hand or by the machinery.  In this way
is the operation to be continued till the male instrument has entered com-
pletely, and tbe instrument is perfectly closed, by which the actual crush-
ing, or the  escape of the stone is shown.  In the latter, as in the former
case, the stone, or its pieces, must be  again caught, and they must be
crushed  as  already described, and the process repeated till the stone is
completely  broken to pieces, unless  great urging to pass the urine, dis-
eased contraction of the bladder, and discharge of the urine, violent pain,
the patient's distress and the like, prevent the completion of the operation. 
292
STONE IN THE BLADDER)
After the fragments still clinging to the instrument have been got rid of,
by pushing forwards, and pulling back its  male branch, and  by other
gentle  motions,  and the instrument completely closed, it must  be with-
drawn by a gentle rotatory motion.   If there be yet any obstruction from
a little piece of stone between the branches of the instrument, it must be
again pushed into the bladder, and attempts, as already mentioned, made
to get  rid of it, so  that the  instrument may be  withdrawn completely
closed.
  2048.  The duration of a lithotriptic sitting, depends on the sensibility
of the patient and the symptoms it produces.  In general, it occupies five
or six minutes, but persons who are not very sensitive, can  without in-
convenience, bear it much longer.   The  symptom usually arising after
the  introduction  of  the instrument, is, violent urging to make  water,
which, however, often  ceases, when the instrument is managed gently,
or a few drops of urine have escaped.   If a large quantity  of  urine be
voided, and in consequence of other circumstances, the operation be still
continued, it must be proceeded with only with the greatest caution and
tenderness, on account of the great danger of injuring the walls of the
bladder.
  2049.  After the operation,  the treatment must be directed to the pre-
vention and removal of the  irritative and inflammatory symptoms, and
the  passage of the fragments  of stone through the urethra.  The patient
must be kept quiet  in  bed, or the generative organs supported in a sus-
pendor, and he should  take only thin broth and mild mucilaginous drink,
till no trace of irritation remain.  But when this has completely ceased,
he may gradually return to more and solid food, sit up, and go about for
any length of time,  but always having the generative  organs supported.
If febrile symptoms, inflammatory irritation and swelling of the  mucous
membrane of the bladder and urethra, of the prostate and generative
organs, and of the inguinal glands occur, antiphlogistic treatment, suiting
the  degree and character of these symptoms, and the constitution of the
patient, by general or  local blood-letting, lukewarm  baths, washes and
internal treatment must be resorted to,.  If with these symptoms, general
coldness of the body, and wTeak, often very small pulse  show a prostration
of the  powers, then dry rubbing, aromatic applications, the internal use
of aromatic  infusions,  and  even of volatile irritants,  with due  caution,
must be employed.  Inflammatory affections  of other organs,  which,
although depending on the constitution of the patient,  maybe excited by
the  operation,  require the closest attention and corresponding treatment.
  2050.  The escape of sand and small portions of stone produced by the
crushing, generally follows the first voidance of the urine, and is repeated
each time it is afterwards passed ; accompanied with more or less burning
sensation in the urethra, but without further irritation.   Small fragments,
even up to four lines, if they be round, do not in general cause any parti-
cular symptoms; but if larger, hard  and angular, they irritate  and wound
the  mucous membrane  of the  urethra, excite inflammation, get fixed most
commonly in the fossa  navicularis, and producing difficulty in passing or
entire retention of urine, excite the most violent  and painful symptoms.
This fixing of the fragments  of stone  in  the urethra is very frequent,
according to Leroy in  four cases to one,  and hence has arisen the great 
CRUSHING, OR LITHOTRITY.                293
number of instruments proposed for their removal.  Often, however,
even small pieces cannot be forced out, because either the bladder is
paralysed or its neck is spasmodically contracted.
  2051.  To prevent this accident, various plans have been attempted to
get rid of the fragments of stone  from the bladder.   Heurteloup with
his lithocenose, a straight or curved steel canula, with two side openings
and a hemispherical terminal piece introduced into  the bladder, injects
water, and allows it to flow out again.  The small pieces escape with the
water, the larger get entangled in the openings, and must then be broken
up, either by the introduction of a  solid tube, or with a toothed knob,
which can be rotated (Leroy).   This  operation  may be often repeated
without removing the tube till its blind end is loaded with the fragments
of the stone.  Heurteloup also uses spoon-shaped forceps in form of his
percuteur, and  Leroy the small instrument of Jacobson,  introduced
through a  canula.   Schleiss (a) has for this purpose constructed   an
evacuating catheter, after the fashion of Heurteloup's percuteur, by
which he can at the same time  inject; and some have also employed
Cooper's curved forceps.   All  the  instruments,  however, with which
fragments are caught hold, of and  drawn through the  urethra are attended
with danger of wounding, and injuriously irritating  the urethra,  in con-
sequence of the projection of the angles of the fragments.
   2052.  Fragments of stone fixed in the urethra must be either thrust
back into the bladder, or drawn  out through the urethra, or removed by
a cut into the urethra.   The suitability of one or other of these modes of
proceeding must depend on the seat of the lodgment of the fragment: if
the  piece of stone be fixed in the neck of the bladder, or if it have  not
passed the prostatic part, it is most easy and proper  to push it back into
the bladder, which  may be done with  a thick elastic or metal catheter,
or  by forcible injection into the  bladder, so  that, when the  piece  has
been there pushed,  it  may be further crushed.   When the fragment  has
penetrated into the membranous part, it often cannot be  pushed back
into the bladder, as the enlargement of the prostate in the urethra which
frequently accompanies stone, opposes its return ; it is then  more advisa-
ble and necessary to pull it out: and the same practice must, be adopted
in reference to fragments in the fore part of the urethra.
   2053.  A variety 6f instruments have been employed for withdrawing
fragments of stones fixed in the urethra; some of these  were known in
old times, others have been proposed  since the introduction of lithotrity,
in consequence of the more frequent occurrence  of  this accident.  The
old instruments are, Lamotte's forceps, in shape of a snipe's bill; Hun-
ter's or Hale's forceps ; Fabricius Hildanus's forceps; Pare's borer;
that of Fischer for  crushing the stone ; and Marini's metal loop.  The
latter  instruments  are,  Hunter's forceps,  modified with  a moveable
branch ;  Cloquet's metallic loop, which is passed through a canula, and
drawn together by  means  of a screw, so as to crush the stone when
caught ;  Colombat's figure-of-eight loop ; Jacobson's miniature instru-
ment ; Cooper's curved  forceps  ; Amussat and Sagalas's small percu-
teur; Civiale's hook; Leroy's three-limbed forceps, with or without a
borer; Amussat's  four-limbed forceps;  Lerov's jointed  curette, with
(a) Above cited, pi. viii. f. 15, 17. 
294
STONE IN THE BLADDER ;
Dubowisky's modification, which has a borer added; Leroy's urethral
forceps, with an articulated curette, and a percuteur with a curette; and
Amussat's and Sanson's catheter furnished with a very large side open-
ing-
  2054. From the number of these instruments may readily be compre-
hended the difficulty accompanying  the withdrawal  of the fragments of
stone from the urethra.   Their use always requires the greatest circum-
spection and care.  The straight or curved canular  forceps of Hunter,
Leroy, and others, are  in general the most fitting, as are also Cooper's
forceps, when the fragments are deeper seated in the  membranous part
of the urethra.  Leroy's jointed curette,  indeed commonly grasps the
stone, but only moves, without drawing it  out, if it be not also fixed  or
crushed by the  borer.   According to  Pigne, Sanson  has in  several
instances  where he  had in  vain used  the  most suitable  instruments,
effected the withdrawal of stone by means of an elastic catheter, with one
or two large side openings, with the greatest ease and without pain.  The
position of the fragment of the stone is first determined with a  metallic
catheter, which is then withdrawn, and an elastic catheter with its metal
stem  passed down to the fragment, shows its  place a second time, by
rubbing against it; the metal stem must then be drawn back about two
inches, and by twisting  the catheter, its opening must be endeavoured to
be applied to the stone,  which almost always  at once gets into it, and is
withdrawn with  the  catheter.  If the  fragment be quite close to the
orifice of the urethra, it  may,  after slightly enlarging  the orifice with a
little cut downwards, (par. 2042,) be pulled out with a pair of common
forceps.
  2055. If a fragment of stone stick so fast  in  the urethra, that it can
neither be  thrust back  into  the  bladder, nor pulled out,  and if it be
situated at an accessible part of the urethra,  the coverings  must be cut
through, and  the fragment removed  through the wound.   An elastic
catheter must then be introduced into the  bladder,  and  the wound per-
fectly united.
  2056. When after the escape of all the  fragments of stone, no further
symptoms appear, a close and careful examination of the bladder must be
made, according to the  rules already laid down, to be perfectly  satisfied
that there is no remnant of the stone, which may cause its reproduction.
Prudence  also requires  that  the examination should  be repeated from
time to time, before  it can be ascertained  that the  patient is quite freed
from the stone.
  2057.  Crushing the stone is effected in  women in the same way, and
according to the same rules as in men.  The shortness, greater width,
and  extensibility  of*the female urethra  render the introduction and
management of  the instrument, as well as the withdrawal of large  frag-
ments of stone,  easier.  It  must,  however,, be remembered  that  on
account of this very condition of the urethra,  it is more difficult to retain
the proper quantity of the injected fluid, and that the stone mostly lies on
the sides of the bladder, on which account it may be more easily seized
with curved than with straight forceps.   The finger, however, introduced
into  the vagina  can alter the  position of  the stone, and  bring  it to the
instrument. 
CRUSHING, OR LITHOTRITY
295
  Besides the works already quoted, the following may be referred to:—
  Civiale, Nouvelles Considerations sur la Retention d'Urine, suivies d'un Traite
sur les Calculs urinaires, sur la maniere d'en connaitre la nature dans I'interieur de
la vessie, et la possibilite d'n  obtenir la destruction sans avoir recours a la Taille.
Paris, 1823.   8vo.—Premiere  Reclamation, 13 Fevrier, 1823.—Lettre au Chevalier
Kern.   Paris, 1827.   8vo.—Lettres sur la Lithotrite.  Paris,  1828, 1831,  1833,
1837.—In Revue Medicale,  1826. vol. iv. p. 332.—1828. vol. i. p. 492.—1828. vol.
iii.  p. 97.—Archives generales de Medecine, vol. xii. p. 156.—Lancette, vol. iii. p.
369.  1820.—Gazette  Medicale, vol. ii. p. 141.   1830.—Lettre sur la Litfiotrite
Urethrale.   1831.—Mem. de l'Academie de Medecine, vol. iv. p. 243.   1835.
  Leroy d'Etiolle,  Seance  de l'Academie de  Medecine,  du 13 Juin,  1822.—
Archives generales de Medecine, vol.  i. p. 616.  1823; vol. iii. p. 396;  vol. xii.
p. 619.—Gazette de Sante.  July, 182"2.—Journal Cornpl. des Sc.  Med., vol. xiii.
p. 214.—Lettre a Scarpa, ibid. vol.  xxiv.—Journal generale de Medecine, vol. xcii.
p.  287;  vol.  xciii. p.  282.  1825.—Lancette, vol. iv. p. 271.   1831.—Gazette
Medicale, vol. iii.  p.  365.   1831 ;  Reponse  aux Lettres de Civiale.   1831.—
Memoires de l'Academie de Medecine, vol. v.  p. 221.   1836.
  Amussat, Note sur la possibilite de sonder 1'Uretre de l'homme  avec  une sonde
tout a fait  droite, &c.  Paris, 1822.^-Seance  de l'Academie, 13  Janv.,  1832.—
Archives generales de Medecine, vol/tv. p. 31.  p. 517.  1823 ; vol. xii. p. 146.
1826 ;  vol. xvi. p. 110.  1827.—Journal Analytique, p. 385.  1829.—Lancette, vol.
ii. p. 157.   1829.—Gazette  Medicale, vol.  ii.  p. 71.   1830.—Table synoptique de
la Lithotriptie.  Paris. 1832.
  Heurteloup;  in Archives generales  de  Medecine, vol. v. p. 150.  1824.—Re-
ponse  a. Civiale, ibid.;  vol.  x. p.  480.   1826.—Lettre a l'Acad. des Sciences.
Paris,  1827.—Revue Medicale,  vol.  iii. p. 342.  1828.—Cases of  Lithotrity, or
Examples of the Stone cured  without incision, &c.   London, 1830.  8vo.—Lettre
sur I'avantage de preferer la Percussion et la Pression.  Paris, 1833.
   Cooper, Astley; in Med.-Chir. Trans., vol. xi. p. 358.  1820.
   Lukens ; in Philadelphia Journal, vol. i.  p. 373.
   Brousseaud, Archives generales de Medecine, vol. x. p. 566.  1826.
   Murat,  Rox, Gimelle, Rapport a l'Academie.   1825.
   Delattre, Quelques Mots sur le Broiement de la Pierre.  Paris, 182o.
   Bellinaye, On the Removal of the Stone without cutting instruments.  London,
 1825.
   Harveng, Heidelberger klinische Annalen, vol. i. p. 424.
   Meyrieux; en Archives generales de Medecine, vol. x.  p. 628.  1826.
   Kern, Bemerkungen fiber die  Civiale and Leroy's che Methode.  Wien, 1826.
    Desgenettes, Lettre  a  Scarpa; in  Journal Complementaire, vol. xxiv. p. 36.
 1826.
   Tavernier; in Journal de Progr&s, vol.ii. p. 174.   1827.
    Scheinlein; in  Salzb. Med.-Chir. Zeitung., June, 1826.
   Seiffert, Ueber die franzosische  Methode  Blasensteine zu entfernen, u. s. w.
 Greifswalde, 1826.
    Magendie, Rapport a l'Institut, 1825; in Revue Medicale, vol. ii. p. 454.
    Lemaitre, Florian, Du Traitement de la  Pierre; in Clinique, vol. ii. p. 282.
 1828.
   Fournier,  (de Lempdes,) Lithotritie perfectionnee.   Paris, 1829.
    Rigal;  in  Clinique Universelle, vol. i. p. 231.—Archives generales de Medecine,
 vol. xxi. p. 459.  1829.—Lancette,  vol. ii. p.  176.  1829.—Brochure sur la Litho-
 tritie.   1829.
    Pamars, Lithotriteur courbe;  Clinique, vol.  i. p. 231.   1829.
   Bancal, Manuel pratique de la Lithotritie.   Paris, 1829.
   Dumeril, Rapport a l'Institut; in Revue Medicale,  vol.  iv. p. 482.  1829.
   Drouineau, Consideration sur la  Lithotritie;  These.  Paris, 1829.
   Blandin, Journal Hebdomadaire, vol. iii. p.  193.  1829. vol. vi. p. 301.  1830.
    Waenker, Ueber den praktischen Werth der Lithotritie.  Freiburg, 1829.
   Jacobson;  in Hamburg. Magazin der ausl. Heilk.   1830.
    Pravaz, Lithotriteur courbe;  in Archives generales, vol. xxii. p. 256.   1830.__
 Lithotriteur droit, in same, p.  413.—Gazette Medicale, vol. ii. p. 207.  1831. 
296          CUTTING FOR  THE STONE, OR LITHOTOMY J
  Tanchou ;  in Archives generales, vol. xxiii. p. 300.   1830.
  Thiaudiere, These sur la Lithotritie.   Paris, 1830.
  Dollez, These sur la Lithotritie.  Paris, 1830.
  Demetrius, These sur la Lithotritie.  Paris, 1831.
  Segalas, Observations de Lithotritie.   Paris, 1831.
  Benvenuti, Essai sur la Lithotritie.  Paris, 1833.
  Blandin, De la Taille et la Lithotritie.  Paris, 1834.
   [Randolph, N. R. Smith & Gibson  in  the Am. Journ. of Med. Sci.
vols. 15, 18 and  19.—g. w. n.]
  Begin, Dictionnaire de Medecine et de Chirurg. prat., vol. xi. p. 113.   1834.
  Caffe, Journal de Connaissances Medico-ChirurgicaleS.  Sept. 1835.
  von Wattmann,  Ueber die Steinzerbrechung und ihr Verhaltniss zum  Stein-
schmitte.  Wien, 1835.
  Doubovitzki, Reproduction fideles des  Discussions qui ont eu lieu sur la Litho-
tripsie et la Taille a l'Acad. de Medec.   Paris,  1835.
  Hecker, Die Indicationen der Steinzertriimmerungsmethode.  Freiburg, 1836.
  Charriere, Catalogue des Instrurnens destines  a l'Operation  de la  Lithotritie.
Paris, 1838.
  Graf; in Oestereich. Medic. Wochenschrift, 1841.
          OF CUTTING FOR THE STONE, OR LITHOTOMY.

(Lithotomia, Cystotomia, Lat.;  Steinschniite oder Blasenschnitte,Ge,Tm.',  Taille, Fr.)

  Schaeffer, Dissert, de variis Lithotomiae generibus.   Argent, 1724.
  Le Dran, F. H., Paralleje des differentes manieres de tirer la Pierre hors de la
Vessie.  Paris, 1730.
  ------Supplement au Parallele.   Paris, 1757.
  Le Cat, C. L., Recueil de Pieces sur l'Operation de la  Taille, Part I.  Rouen,
1749;  Part II.   1752; Part III.   1753.
  Pallucci, N. L, Lithotomie nouvellement perfectionnee; avec quelques  Essais
sur la Pierre et les moyens d'en empecher la formation.   Paris, 1757.  12mo.
  Dubut, (Praes. Ferrand,) De variis Lithotomiee methodis.   Paris, 1771.
  Morand, Salvat.,- Opuscules de Chirurgie,  part ii.
  ------, Eloge de M. Cheselden; in  Mem. de l'Acad. Roy. de Chirurgie, vol.
iii.
  Louis, Rapport des  Experiences faites par  l'Academie Royale de  Chirurgie sur
differentes methodes de tailler; in Mem. de l'Acad.  de Chir., vol. iii. p. 623.
  Sammlung auserlesener, zur  Geschichte und Ausiibung des Blasensteinschnittes
gehoriger Abhandlungen; mit Kupfern.  Leipsig, 1784.
  Hartenkell, Tractatus de Vesicae Urinaria?  Calculo.   Bamb. et Wirceb., 1783.
  Earle, Sir James,  Practical Observations on  the  Operation  for  the  Stone.
Second Edition.   London, 1796.
  Deschamps, Traite historique et dogmatique de l'Operation de la Taille.  Paris,
an iv.  4 vols.; avec un supplement, dan lequel I'histoire de la Taille estcontinuee,
depuis la fin siecle dernier jusqu'a ce jour; par. L. J. Begin.   Paris, 1826.
  Schuler, Antiquitates Lithotomiae.  Hal., 1797.
  Thomson, Observations on Lithotomy.  Edinburgh, 1808.
  Allan, Robert, Treatise on the Lithotomy.  Edinburgh, 1808.  fol.
  Dupuytren, G., Lithotomie.   Paris,  1812.
  Mechlin, A.,  Dissert. Apercu historique et  pratique sur  l'Operation de la Taille
chez l'Homme.  Strasbourg, 1822.   4to.
  von Kern, V., die Steinbeschwerden der Harnblase, ihre verwandten Uebel und
der  Steinschnitt bei beiden Geschlechtern.  Wien, 1828.  4to.
  Dupuytren, Memoire sur l'Operation de la Taille, acheve par Sanson et Begin.
Paris,  1826.
  Bassow, B., Diss, de Lithiasi vesicae urinariae in genere et in specie de retractione
Calculi per sectionem perinaei; cum  tab. ix.   Mosquae, 1841. 
TREATMENT PREVIOUS TO OPERATION.             297
   2058.  The operation of cutting for the stone consists in the artificial
opening  of  the  bladder  or of its neck, at some one part, and  to  such
extent as will allow the  removal of the  stone.   This operation  should
always be undertaken  as soon as possible, because otherwise the stone
enlarges, and renders the operation  proportionally more  difficult  and
dangerous.   It  is, however, contraindicated  in  severe continued  pain in
the kidneys, which depends either on stone, suppuration, or other destruc-
tion of those organs ; in  ulceration of the  bladder, which may be  dis-
tinguished  from   its simple  blennorrhagic   affections; in  considerable
thickening  or carcinomatous degeneration  of its walls;  also when  the
powers are  very low sunk, and there has been previous wasting fever;  in
great  enlargement of the stone: and, finally,  in its being  completely
encysted.   The operation must be deferred  if there be any accidental or
passing  disease,  if great  inflammation of the bladder and its neck, if
much sympathetic irritation of the  digestive organs, continued uneasi-
ness, vomiting,  and  the  like, as  also if there be stricture  of the urethra,
untill the passage be restored.
   The circumstances which contraindicate cutting for  the stone require close and
careful consideration, as  experience  frequently shows that, even  under the most
unfavourable circumstances  the operation is successful, and that with the removal of
the stone, the symptoms depending on its presence, as  for example, the chronic in-
flammatory affection of the bladder, cease.  If  it be well ascertained that the stone
is encysted, it being perfectly so, must decidedly contraindicate the operation, as in
most cases it is impossible to set such stone  free, or the case may terminate fatally.
An enormously large stone can only  be considered as  contraindicating one special
mode of operation.   Cases  may occur, though very seldom, in which, though the
presence of a stone in the bladder is proved by sounding, few or no symptoms occur;
its enlargement is very gradual, and the operation does not  seem to be necessary.
It is always,  however, to be feared, that in deferring the operation till the appearance
of symptoms which require it, such  changes may accrue as will render its result
doubtful.  This especially applies to young persons; as, on the contrary, in old per-
sons, the  operation must be  considered to be  contraindicated (1).
   [(1)  "The age of the patient," says Astley  Cooper, "does not much influence
the result of the operation, with the exception I shall mention.  Old age is not to be
a bar to it if, so far as the stone will permit, the patient be active and have no other
complaints.   Mr.  Cline, senior, operated successfully upon a patient at eighty-two;
Mr. Attenburrow, of Nottingham (2), at a still more advanced age.  I operated on
a gentleman aged seventy-six, and he  died about ten years after.  About sixty years
 of age is the  period at which stone is most frequent in the adult, and then the opera-
 tion is very successful.  In the middle period of life, fever is more violent from the
operation, and the patient is often too much loaded with fat to be  submitted to it.
Fat persons  do not generally bear operations well; they have little vital power;
they should be reduced by diet and  medicine; and they must be accustomed to
irritation of the bladder, by the frequent introduction of the  sound; but still  they
have more fever and disposition to peritonaeal inflammation than at a later period of
life.  The age at which there is least danger  is from  three to twenty, for death is
then  a very rare occurrence.  Under  the age of two years, children often become
convulsed, and die from the operation, on account  of their excessive  irritability."
(pp. 244, 45.)
   (2)  His son informs me  that this patient was eighty-five years old;  and  that his
father had also operated on a man of eighty-seven, who lived to the age of ninety-five.
   The earliest age  at which I have known  the operation for stone performed with
success was twelve  months, in two instances  successfully by Keate, at St. George's
Hospital.  John Hunter operated on a child of eighteen months, but the result is
not stated.  I have  recently cut a child of twenty months, but he died on the four-
teenth day of peritoneal inflammation, accompanied  with small abscesses in the irn-
   Vol. iii.—26 
298            CUTTING FOR THE STONE IN MEN;
mediate  neighbourhood of the wound.  Civiale (a) has, however, collated many
instances of infants affected with stone, one of which was cut at ten weeks, but with
what result is not stated.      ,
  Although fat persons are not very favourable subjects for stone-operations, yet with
management they may do well.  My friend Green cut a man about fifty, who a
short time before the operation weighed eighteen stone, but had been  reduced, and
the girth of whose waistcoat was nearly two yards.   He did well of the operation,
but  stone formed again; he  was lithotritized, and died with inflammation of the
mucous membrane of the bladder.—j. f.  s.]
  2059. If the stone-patient's health be otherwise good and his  mode
of living regular, it will be sufficient preparation for the  operation  to
diminish, a few days previously,  the ordinary quantity of his diet, to bathe
him several times in lukewarm water, and for  the two immediately pre-
vious days to restrict his  diet  further,  and  to  give clysters.   In full-
blooded persons, one or two bleedings should be resorted to; in haemor-
rhoidal  affections  and especially with loading of the  liver, leeches must
be  applied to the anus.  In  stout persons, with weak constitution, the
condition of  the juices and the state of the bowels must be attended to,
as this kind of constitution  may be most prejudicial to the  result of the
operation.   Under these circumstances  bathing must be used  with the
greatest caution,  and tonics  are often  called for.   The use of purgatives,
commonly  employed in the  preparatory  treatment to  cutting the  stone,
requires care; if necessary, at least a few  days must intervene between
their use and the operation.   If the  patient have worms, they must either
be first  got rid of, and then  the  operation  be performed; or  he may be
left to his ordinary quantity of  diet,  attention being paid to  its quality,
and on the day  before the operation have broth three or four  times,
according to  his appetite, and on the morning itself, bread soaked in beef
tea or rice porridge.   Old persons are to  be treated in the same way.  In
country people, who are accustomed to  coarse food, a quick change of
food, and to  a lighter kind, may be  unfavourable to the result of the
operation.   In very sensitive subjects,  small doses  of opium, extract.
hyoscyami, or aq.  lauro-cer., may be administered.
                 A.—Of Cutting for the Stone in Men.
  2060.  The history of cutting for the stone presents six different modes
in which it is performed on the male, to wit: —
   First,  Cutting with the  little apparatus.
   Second,   ,,     ,,      great    ,,
   Third,    „    ,,      high operation.
   Fourth,   „  by  the lateral     ,,
   Fifth,    ,,  into the body of the bladder from the perineum.
   Sixth,     ,,  through the rectum.
   2061. Cutting for the Stone  with  the  Little Apparatus {Apparatus
parvus, Hypocystomia, Lat.; der Steinschnitt mit der kleinen Gerdthschaft,
Germ.; la  Tuille par le petit Appareil, Fr.,) called also Celsus's method,
because  he first described it, consists in making a cut  upon  the  stone
through the perineum and neck of the bladder, and drawing it out with a
stone-spoon.   This plan  remained  the  only one, and unchanged up to
the  sixteenth century, when it yielded to  the great apparatus, and was
                       (<i) Traite,  above cited, p. 506. 
THE LITTLE  AND GREAT APPARATUS.           299
almost entirely confined to childhood.  Heister and Morand alone hare,
in more modern times,  taken it under their protection.
   2062.  A strong man sitting on a chair takes  the patient on  his lap,
and holds the thighs bent  at the knee properly apart.   If  he be not in
this way  sufficiently fixed, the feet  must be  held by other  assistants on
each side.   The operator introduces two fingers of his left hand  into the
anus, and endeavours, whilst with his right  hand above the pubic sym-
physis he presses the belly downwards, to push the stone into the neck
of the bladder; then,  upon the pVojection formed  by the  stone in  the
perineum,  on the left  side of the raphe, he makes a semilunar  cut, the
horns of which  are directed towards the  left hip-socket, through the
perineum into the bladder,  divides  its neck by a second transverse  cut,
and pulls out the stone with his finger or with  a stone-spoon.

   Such is the usual interpretation of the text of Celsus:—"Ut super vesicae cervicem
fit, juxta anura incidi cutis plaga lunata  usque ad cervicem vesicae debet, cornibus
adcoxas spectantibus paululum : deinde ea parte, qua strictior ima'plaga est,etiamnum
sub  cute,  altera transversa plaga facienda est, qua  cervix aperiatur" (a).  As a
deviation from this text, must be considered the direction, to press the  stone upon,
and  not into, the neck of the bladder, by which process the cut seems to be made
into the body rather  than  into the neck  of the bladder, which  Heister distinctly
directs; according to whom, the parts which must be  cut through are, the  skin, the
fat, and between the  left m. erector penis and the bulb, the hinder and under part of
the bladder up to its neck.   According to Bromfield (b), the semicircular cut should
be carried in such way above  the anus, that it may pass through the raphe and its
horns lie opposite to the ischial tuberosities.  This statement, which is objected to
by Closius (c), was assumed by Chaussier (d) and by Beclard (e), to be the true
interpretation of the text of Celsus, and both these surgeons have proposed a peculiar
practice by the addition of a staff, which Dupuytren adopted successfully in a living
person in the year 1824.   This proceeding, in which the neck of the bladder is cut
into on both  sides, in a corresponding direction to the external cut, will be more fully
entered into  in considering the lateral operation (f).
   The objections to this interpretation may be found in Jourdan (g), Turck (h)
and  in Begin (i).  Schonmann  (j) defines the  external  cut, as being semilunar
with its convexity towards the hip-socket, its upper horn towards the  left side of the
raphe, and the lower,towards the left ischial tuberosity.

   2063.  This mode oftreatment, which has  only historical  value, is de-
servedly  objected to, as it  is  very difficult,  and sometimes impossible to
press the stone  into  the neck of the bladder, which  is bruised by so
doing ;  as there  is no certainty of what parts are cut through; and as the
operation is performed without  a staff, the  urethra  may be cut  through
transversely, and the ureters, seminal vesicles, and the vas  deferens of
the  left side may be  injured (/c),  It  can only be  called for in the rare

   (a) De Medicina, lib. vii. cap. xxvi,       de la Taille chez les Hommes.  Strasb.,
   (b) Chirurgicale Cases and Observations,  1818.
vol. ii. p. 218.                            (g) Article Lithotomie, in Diet, des Sc.
   (c) Analcetaquajdam ad historiam Litho-  Medicales, vol. xxviii. p. 384.
tomioe Oelsiaiice.  Tubing., 1782.             (A) Journal Complement,  du Diet, des Sc.
   (d) Moreland, Dissert. Propositions sur  Med., voL iii. p. 184.
divers objcis de Medecine.   Paris, 1805.       (i) Supplement to  Deschamps, Traite  p.
  (e) Propositions  sur quelques points  de  420.
Medecine.  Paris, 1813.                    (j) Oommentatio de Lithotomia Celsiana.
  (/) Ilsemann, J. G.,  (Praes. L. Heister,)   Jenae, 1841.
Dissert, de Lithotomiae  Celsianae prtsstuntia    (k) John Bell, Principles of Surgery, p.
et  usu.  Helmst., 1745.—Turck, De ITnci-  59.  pi.  v. London, 1815.—Froriep's Chi.
sion  pratiquee par Celse dans l'Operation  rurg. Kupfertaf., pi. lxxi. 
300
CUTTING FOR THE STONE ;
case of a stone developed in the  neck of the bladder, forming a distinct
projection in the perineum, and when no staff can be introduced.
  Upon this operation the following works may be consulted :—
  Celsus, De re medica. lib. vii. cap. xxvi.
  Ilsemann, J. G., (Praes. L. Heister,) Dissert, de Lithotomia Celsianae praestan-
tia et usu.  Helmst., 1745.
  Clossius, Analecta quaedam ad historian Lithotomiae Celsianae.  Tubing., 1792.
  Turck, De l'Incision pratiquee par Celse, dans l'Operation de la Taille chez les
Hommes.  Strasb., 1818.
  2064.  Cutting for the Stone with  the Great Apparatus, (Apparatus
magnus, Lat.; der grossen Gerdthschaft, Germ.;  le grand Appareil, Fr.,)
so named on account of the great number of instruments required for the
operation,  was invented by Johannes de  Romanis in the beginning of
the  sixteenth century,  and subsequently made  public  by  Marianus
Sanctus de Barletta, on which account it was long called the  Sectio
Mariana.   This method consists in first passing a staff into the bladder,
in opening the urethra in its spongy part, by a cut through the perineum,
and in enlarging the neck  of the bladder, by particular instruments, to
such an extent that the stone can be pulled out.
  2065.  The patient having  leaned  backwards on an oblique surface,
was placed upon a high stool, or on the edge of a table; his hands bound
to his feet, which were drawn up and separated from each other, and at
the same  time several turns of the bandage passed round his neck and
shoulders, and himself held by assistants.  A staff was then introduced
into  the bladder, with which it was attempted  to ascertain the presence
of the stone, and  at  the  same  time, also,  if possible, its  size.  The
handle of the staff was given to an assistant, who inclined it  a little
towards the belly, and at the same time also  raised the scrotum.   A cut
was  then  made on the left or right side of the  raphe, upon the staff, be-
ginning below the  scrotum, and terminating  an inch above the anus, in
males  usually about four fingers' breadth long.  If the bistoury did not
at first hit upon the groove of the  staff', a second cut divided the bulb
and  a small part of the pars membranacea urethra; the gorget, conductor,
or dilator, was then entered on  the groove of the  staff, the staff drawn
back, and the neck of the bladder enlarged with the gorget.  The stone-
forceps were then passed in, and assisted  also in enlarging the neck of
the bladder,  and with them the stone was grasped and drawn out.
  2066.  This mode of operating has manifestly great advantage over the
little apparatus, but instead of the simple enlargement of the neck of the
bladder, as was the object for which it was employed, considerable tear-
ing and bruising was always produced,  as experiments on the  dead body
at least have proved, and pulling out the stone was always accompanied
with  great difficulty, and  injury of the parts.  The serious symptoms
which mostly followed this mode  of operation were, extravasation of
blood, abscesses, destroying suppuration, gangrene, fistula, incontinence
of urine,  and the like.   It  must not, however, be overlooked  that the
results with  the great apparatus were not exactly so unfavourable, as
usually considered  to its prejudice ;  this Deschamps proved, and in re-
ference to  the consideration of  the  several modes of proceeding in the
lateral operation, is of very great importance (a).
  (a) Chelius, Bemerkungen iiber den Steinschnitt; in Heidelb..kliuiscb.Annalen,.voL.vi»
pt. iv. 
THE  HIGH OPERATION.
301
  Mareschal, by his coup de maitre, in which, for the purpose  of separating the
urethra from the anus, he raised the staff under the pubic symphysis, inclined the
handle towards himself, and thrusts his lithotome further into the urethra,endeavoured
to give the cut a greater extent; but  by this method the rectum was  always liable
to be injured.  Vacca Berlinghieri's  (a) treatment, which will be noticed  here-
after, resembles this practice.
  Upon this mode of operating may be consulted
  Mariana Sancti Barolitani, Libellus aureus de Lapide ex vesica, persectionem
extrahendo.  Venet., 1535.
  Fienus, T., Tractatus de  Sectione Calculi, seu  Lithotomia.—Wundarzneikunst.
Nurnberg, 1675.
  Franco, P., Traite des Hernies, &c.  Lyon, 1561.
  PineAu, S., Discours touchant l'Invention et l'Extraction du Calcul de la Vessie.
Paris, 1596.
  Hildani, G. Fabric, Lithotomia Vesicae.  Basil, 1628.
  Toilet, F., Traite de la Lithotomie ou l'Extraction de la Pierre hors de la Vessie.
Paris, 1708.  Cinq. Edit.
  Alghisi, T., Litotomia, overor dal  cavar la Pietra.  Florenza, 1707.
  Goelicke, A.  O., De optima Lithotomiam  administrandi  ratione.   Halae,  1713.
  Colot, De l'Operation de la Taille.  Paris, 1727.
   2067. Cutting for the Stone by the High Operation  (Apparatus altus,
Epicysteotomia,  Cystotomia  epigastrica, Lat.; der Iwhe Apparat, Bauch-
blasenschnitt,  Germ.;  le haut Appareil,  Fr.)  consists in  opening the
bladder between the upper edge of the pubic symphysis and the foloj of
peritoneum, passing over the bladder.   This operation was first performed
by Franco (b) in the year 1561, and he must be considered as  the dis-
coverer  of the  method,  although Archigenes  had previously proposed
it.   Rousset  (c)  closely  describes  the proceeding, and points  out  its
advantages.   It found, however, but little acceptation, on account of the
still general opinion  of the great danger of wounding the  body of the
bladder, till it was first again performed in England by Proby (d);  then
ao-ain brought into some repute by  John  Douglas (e), Cheselden  {f),
Prye  (g),  Thornhill, Macgill (h), Heister {i), and Morand  (_;).
The lateral operation, however,  soon displaced it; but Frere C6me's(&)
fortunate experience raised it again  for a short time ; since then, how-
 ever, it  has  been  restricted to those  extreme cases only in  which,  on
 account of the great  size  of the stone,  it could  not be got through the
 lower opening of the pelvis.   In more recent times it has been performed
 especially by Souberbielle, at  Paris,  with  success; and  has  been

   (a) Delia Litotomia nei due sessi,  4th     (/) A Treatise on the High Operation for
 Mem.   Pisa, 1825.                      the Stone.  London, 1723.  8vo.
   (b) Traite des Hernies, contenant, &c, et     (g) Some  Observations  on the several
 autres excellentes Parties de la Chirurgie,   Modes of Lithotomy.  London, 1724.
 assavoir  de la Pierre, &c,  p. 139.  Lyon,    (h) Middleton,  A short  Essay on the
 1561.                                  Operation of Lithotomy, as is performed by
   (c) Traite Nouveau de l'Hysterotomoto-   the New Method above the Pubes; to  which
 kie ou EnfantementCesarien.   Paris, 1581,  is added, A Letter relating to the same sub-
 chap, vii.__Petrus le Mercier, Thesis, An  ject, from Mr. Macgill to Dr.  Douglas.
 ad extrahendum calculum  dissecanda ad  London, 1727.   4to.
 pubem  vesica?  Paris, 1685; in  Halleri    (i)  De Apparatu Alto. Helmst, 1728.
 Disputationes Chirurff., vol. iv. p. 985.         (J) Traite de la Taille ou Haut Appareil.
   (d) Philosophical Transactions, vol. xxii.  Paris, 1728.  8vo.
 p. 1700.                                 (^)  Nouvelle Methode d'extraire la Pierre
  ' (e) Lithotomia Donglasiana, or an ac-   de  la vessie urinaire par dessus le pubis
 count of a New Method of making the High   qu'on nomine vulgairement le  Haut Appa-
Operation. London, 1719.—Lithotomia Dou-   reil, dans l'une et  l'autre sexe sans  le  se-
glasiana.  London, 1723.                  cours d'aucun fluide retenu ni force dans la
                                       Vessie.  Bruxelles, 1779.
                                    26* 
302                  CUTTING  FOR THE STONE";
 defended by  Carpue (a) and  Home (b).   Scarpa (c), and' still more
 recently,  Dzondi  (d), Belmas (e), Amussat,  Baudens,.  and  Leroy
 d'Etiolle (f) have endeavoured in various ways to improve the opera-
 tion and the instruments.
   2068. The following  is the mode of proceeding usually employed in
 cutting for the stone with the high apparatus.  The patient lies on a bed
 covered with  a matress ;  the pelvis a little raised by a pillow  beneath it;
 the lower limbs half-bent at the knee and  hip-joints; the head moderately
 supported so that the abdominal muscles  may be relaxed.  After the in-
 troduction of the arrow sound (sonde a darde sonde a fieche) of Belmas
 into the bladder, and the discovery of the stone, the operator standing on
 the patient's right side, makes a cut of three inches' length with a convex
 bistoury,  whilst on both sides of the white line he tightens the skin above
 the edge of the pubic symphysis with the fingers of the left hand, exactly
 in the direction of  the white line, through the skin, cellular  tissue, and
fascia  superficialis.  He now  thrusts, immediately  behind the pubic
 symphysis, a straight bistoury into the under  part of the white line, about
 an inch deep, and ascertains by the obstruction ceasing, and the fat and
 loose  cellular tissue protruding,  that  the white  line  is divided, and
 the bistoury has  penetrated into the space between the pubic bones, the
 bladder, and  the convexity of the peritoneum.   The  point of the left
 forefinger is now introduced into this opening, the "peritoneum separated
 from the wall of  the belly, and  the wound  enlarged' upwards by means
 of a common  button-ended bistoury, or by Belmas's buttoned bistoury,
 introduced  on the volar  surface of  the forefinger, which is  to be done
 rather by pressing the bistoury on,  than by a stroke.   The operator then
 grasps  the handle of the arrow sound with the right hand, and sinks it,
 so that the  other end rises up immediately behind the pubic symphysis,
 and lifts up the front wall of the bladder like a hillock  into the%wound;
 the left finger  already in the wound at the same time directing the move-
 ment of the beak of the sound, and pressing back the peritoneum.  The
 beak of the sound,  with the portion of the  bladder covering it, is now
 fixed with  the thumb and forefinger of the left  hand, and the arrow of
 the sound pushed out by an assistant.  A straight  bistoury is then thrust
 upon the groove of the  arrow,  and the front  wall of the bladder cut
 through from above downwards, the forefinger of the left hand quickly
 introduced  through this wound into the bladder, and its volar surface
 being directed upwards, and the finger crooked seizes the upper angle of
 the wound  m the bladder, and holds the bladder in a position correspond-
 ing to the external wound.  If the wound in the bladder do not answer
 to the size of the stone, it must be  enlarged  with a button-ended bistoury
 downwards, towards the neck of the bladder.  If the fingers  of the right
 hand cannot seize and draw out the stone, a pair of common stone-forceps

   (a) A History of  the High Operation for   (d) Eine leichtere und sichere Weise, den
 the Stone by incision absve the Pubes.  Lon-  Stein aus der Urinblase zu entfernen; in vox
 don, 1819.                            Graefe  und von Walther's Journal,  vol.
   (b) On, a New Mode of performing the  xiv. p. 173.
 High Operation for the Stone; in his Practi-   (e) Traite de la Cystotomie suspubienne.
 eal Observations on  the Treatment of Stric-  Paris, 1827.
 tares in  the Urethra, vol. iii. p. 359. London,   ( f) De la Cystotomie epipubienne. Paris,
 1821.                               1637.
   fc) SuK Taglio epigastrico.  Pavia, 1820.. 
THE  HIGH  OPERATION.
303
may be introduced into the bladder, with which  it is easily caught and
pulled  out, and which may  also, if necessary, be  assisted by introducing
the finger into the rectum.

  The two most important accidents which may occur in cutting for the stone above
the pubes, to wit, wounding the peritonaeum, and dropping down of the bladder, at the
moment it is cut into, have led to various modes-of proceeding in reference to cutting
through the coverings and the bladder.
  Franco, with his finger introduced  into the rectum, pressed the stone against the
back of the white line, and cut directly upon it.   Rousset distended the bladder with
a mild fluid to such an extent as to raise it above the pubes, and bring  it  near the
wall of  the belly.   Douglas, Cheselden, and Morand, increased the size and re-
sistance of the bladder, by injecting only moderately, as a greater distention is very
painful  and often not possible.
  Frere Come, instead of injection, used the dart sound (a), which he  introduced
through a cut  previously made in the membranous part of  the urethra  into the
bladder.  Loder (6)  objected to this  previous cut in the perinaeum,  and passed the
arrow sound  through the  urethra into the bladder;  and the  same practice  was fol-
lowed by Zang and Home.   Zang further  advises that the patient should perfectly
discharge his urine before the operation ; and for the purpose of effecting this more
certainly, a small quantity  of  decoction of mallows  may be injected through the
catheter into the bladder, and afterwards allowed to escape.  Then, if  the patient
can bear it, a tolerable quantity of the same decoction  may be injected gradually
into the bladder, which being thus distended, separates the  peritonaeum more from
the upper edge of the pubic symphysis, and saves it from injury.  The  penis must
be tied  till the bladder is  exposed, and then the dart sound  introduced through the
urethra.
   Scarpa gives the dart sound a large  sweep and a deep groove, and dips the bistoury
a line and a half from its tip into the bladder, more  certainly to prevent its slipping
off the sound.  The  large curve of Frere Come's dart sound  easily permits its beak
to be thrust against the upper part of  the bladder, and by its  movement  against the
pubic symphysis, the drawing away also of the peritonaeum, for which purpose Bel-
mas makes the curve of his instrument shorter and greater, and  the further alteration
that the beak of the instrument is furnished with a button  end, can  be protruded
further, so that as soon as it is  properly introduced into  the bladder, the arrow may
be pushed forwards. Dzondi uses, as had been done previously by Rousset and
Sermes, a catheter grooved on its concave side, which is very safe, if the knife be
dipped  some lines  before  the point of  the catheter  into the  bladder.  Leroy
d'Etiolle has recommended for raising the bladder, an instrument similar to Heur-
 teloup's percuteur,  with moveable  branches for  that purpose.   Many modern
 surgeons (Baudens, Amussat) object to such instrument for  raising the bladder, and
 pressing it forward, when it has fallen together, and is empty, a proceeding which
must always be considered venturesome, as  Belmes's  arrow  sound, or a catheter
 properly used, is more safe.  Dupuytren (c), in a case where a small arrow sound
 was introduced  into  the bladder, which could not be distended  by injection, pressed
 the stone by assistance  from the rectum,  upwards,  and opened the bladder imme-
 diately upon it.
   The  best direction for the external wound is that of the  white line.  Home (d)
 made one vertical cut through the skin, above the pubic symphysis, a second deeper
 through  the fascia, and  the belly of the m. pyramidalis, and by a third cut made
 transversely, and at  a right angle with  the first, the insertion of the muscle to the
 pubic symphysis, and the loose cellular tissue  on the bladder, and then raised it up
 with the finger.  Le Dran had previously proposed cutting  into the bladder trans-
 versely.  Franck, of Montpellier, also divides two-thirds  of the  m. rectus trans-
 versely.  According to Baudens and Amussat, the  cut should be made on the  side
 of the  white line, so as to lay  bare the inner edge of one or other straight muscle,

   (a) This is a sound of which the  tip  can    (6) Koiiler's  Anleitung zum Verbande,
 be projected by a stilette, and is called by   p. 477.
the French Sonde a dard,  and by the Ger-    (c) Lecons  orales  de Clinique Chirurgi-
  mans Pfeitsonde.                        cales, vol. ii. p. 366.
                                          (d) Above cited,  p. 359. 
304
CUTTING FOR THE STONE ;
which done, and the  muscle drawn  outwards, there is  only the thin plate of the
transversal fascia to be torn through to get at the bladder.  Belmas thinks that the
cut should  be carried down  to the root of the penis, to prevent infiltration of urine
into that organ; whilst others hold that by such practice an earlier infiltration would
be produced.
  For cutting into the white line, Frere Come used the trocar bistoury and the len-
ticular  bistoury; Leroy a special aponeurotome, and the button-ended bistoury of
Rousset and Belmas ; Scarpa employed a staff.
  The  forefinger of the left  hand, which is to be introduced as speedily as possible
into the bladder when opened, serves best to steady it, and renders the blunt hook,
the gorgeret suspenseur of  Belmas  and  Leroy's instrument,  unnecessary.  The
enlargement of the wound in the bladder must be made when the size and condition
of the stone has been decided by the introduction of the finger, in which case, by the
yielding of the edges of the wound in  the bladder, a small cut is sufficient for the
removal of a large stone.  Dzondi also proposes raising the stone into the wound by
means of a button fixed upon the beak of the catheter, and to enlarge the wound if its
edges offer  much obstruction.  Home has recommended a particular kind of forceps
with a  net (a).
   2069. When the stone has been drawn  out, the  bladder carefully ex-
amined with the finger, and the wound cleaned, the end of a piece of half
unravelled linen should be passed through  the wound into the bottom of
the bladder,  but Scarpa thinks  it better merely to insert  it  in the space
between the bladder and abdominal muscles, leaving its end hanging out
of the  lower angle  of the wound.  The wound is  to be covered with lint
and compress, and the whole dressing fastened with a linen belly-bandage.
  When an opening is first made into the pars membranacea, a  silver or elastic
catheter, for the escape of  the urine, must  be introduced, and properly  fastened
(Frere  Come); by which, however, the urine does not escape  more easily nor in
larger quantity than  from a catheter introduced into  the  urethra (Home,  Zang.)
Souberbielle  (b) employs  merely a dressing covering  the outer wound,  and for
the purpose of drawing away the urine from  the wound an elastic catheter, at least
eleven  inches  long,  much curved like an S, and  furnished with several openings
along its beak ; to its outer end a  second tube of similar length is closely and firmly
attached, so as  thus to make a perfect syphon.  Segalas drew some threads of cotton
through the whole length  of an elastic catheter, so as to  hang out at both  the side
openings, and at the mouth of the  catheter (c).   By Cloquet's attracting catheter
(sonde  aspiratrice) the urine is well drawn off; and Amussat  has endeavoured to
improve it by an elastic tube curved, with an olive-shaped beak, having side open-
ings, and at the mouth furnished  with a spout, to which  a pig's bladder may be
attached.
   With the same view, to wit, the prevention of the infiltration of urine, it has been
proposed, first only to make a cut into the  lower part of the white line, to introduce
a rod, having its front end bent at a right angle, by which the bladder can be fixed
against the back of the white line, till adhesion is effected:  and, three or four days
after, to cut into the  bladder within the bounds of this adhesion (Vernieres;) or to
operate at two intervals, first to  cut  through the parts to the bladder, then three or
four days after to open the bladder, when the  surrounding cellular tissue has become
firm and  impenetrable to the urine (Vidal de Cassis.)   Here, also, may be men-
tioned  the  union of  the wound of the  bladder by suture, (Solingen, Gehlkr,) in
reference to which Pinel Grandechamp instituted experiments on animals (d), from
whence he  concludes that the danger of the high operation may be diminished.
   2070.  For some little time after  the operation, the dressings must be
changed twice or  thrice  a day, during which  time  all the urine escapes

   (a) Above cited, p. 382.                   (c) Froriep's Chirurg.  Kupfertaf., pi.
  (6) Observations sur les Operations de   318.
Cystotomie  suspubienne   pratiquees  sur     (d) In Ollivier, above cited, p. 74.
rhomme et sur la femme; in  Journ. Gener.
de Medec, vol. cv. p. 274.   1828, Nov. 
THE HIGH OPERATION.
305
through the wound in the belly, and passes between the pieces of the
dressing.   After three or four days, the strips of linen may be taken away,
as then the swelling of the edges of the wound and of the cellular tissue
between the bladder and walls of the belly is so great that the urine can-
not infiltrate.  The water now begins to flow  gradually  through the
urethra, in proportion  as the passage through the  wound narrows, and at
last it closes with simple treatment.
  Dupuytren (a) considers all precautionary rules to keep the  urine entirely away
from the wound  above the pubic symphysis as fruitless, the approximation of the
edges of the wound by the stitch openings through the perinaeum and rectum, and the
introduction of the catheter through either of them, or through the urethra, of no use,
and sometimes even dangerous, as they may produce infiltration of urine, and inflam-
mation of the peritonaeum, and  of the cellular tissue in the cavity of the pelvis.
  2071.  The untoward circumstances which may arise during and after
this operation are,—great difficulty in its performance, on account of the
bladder becoming much contracted; wounding the peritoneum ;  protru-
sion of the intestines from  the opening, and flow of urine into the cavity
of the  belly; violent inflammation of the peritoneum ;  infiltration of the
urine into the  cellular tissue, abscess, and gangrene.   When the  Con-
tracted bladder is very deep, the operation must  be performed with the
greatest care; and it must be specially remembered that the front  wall of
the bladder must be cut into, not above the pubic symphysis, but  behind
it.  If the peritoneum be wounded, the opening must be at once closed
with a  sponge.   This  is the  most serious accident; but not always  does
there  occur fatal  extravasation  of  urine  into the  cavity  of the belly
(Douglas, Frere Come, Souberbielle.)  Zang (6), in  cases of injury
of the peritoneum, recommends  for completely drawing off" the urine, the
puncture of  the bladder through the  rectum, and, in  women,  by the
vagina ; a proceeding which Deschamps (c) has generally practised, and,
for  the more safe  performance  of the puncture,  recommends a hollow
cylinder with a handle, which is brought through the wound in the blad-
der, and, by  the trocar, introduced into the rectum, the: hind wall of the
bladder is thrust into the  cylinder, and may be there perforated.  The
inflammation to be  feared after the high operation for the stone must be
prevented and  got  rid of by  suitable antiphlogistic  treatment, as  in the
lateral  operation.  Infiltrations of urine and abscess  require the use of the
knife, and such posture as  will prevent the collection of urine and of pus.
In this respect  it is  most important that the operation should be performed
with the  greatest possible  care  and  dexterity, so that the cellular  con-
nexions of the bladder be  not very much torn, nor separated to a great
distance.
  Pallucci practises  thrusting a trocar from the bladder outwards, near its neck, so
that there may be an opening in the perinaeum by the side of the anus, into which a
canula should be  inserted for the  discharge of the urine.
  2072.  If the advantages  and disadvantages of cutting for the stone
above the pubic symphysis have to be  critically reviewed, this can  only
be done from the results which  Douglas,  Cheselden, Frere Come, and
Souberbielle, have kept, without  distinction,  of the operations  they

  (a) Lecons orales de Clinique Chirurgi-    (6) Above cited, p. 274, pi. i. ii. f. 6.
cale, vol. ii. p. 361.                       (d) Above cited, vol. iv. p. 113, pi. viii. 
306
CUTTING FOR THE STONE ;
performed on a certain  number of patients, both men and women, with
small and large stones.  These  results  are but little distinguished from
those of the lateral operation.  Bleeding is not at all to be feared in this
operation; very large stones especially may be removed by it; and palsy
of the  bladder is  never consequent to it.   In our days, however, this
mode of operation, is mostly confined to those cases in which the lateral
operation is not proper, on  account of disease of the neck of the  bladder
and  of  the prostate gland; also in very large stones, which are ascer-
tained to be so previous to  operation, or during the performance of the
lateral operation; and when, on account  of peculiar crippling of the lower
limbs,  the perineum  cannot  be  well  got  at.   It must, however, be
remarked, in reference to the large size of the stone, that if it entirely fill
the contracted bladder, if the walls of the  bladder be very thick, and the
like, cutting for the stone above the pubic  symphysis is very difficult, and
may be  even impossible, because the arrow sound cannot be raised up
between  the stone and the bladder, or the  thickened  and  contracted
bladder cannot be pushed up behind the pubic symphysis; and in such
cases, especially on account of the organic changes  in the bladder, the
operation in general causes  the death of the patient {a).
  [The  following is the interesting notice left by Cheselden of the revival, as well
as of the disuse, of the high operation in his time :—" In the year 1717-18 Dr. James
Douglas, in a paper presented to the Royal Society, demonstrated from the anatomy
of the parts, that the  high operation for the stone might be practised;  which had
been once performed by Franco injudiciously, and by him disrecommended, though
his patient recovered ; and afterwards strongly recommended, but not practised, by
Rosset.  Yet no one undertook it, till his brother Mr. John Douglas, about three
years after, performed it, and with great applause, his two first patients recovering.
Soon after, a  Surgeon of St. Thomas's Hospital cut two, who both recovered ; but
the same gentleman afterwards-cutting two, who miscarried by the cutting or burst-
ing of the peritonaeum, so that  the  guts appeared, this way immediately became as
much decried as it was before recommended ;  upon which the Surgeons of St. Bar-
tholomew's Hospital, who had prepared to perform this operation, altered their reso-
lution, and went on in the old way.  The  next  season, it being my turn (b) in St.
Thomas's, I resumed  the high way, and cutting nine with success, it came again in
vogue.  After that every lithotomist of both hospitals practised it; but the peritonaeum
being often cut.or burst, twice in my practice, though some of these recovered, and
sometimes the bladder itself was burst, from injecting too much water, which gene-
rally proved fatal in a day or two.  Another inconvenience attended every operation
of this kind, which was, that the urine's lying continually in the wound retarded the
cure ; but then it was never followed with an incontinence of urine.  What the suc-
cess of the several operators was, I will not take the liberty to publish; but for my
own, exclusive of the two before mentioned, I lost no more than one in seven, which
is more  than any one else, that I know of, could  say; whereas, in the old way, (cut-
ting  on  the gripe,) even at Paris,  from a fair calculation of above eight hundred
patients, it appears that near two in five died.  And though this operation came into
universal discredit, I must declare  it my opinion, that it is much better than the old
way, to  which they all returned, except myself, who would not have left  the high
way, but for the hopes I had of a better; being well assured that it might hereafter

  (a) Scarpa  in Ollivier, above cited, p.   number of months,  alternately;  it  being
70.—Hunauld, Dissert.  Recherches com-   supposed  that the  surgeon  would operate
paratives sur la Lithotomie.  Paris, 1824.    better  for having "his band in," than if he
  (6) This expression, "my turn," alludes   had merely his own cases.  At our hospital
to an old regulation at St. Thomas's, and I   this arrangement still existed when I was
believe most other hospitals, by which each   first a student, but it was given up in 1814;
of the surgeons was directed to  operate on   after which time every surgeon operated on
all the stone cases admitted during a certain   his  own cases. 
THE HIGH OPERATION.                    307
be practised with greater success; these fatal accidents having pretty well shown how
much water might be injected, and how large the wound might safely be made."—
(pp. 327, 28.)]
   2073.  The Lateral Operationfor the Stone {Sectio lateralis, Cystotrache-
lotomia, Lat.; der  Seitensteinschnitt, Germ.; la Taille laterale, Fr.) is at
present the most usual method of operating, independent of the various
modes of proceeding  by  which  its  several  acts are performed.   It is
generally characterized by a cut made  in the perineum, extending from
the side of the raphe towards the ischial tuberosity between  the m. erector
penis and accelerator urine, by which the membranous part  of the urethra
is opened, and the neck of the bladder, the prostate  gland, and part even
of the  body of the bladder, are cut into.
   2074.  History names Franco as the inventor of this method, although
it was first brought into  use by Frere Jacques Beaulieu, at  the end of
the seventeenth century.   Mery improved  it.   In Holland,  Rau, who
had learned this operation from Beaulieu himself,  practised it with  the
greatest  success;  but  he  never  made  any thing known of his practice,
and therefore opinions  were divided about it (1).   Heister  seems to have
first rightly determined it;  and  Cheselden,  after  fruitless attempts to
make out Rau's method,  which he  wrongly thought  consisted in opening
the body of the bladder, was led to his own particular method.
   Le  Dran,  Le Cat, Frere C6me, Hawkins, Guerin,  Payola, and  others have
especially modified  the  necessary instruments, and  more recently Langenbeck,
 Klein, and Dubois, have contributed to the simplification of the operation.
   [(1) Rau's experience must indeed have been very large,  for Albinus (a), quoting
 from an oration (o) of Rau's, says that he "performed his operation on fifteen hundred
 and forty-seven men, and that he continued to perform  it frequently up to his death."
 Albinus states:—"There was undoubted proof that Rau at first treated  stone-
 patients in Holland by opening the urethra in the perinaeum, with the  great apparatus,
 which he had certainly learned at Paris.  It is also  sure that he not only saw Frere
 Jacques operate, but that he  several times examined the bodies of persons who had
 died after these operations.   But  afterwards he always practised a new method of
 his own, by which he cut into the same place as the monk had.
   " In this operation it was proposed, neither to cut into the neck of the bladder, as was
 first done, nor into the urethra, as  at that time most were accustomed to do, but into
 the bladder itself, close to its neck, on the side, and somewhat towards its lower and
 back part; which section of the bladder  could not in itself be much more dangerous
 than that of the neck or of the urethra.  And as thus the  urethra  and neck of the
 bladder remained entire, and these necessarily narrow passages, and very delicate
 parts were injured, neither by the introduction of instruments, nor withdrawing them
 with  great violence, nor by extracting even the stone, oftentimes large, rough, and
 pointed, violently and cruelly, and as much which usually happened, and very great
 evils were avoided,  it seemed far  to exceed the ordinary methods." Albinus then
 notices the dangers  and difficulties attendant on the operation, and which, he says,
 "he  had read and heard  often happened to Frere Jacques, who neither understood
 the structure nor situation of the parts, nor had any certainty by which he could guide
 the knife and forceps.  It therefore needs only when we would praise his method,
 that we should not  hesitate  openly to  affirm  it was rather  practised  by him with
 great loss of mankind, and to the  destruction of the patients, and that it would have
 been better he should never  have  thought of it, had it not given Rau the opportunity

   (a)  Index Supellectillis  AnatomicoG quam    (b) Quaere, That De Methodo Anatomen
 Aead.  Batav.  qure Ltidce est legavit vir  Docendi  et Discend.i, delivered in 1713  on
 cbrissimus  Johannes Jacobus Rau,  &c,  the day  of his  reception as  Professor of
 confectiis a B. S. Albino, qui vitam  ejus et Physic, Anatomy, and Surgery, in the Unii
 cQrationem quam Calculosisadhibuit instru- verity of Leydem?  I  am unaware of any
 mentorum que figuras addidit.  Ludg. Bat., other.—j. f. s.
 1J.BCC.XXV. 
308
CUTTING FOR THE STONE ;
 of discovering the best mode.   For he, when clearly acquainted with the structure
 and situation of those parts which were to be cut into or avoided, considered nothing
 was wanting to this method, than that a plan should be found by which instruments
 mio-ht be immediately and certainly directed to that part of the bladder; this he dis-
 covered, and  most successfully practised.  It cannot indeed be denied that Frere
 Jacques preceded Rau; but to Rau now and for ever is due the greatest praise and
 glory, that  by his  own skill, ingenuity, and industry, he made  that  addition by
 which alone  treatment, otherwise uncertain, dangerous, and even  hurtful, was ren-
 dered  sure, safer, much better,  and  more  excellent  than  others.  He added the
 catheter, as it is called, which he had deeply grooved on  its curved side; this he
 passed by the urinary passage into the bladder, and applied its convexity to that part
 of the  bladder which was to be cut, so as to enable him to find it externally, to make
 the cut through the skin upon it, to direct the knife towards it, to cut the bladder
 upon it with certainty, and to introduce the forceps directly, just as was wont to be
 done by  the great apparatus."   Not considering the common catheter sufficiently
 curved, Rau had " the curve of his made a little greater  at the termination of its
 straight part and the beginning of the  groove, and at the end of the curve  the beak
 was made straighter and longer, so that the knife might be carried backwards upon
 it, and a sufficiently large wound made in  the bladder."   Having  introduced the
 catheter, he so placed it that " its grooved curve resting near the neck, was applied
 to that part of the bladder to be  cut, on the left side, and a little below and behind
 the neck; which done, the catheter was gently pressed on that part, and the thumb
 moved externally over the soft part of the buttock, to the left of the anus between it
 and the great tuberosity of  the  haunch-bone.  Then  gently inclining the catheter
 towards his right thumb, which  he pressed from  the  right and upwards, he found
 externally, and noted the spot opposite the  curve of the catheter, at which the first
 cut was to be.  This was made on the left of the anus, about a thumb or two fingers'
 breadth from it towards the ischial tuberosity, not  nearer, lest the rectum should be
 wounded; nor farther from  it, lest  the knife  should need be thrust  too obliquely
 towards the catheter. *  * * The spot found, he first divided merely the skin  and
 a little of the fat, with a straight cut of sufficient length, from above downwards and
 outwards, that is towards the ischial tuberosity, so as to get away from the rectum;
 but he did not take much trouble about this wound.  He then passed his right thumb
 or forefinger into the wound, with his nail towards the catheter, which was kept as
 closely as possible to that part of the bladder to be cut into, again seeking for that
 instrument, and having found it, he withdrew his thumb and carefully carried in the
 point of his knife,  not, however, too  high,  and cautiously directed it towards  the
 catheter, which he had just before found with his thumb, and then gently cut through
 whatever he met.  In order that he might not easily wound the rectum, he in general
 first gently passed his finger into it, so that he  might ascertain its position and avoid
 it.   When by thus cutting gently he had nearly reached the bladder, he passed  the
 thumb or forefinger into the  wound, again seeking for  the catheter, and replacing it
 if disturbed by the patient tossing about. * * * Keeping the catheter applied on
 the left to the part  to  be cut, he then carried  the knife cautiously from the right
 through the wound, not  cutting with it, but that its point might directly reach  the
 catheter.   He then  attentively and cautiously thrust the point of the knife  into the
 groove of the catheter; and when he  knew by the feel that  the point of the knife
 and the catheter touched, and by moving it gently on either side, that then it was
 retained within the groove, then moving the knife carefully and firmly up and down,
 he cut rather  downwards, and cautiously accommodating the catheter to the knife,
 he cut into  the bladder with a moderate-sized wound, which he made to  descend
 from above  outwards  by placing the  catheter, which was obviously necessary to
 prevent injury of the neighbouring parts.  He then took care that the catheter should
 not recede from the wound  in the bladder, and having introduced  his finger, gene-
 rally discovered the  extent of the wound  and the naked catheter; especially if he
 thought it had moved its place,  it being necessary that the groove of the  catheter
 should be bare at the wound of  the bladder, so that the male conductor might be
 without doubt passed into it.  When  all was  again right,  he took the male con-
 ductor with his right hand, and attentively, carefully, and steadily pressed it forwards,
 so that it might enter the groove of the catheter without being intercepted, which
the resistance  and hardness of the latter informed him of.  Being  thus assured, he
 thrust the conductor much to the right, and drew back the catheter in proportion, at 
THE  LATERAL OPERATION (RAU's.)             309
the same time gently inclining its handle to the left.  The object of thus doing was
that the curve of the catheter might escape from the wound of the bladder into its
cavity, and at the same time the conductor still resting in the groove of the catheter,
and pushed forwards might more safely and certainly enter the cavity of the bladder.
He then moved the conductor gently about,  and if he found the bare catheter, and
especially the stone, he more certainly knew  that it rested in tbe cavity of the blad-
der.  The rest of the operation was performed, as with the great apparatus; for the
right hand held the male  conductor in the bladder, the left withdrew the catheter
from it by the urethra; then the left hand grasped the male conductor, and the right
carried the female, guided by the male, into  the bladder.  He  then  cleverly held
both conductors  apart with the fingers of the left hand, and  with the  right pressed
the forceps between them directly into the bladder, and withdrew the female  con-
ductor.   He  then sought for the stone with  the forceps, and having found it, was
certified that the forceps had not gone wrong,  but were in the bladder, and withdrew
the male conductor.  He then opened the forceps somewhat and sufficiently both to
enlarge the wound and dilate the bladder as much as possible to separate it from the
stone.  Finally, he  searched for, seized and extracted the stone, using the  same
precautions as those are  accustomed and ought  to use, who well perform this cure
by cutting into the urethra in the perinaeum.
   Such  is  the account, not very clear, certainly, which Albinus has left of Rau's
operation, but important as being the  first which  was grounded on anatomy, and not
merely empirical.   It also led Cheselden to give up the high operation; for, " hear-
ing," says he, "of the great success of Mr. Rau, professor of anatomy at Leyden, I
determined to try, though not in his manner, to cut directly into the bladder; and as
his operation was  an improvement of Friar Jacques', I endeavoured to improve upon
him by filling the bladder, as Douglas had done in the high way, with water, leaving
the catheter in, and then  cutting on  the outside  of the catheter into the bladder in
the same place as upon the gripe, which I could do very readily, and take out a stone
of any size with more ease than in any other way.  My patients, for some days after
the operation, seemed out of danger, but the  urine which came out of the bladder,
continually lodging upon the cellular  membrane on the outside of the rectum, made
fetid ulcers, attended with a vast discharge  of stinking matter;  and from this cause
I lost four patients out of ten. * * *  I then attempted to cut into the bladder in the
same manner  that Mr. Rau was commonly reported to do, but there had the  same
inconvenience from  the urine's lodging upon  the cellular membrane on the outside
of the intestinum rectum.   Upon these disappointments I contrived the manner of
cutting which is now called the .lateral way." (p. 328-30.)]

   2075. The preparation for this operation consists in  clearing  the peri-
neum of hair, and in emptying the rectum by a clyster.   The patient is
placed on a table covered  with  a firm  mattress, in a horizontal, and by
some in a  rather reclined  posture, with his head supported by pillows.
The ischial tuberosities should project a  little beyond the  edge of the
table.   The hands are  attached by bandages to the feet, which are drawn
up.  In children, also, especially, who are  generally very difficult to hold
in the operation,  it is advantageous to bind the body with a broad cloth
to the table (1).   Two assistants grasp the feet, so  as each to press a knee
with one hand against their  breast, and with the other placed on the inside
of the foot, to  hold  it  out, and  to separate the thighs  moderately from
each other;  a  third  assistant fixes the  pelvis, and  a fourth hands  the
instruments  to the operator (2).

   [(1) The direction here given of fixing a child to the table with a bandage is very
objectionable on account of the pressure it must  make upon the chest and its inter-
ference with his breathing.   It is also wholly unnecessary, if the assistants know how
to  hold the patient and do so properly.
  (2) Trifling as it  might at first seem, the holding a patient properly and steadily
during the operation for the stone, is a most important part of the proceeding, and is
of  material advantage or disadvantage  to the operator, as it is well or ill done.  The
patient ought to  be, and may be, without difficulty, so effectually fixed, that when
   Vol. iii.—27 
310                   CUTTING FOR THE STONE ;
once placed he cannot move.  The knees should always be kept as far apart as pos-
sible, and the heels close upon the outside of the great trochanters, by which the
operator has ample room for the use of his instruments.  The best mode of effecting
this is by the assistant fixing the patient's knee deeply in his own armpit, and then
dropping his upper arm vertically on the  inside of the bound limb, he hugs it closely
to his own chest, and if the patient be powerful and resisting, the assistant throws
the weight of his body upon the knee, and thus  easily inclines it outwards.  The
fore-arm  and hand being at liberty, are placed on the inside of the leg, to assist the
other hand of the assistant, which  should grasp the foot, either across the instep or
the middle of the sole, and bear it outwards.  This is the easiest and least fatiguing
mode of fixing, both to patient and  assistants, and but rarely requires any correction
during the operation.  The neck ligature, consisting of a bandage' round the neck,
carried from within outwards at the bent hams, and tied upon the  neck, adds much
to steadying  the patient, and is always advantageous; care  should, however, be
taken to insert a pad between  the neck and the bandage, otherwise the former will
be unnecessarily wrung.
  In the  operation for the stone  it should also be specially remembered that hand-
kerchiefs should be removed, and shirt-collars opened at the throat, or the patient, in
his struggles, may be choked, or at least much distressed;  and in holding him the
assistants should  be careful not to make any pressure upon the chest.
  There  is no necessity for special fixing the pelvis beyond  that which the two as-
sistants, standing on either side, are capable of;  but if the patient be very powerful
and restless a third assistant may fix his shoulders, by standing behind and grasping
them with either hand.—j. f.  s.]
   2076. The operation itself consists  of the following acts:—«.  the intro^
duction  of the staff; /3. the cut through the skin and muscles; y. open-
ing the  membranous part of the urethra ;  <J. cutting into the neck of the
bladder ; e. the drawing out the stone.
   2077. The  staff is to be introduced into the bladder, after having been
oiled, in the  same way as the catheter; the presence of the stone  is at
once ascertained with it;  but the  operation  should be  put off if it cannot
be distinctly felt.   The staff must be held  by an assistant, who, at the
same time  lifts up the scrotum, either  quite straight or  inclined a  little
towards  the right  side, or  the operator himself holds  it  with his left
hand (a).  As  the  introduction of the staff, after the patient-is put in the
posture  direc-ted, is often  very difficult, it may be passed before the per-
son is bound.
   [Brodie mentions a remarkable instance of this kind which occurred  to him:—
"The stone could sometimes be felt distinctly with the sound, appearing to  be of
large  size, while at other times it could  not be felt at all;  and sometimes when the
bladder was empty of urine, it could be perceived distinctly with the finger from the(
rectum,-  while at other times, when there was urine in the bladder, it could not be
detected  at all by this mode of examination.  In performing the operation," says
he, "when I had introduced  my finger into the bladder, I could at first discover no
stone. At last I felt it on the anterior part of the bladder, behind the pubes.  It was
not lying loose in the cavity  of the bladder, but evidently contained in a cyst, com-
municating with  the  bladder by a round  opening.  By means of a prcbe-pointed
bistoury, 1 carefully dilated the orifice of the cyst, and then introducing my finger,
separated the membrane of it from the calculus, until I was enabled to take hold of
the stone writh the forceps.  It was not  only encysted but adhering also, for it was
brought away with a portion of the membranous lining of the  cyst closely attached
to it.  The boy recovered."  (p. 323.)
   Without the stone being encysted, I have  frequently known it  impossible to find
the stone by the most careful sounding for  many months, although the symptoms
have  been so severe as almost to preclude  the possibility of doubling its existence.
I recollect one  instance where the stone was not found for nearly eight years, but

   (a) DuruYTREN, above cited, p. 15.—Dubois, Propositions sur diverses parties da l'Art de
 gulrir.   Paris, 1818. 
THE LATERAL OPERATION.                  311
was then struck, and the boy, at that time  thirteen years  old, was operated on suc-
cessfully.—j. f. s.]
   2078.  The cut through the skin and muscles is commenced, in adults,
from  twelve to fifteen, in young  people, from  nine to twelve, in boys,
from  six to seven, and  in children, five  lines  above the anus, on the left
side of the raphe, some lines  distant from it, and carried rather obliquely
from  above downwards, parallel with the ascending branch of the haunch-
bone, and at proper distance from it  to the middle of a line  supposed  to
be drawn from the anus to the ischial tuberosity.   The first stroke of the
knife divides  the  skin  and  underlying cellular tissue, and a second, ex-
tending not> quite so low, cuts  through  the  m. transversus perinei com-
pletely, and the m. levator ani partially.   If by this the membranous  part
of the urethra be not laid  bare,  so that the groove of the catheter can be
distinctly felt  by the forefinger of the left hand, that finger is to be placed
with  its volar surface towards the patient's right side, at the  upper angle
of the wound, and near to it  the part still covering the membranous  part
are to be divided.  At this place I generally press the bistoury on to the
staff, thrusting it in the direction as if I would  push  it up behind the
pubic symphysis,  and then complete the  cut by carrying the knife down-
wards (1).
   If the outer cut be begun higher than directed, there is danger of wounding the bulb
of the urethra, and the transverse artery of the perinaeum.   Continuing the cut lower
endangers either the rectum, or, if the cut be made too much outwards, the internal
pudic artery.
   Rheineck (a) always makes the cut on the right side, which has  no advantage,
and is only proper if the patient must be cut  on the right side (b), which may  be
the case if the  rectum, instead of being directly behind the prostate, be on its left
side (c).
   [Brodie directs that the staff be  " held nearly perpendicularly, the handle  of it
being, however, a little inclined towards the patient's right groin.  This causes the
convexity of the instrument to project slightly on the left  side of the perinaeum.   In
the first part of the  operation, your attention is to be directed  to the staff.  You are
to feel it with your left hand, and  the knife, held in your right hand, is to be directed
towards  it.  It is  a sure guide, following which, you can never err, even in the
deepest perinaeum.  *   *  *   Where  there is any quantity of fat in the perinaeum,
or any thing  even distantly approaching to what we call  a deep perinaeum, if you
attempt to cut at once  into the  groove of the  staff, the result is, that you open the
urethra too far forwards ; you divide the corpus spongiosum of the pern's, which  need
not in reality be divided at all; and you are then certain  of wounding the artery of
the bulb of the urethra, which otherwise is in  most instances avoided. Another in-
convenience which  attends on  this  method of proceeding is, that the wound being
too near  to the scrotum, the cellular  membrane of it is in  danger of being infiltrated
with  blood; and another still is, that a greater  mass of substance is left to be divided,
when you continue  the incision into the bladder, than there would have been if you
had cut into the urethra further back in the first instance.  I say, then, let the open-
ing in the urethra be made deep in  the perinaeum, behind the bulb, and as near as
can be to the prostate.  Place the thumb-of your left hand on the skin over the staff;
and in a  man of ordinary size, about an inch and a quarter before  the anus.  Begin
your incision immediately below this, on the left side of the  raphe, and continue it
backwards and  towards the left side, into the space between the anus, and the tube-
rosity of the  left  ischium.  Here you may cut freely; you  can  injure nothing  of
consequence.  Then feel for the staff in the wound ; direct the point of your knife
towards it, and  carefully cut into  the groove, where it lies in the  membranous part

  (a)  Medic, und Chirurg. Betracht. iiber die    (b) Klfin ; in Loder's Journal, vol. iv. p.
einfache Methode des Seitenblasenschnittes;   255.
mit einer Vorrede von C. L. Mursinna.  Ber-    (c) Deschamp's, above cited, vol. iii. p. 89
Un, 1815.                               Obs. 163, 169. 
312
CUTTING FOR THE  STONE ;
of the urethra.   All  these incisions are made low down in the perinaeum, that is,
near the rectum." (pp, 309, 10.)
  A free  cut through the skin, proportioned to  the patient's size, is always very
advantageous, as it materially facilitates the withdrawal of the stone, if it be large,
and prevents much bruising, which is  an object of great importance.  I have seen
both small and large external cuts made, and am sure that the latter are preferable
to the former, although I am not inclined to make the eut so large as to be able to
see through it into the bladder, as was jokingly said of the operations of Chandler,
who was a very good and quick lithotomist, and one of the surgeons at St. Thomas's
Hospital during my studentship.  It is not the first cut which can wound the rectum,
except with excessive carelessness, but the second, and then it may easily be pre-
vented if the surgeon keep the point of his knife raised towards the pubic arch, in-
stead of depressing it towards the rectum, as is too frequently done.—j, f. s.]
   2079.  The opening of the  membranous part of the urethra, and  the
cutting into the neck of the bladder, is that act of the operation by which
the several modes of performing  the lateral operation for the stone  are
distinguished.   These may be  arranged under the following divisions:—
First, the cut into the neck of the bladder made with the same  knife used
for the outer cut;  Second, with some special instrument for the purpose,
and from without inwards; Third, with a  special instrument from within
outwards.
 . [(Scarpa (a) has made the following important observations in reference to  the
division of the prostate in the lateral operation, whether performed with the knife or
with the gorget:—" As the apex of the prostate gland  forms the greatest resistance
to the introduction of the forceps and the extraction of the stone, this part of it ought,
in every operation of lithotomy in  the  perinaeum, to  be completely divided.  But
with respect to the body and base of the gland,  an incision, extending to the depth
of five lines, through its whole length, and consequently including a small portion
of the orifice of the bladd-er, is, with the aid of a moderate and gradually increased
dilatation, sufficient for the extraction of a stone of more than ordinary size, without
the parts through which it passes being greatly contused or lacerated.   In children,
where the orifice of the bladder and base of the prostate gland are easily distended,
and in aged persons, in whom the orifice of the bladder, and neck of the urethra are
generally much larger than in adults, an incision in the*base of the gland less than
five lines in depth, and in children, of two only, is sufficient for the extraction of a
stone of ordinary size, by means, of a moderate dilatation of those parts.  The large
size of the stone, for instance, of one exceeding twenty lines in its smallest diame-
ter, is no sufficient ground for dividing  the substance of the gland to such an extent
as to penetrate into the cellular membrane  beyond it and the fundus of the bladder;
for as an incision of such depth is constantly followed by the infiltration of urine,
gangrenous  abscesses, and fistula, between the bladder and  rectum, it is obvious
that calculi of such size ought never to be extracted by the perinaeum.  The lateral
operation has therefore limits beyond which it is impossible to pass without exposing
the patient to more serious evils than those which coujd arise  from the  presence of
the stone in the bladder." (p. 7-9.)]

  2080.  The cut into the neck of  the  bladder, made with the same knife.
To this belong the methods of Franco,  Frere  Jacques, Rau, Chesel-
den,  Morand, and others,  and as it  has been more or less modified and
employed  in recent times  by Dubois,  Klein, Langenbeck, and Kern.
When the  outer cut is made, and  the membrano.us part laid bare, either
the point of the bistoury is introduced  on the nail  of the left forefinger,
which rests on the groove  of the  staff, into it,  or the  point of the knife
is thrust directly into the groove of the staff,  behind the top of its curve,
also behind the symphysis, in a direction as if it were to  come out at  the

  (a) Memori.i sul conduttore taglienti d'HAWKUSS per 1'estraiioue delfa Pietra della Vesica..
Pavia, 1825.  Translated by Briggs. 
THE LATERAL  OPERATION WITH THE KNIFE.          313
first lumbar vertebra.   The staff is now taken with the left hand from the
assistant, brought in a parallel direction to the Unea alba, pressed towards
the symphysis, and the knife, held with the whole hand, is thrust into the
groove of the staff, according  to the direction of the outer wound, up to
the blind  end of the staff, and then in  drawing out the knife, its  handle
being a little raised, the inner cut  is  enlarged.   A common somewhat
convex bistoury serves the purpose  in this method, but  the most suitable
is a particular knife, the convex blade of which is connected firmly with
a rather long handle, as  the knives of Cheselden (a) and Dubois  (b).
  Le Dran (c), after having made the cut through the skin and urethra, introduced
a director with a beak (sonde a bee) upon the groove of the staff into the bladder, and
having withdrawn the staff examined the stone with the director to ascertain  its size,
and then thrust a convex  bistoury (bistouri h rondache) into the bladder upon  the
groove, turned downwards, of the  director.   Daunt's method is similar, in which,
after  opening the  membranous  part of the  urethra, and introducing a director, or
lithotome  furnished  with  a tongue, was  pushed in sideways  (Dease) (d).  In a
similar  manner Muter (e) operates; after opening the membranous  part,  another
staff is introduced upgn tne former, and with it a sickle-shaped knife, and in drawing
the knife out,  the neck of the bladder is cut into.
  Pouteau (/) is a  modification of Le Dran's method.  Key  (g) employs merely
a staff with a  very short curve, and aconvex bistoury  (1).
   Klein's  (h) method is peculiarly distinguished by his using a common bistoury,
and he not only always cuts completely through the prostate gland, but always also the
bladder itself.
  von Kern (?) places the nail of the left thumb in» the groove of  the staff, and
retains it there whilst he carries the knife to the blind  extremity of the staff.
  Guerin's (.j) method may be here mentioned, which, however, has  but historical
interest.
   [(Key's  operation (k)  is performed  with a straight staff, of which the  point is
curved slightly upwards to the extent of an inch, so as to avoid its catching in any
projecting fold of the bladder, and its groove deeper  than in the common  staff, to
prevent any risk of the  knife slipping out.   His knife,  in form, resembles a common
scalpel, but is longer in the blade, and slightly convex in  the back near the point,
to enable it to run with more facility in the groove of  the director.
  Operation.—"An assistant holding the director with  the handle somewhat inclined
towards the operator, the external incision  of the usual extent is made with  the
knife, until the groove is opened, and the point of  the knife  rests  fairly in  the
director, which can be readily ascertained by the sensation communicated; the point
being kept  steadily against the groove, the operator with his  left hand takes  the
handle  of  the director, and lowers it  till he brings  the handle to  the  elevation

  (a) Douglas, Appendix to the History of    (h) Chirurg. Beobacht., p.  1.  Stuttgart,
the Lateral  Operation for  the Stone, con-   1801.—Praktisehe Ansichten der bedeutend-
taining  Mr. Cheselden's present method of  stem Operationen, pt. ii.  Stuttgart, 1816.
performing it.  London. 1731.                (i) Above  cited.
  (b) Above cited.—Chelius's alteration of    (j) Memoire sur l'Operation de la Taille;
Dubois' knife;  in Wehr, Dissert, de  Litho-   in Recueil des Actes de la Societe de Lvon,
tomia laterale,  Heidelberg, 1836.            p. 390, vol. ii. 1801.—Treyrran, Parallele
  (c)  Traite des Operation, p. 307.  Paris,   des diverses  Methodes proposees pour l'ex-
1742.                                   traction des  Calculs vesicaux par l'appareil
  (d)  Essay on Hydrocele.                 laterale &c.  Paris, 1802.—Chrestieen, Dis-
  (e)  Practical Observations on  the Lateral   sert. de Nova Lithotomia Guerini.   Erlang.
Operation of Lithotomy, and on  the various   1804,—Michaelis, Etwas uber den  Blasen-
and new modes of performing this Opera,   steinschnitt.  Marburg, 1813, tab ii.—Klein.
tion, &c. 1824; with plates.               Ueber Guerin's Instrument  znm  Blastn-
  (/) Taille an  niveau. Avignon,  1765.   schniit; in Chiron., vol. ii. part ii. pi. vi. f.—
pi. i. ii.                                  1-6.—Montagxa ; in von  Graefe und von
  (g) A short Treatise on the Section of the   Walther's Journal vol. iv.p.  507, pi. vi. f.
Prostatic Gland in  Lithotomy,  &c.   Lon-   3-6.—Smith, in Baltimore Med. and Surg.
don, 1824.   4to.; with plates.               Journ. and Rev. 1834, April, p. 13.
                                          (k) Short Treatise, above cited.
                                     27*
7 
314
CUTTING FOR THE STONE ;
described in PL iii.,* keeping his right hand fixed ; then withaa ea9y simui'taneons
movement of both hands, the groove of the director and the edge of the knife are to
be turned obliquely  towards the patient's left side; the knife having the proper
bearing is now ready for the section of the prostate; at this time the operator should
look to the exact line the director takes, in order to carry the knife safely and slowly
along the groove, which may now be done without any risk of the point slipping out.
The knife may  then  be either withdrawn along  the direetor, or the  parts further
dilated, according to circumstances.  Having delivered his knife to the assistant, the
operator takes the staff in his right hand, and passing the forefinger of his left along
the director, through  the opening  in  the prostate, withdraws the director, and ex-
changing  it for the forceps,  passes the latter upon his finger into the eavity of the
bladder.   In extracting the calculus, should the aperture  in  the prostrate prove too
small, and  a great degree of violence be required to make it pass  through the
opening,  it is advisable always to dilate with the knife,  rather than expose the
patient to the inevitable danger consequent on laceration." (p. 28-30.)
   Liston (a) uses a curved staff, and  a long straight knife slightly convex towards
its point.    He " enters the knife freely into the  perinaeum, about an inch  more or
less behind  the  scrotum, and makes it cut downwards  and outwards through the
skin  and superficial  fascia,  in  a line about midway betwixt the tuberosity of the
ischium and the anus, and beyond  that orifice towards the'sacjo-ischiatic ligament.
The forefinger  of the left hand is then placed in the bottom of the wound, about its
middle, and directed  upwards and forwards; any  fibres of the transverse muscle or
of the levator of the anus that  offer resistance, are divided by the  knife,  with its
edge turned downwards ;  the finger then  passes readily through the loose cellular
tissue, but is resisted by the deep fascia, immediately anterior to which the groove
of the staff can be fek thinly covered..  The point  of the instrument is slipped along
the nail of the finger,  and, guided by it, is entered  into the groove at this point, with
its back still directed upwards.   The finger all along is placed so as  to depress and
protect as much  as possible  the coats of the rectum.   The same  knife,  pushed
forwards, is made to  divide  the deep  fascia, the  muscular fibres within its layers,
and a. very small  portion, not more than two lines,  of the urethra anterior to the apex
of the  prostate, together with the prostatic portion of the canal and the gland, to a
very limited extent.   The-external incision eannotbe too  free within certain bounds.
*  * * But the  internal incision must be very limited indeed;  it should certainly
not extend beyond six  or seven lines  from the urethra, outwards  and downwards;
for the less that is cut, the greater will be the patient's safety. * * * The object in
following this method, is to avoid all interferenee with the  reflection of the ilio-vesical
fascia, from the sides of the pelvic  cavity over the base of the gland and side of the
bladder.   If this natural boundary  between the external and internal cellular tissue
is broken  up, there is scarcely a possibility of preventing  infiltration of urine, which
must almost certainly prove  fatal.  The prostate and other parts-around the neck of
the bladder are very elastic and yielding, so that without much solution  of their
continuity,  and  without the least  laeeration, the  opening can  be  so dilated as to
admit the forefinger readily ;  through the same wound the forceps can be introduced
upon this as-a guide."—(p. 508-11.)

                             Cheselden's Qperalioti.

   Cheselden's operation for the stone, his "lateral way," as he calls it, has much
perplexed writers on this subject.  Cheselden  himself has distinctly given two
modes in  which he performed this  operation; the  first described in the  Appendix to
the fourth edition of  his Anatomy of the Human Body, 1730; and the second in the
Appendix to the fifth  edition, 1740; seventh edition, 1750; which was the last
published in his lifetime, as he died  in  1752; and, I presume, also in the sixth,
though I have  not had an  opportunity of consulting this.  In  1731, Dr. James
Douglas  published an Appendix  to  the  History of the  Lateral Operation for the
Stone, containing Mr.  Cheselden's present method of performing it.   4to.   This

                       (a) Practical. Surgery.  Fourth Edition.

   * This is  the only direction  laid down  as to the position of the stafiyand  I am sorry I
am unable to give it more precisely..—j* e. s. 
THE LATERAL  OPERATION  (CHESELDEN'S.)            315
differs remarkably fron* Cheselden's account in his fourth edition;  but it is the
same precisely, though more fully  detailed, as in Cheselden's fifth and seventh
editions; and, therefore, although Dr. Yelloly's (a) observation is perfectly correct,
that " the least consideration will show that this (Douglas's) account of Chesel-
den's improved operation is perfectly irrecpncilable with that which is given by
Cheselden himself, in the  Appendix to the fourth edition of his Anatomy, or by
Mr. Morand, with his sanction and authority," yet the comparison of the fourth and
fifth editions, will prove that Douglas's statement is correct, and not " the absurd
statement," nor "an operation which it is next to impossible to perform," as it has
been designated by a highly distinguished surgeon of the present time.
   Cheselden's instruments were a staff, knife, and blunt gorget with a beak.  The
staff, including its  handle and straight stem,  measured six inches and a quarter in
length, and to its extremity joined  the  grooved part five inches and  a half more.
" The sulcus or groove is remarkably deep and wide, the edges smooth and blunt—
one end of it reaches a little way down on the handle, and the other, ending in an
obtuse point, is without any check,  as is seen in your common staffs.  This  part
may again be  divided into a curved portion and a straight rostrum or beak.  The
curvature next the handle not very great, and extends but a little way back from it;
and  from the extremity thereof, the  long rostrum projects  almost  directly for-
wards." (6).
  This statement of the curve and the length of the beak of the  staff is  important, as
it will be seen in Cheselden's  operation that there could not be any difficulty in
introducing the gorget, as it would run at once into the bladder in a horizontal
direction from the external wound, without depressing,the handle of the staff, which
depression  is  requisite as  the operation is  now  performed, whether  the common
curved or straight staff be used.   The other instruments need no notice.
   Cheselden thus describes his operations, the commencement of which in the
editions of 1730 (fourth) and 1740 (fifth) are alike, almost word for  word :—"This
operation  I  do in the following manner:—I tie the patient as for the  greater appa-
ratus, but lay him upon a blanket several doubles upon a horizontal  table three feet
high, or a little more, with his head only raised.   I first make as long an incision as
I well can,  beginning near the place  where the old operation ends, and cutting down
between the musculus accelerator urines  and erector penis and by the side of the
intestinum rectum ; I then feel for the staff."
   Thus far the two editionsare the same; but now comes the important difference:—
         Fourth Edition, 1730.                     Fifth Edition, 1740.
" and cut upon it the length of the prostate
gland  strait  on to the bladder, holding
down the gut all the while  with one  or
two fingers of my left hand.  The rest
of this operation is the same as in the old
way." (p. 344.)
                                        "holding down the gut  all the  while
                                        with one or two fingers of my left hand,
                                        and cut upon it in that part of the urethra
                                        which lies beyond the  corpora  cavernosa
                                        urethras, and in the prostate gland, cutting
                                       from below upwards, to avoid wounding
                                        the gut." (p.  330.)
 Such are Cheselden's own words, and the only difference  between the operation of
 1740 and Dr. James  Dsuglas's description is that it is more explicit; and, in his
 preface, he says :—"I am obliged to Mr. Cheselden for the chief materials of this
 paper; it was impossible to draw it up to good purpose without him ; and since he
 has been so kind as to communicate to me, with the greatest readiness and without
 reserve all the particulars-which I could not otherwise have come to the knowledge
 of, I am confident that none will pretend to dispute but what I here describe is his
 operation, and his whole operation." The  following is  the  important part of
 Douglas's description of the operation of Cheselden's fifth edition :—After having
 detailed the first incision, he says that Cheselden  " having cut the fat pretty deep,
 especially near the intestinum rectum, covered by the sphincten and levator ani, he
 puts the forefinger of his  left hand into the wound, and keeps it there till the internal
 incision is quite finished  ; first to direct the point of his knife into the groove of his
 staff,  which he now feels with the  end of his finger, and likewise to hold  down the
intestinum rectum, by the side of which his knife is to pass, and so prevent its being
(a) Med.-Chir. Trans., vol. xv. p. 347.      (6) Douglas's above cited, p. 4. 
316   i             CUTTING  FOR THE STONE ;
wounded.  This inward incision is made with more caution and more leisure than
the former.   His knife first enters  the groove of the rostrated or straight part of his
catheter, through the sides of the bladder, immediately above the prostata, and after-
wards the point of it continuing to  run in the same groove in a direction downwards
and forwards, or towards himself, he divides that part of the sphincter of the bladder
that lies upon that gland, and then he cuts the outside of one half of it obliquely,
according to  the direction and whole length of the urethra that runs within it, and
finishes his internal  incision by  dividing the muscular portion of the urethra on the
convex  part of  his staff.  When he first began to practice this method, he  cut the
very same parts the  contrary  way; that is, his knife entered first the muscular part
of the urethra, which he divided laterally from the pendulous part of its bulb to the
apex, or first  point of the prostate gland, and from  thence directed his knife upward
and backward all the way into the bladder;  as we may read  in the Appendix he
lately published to the fourth edition of his Book of Anatomy.   But some time after
he observed,  that in that manner of cutting, the bulb of the urethra lay too much in
the way;  the groove of the staff was not so easily found, and the intestinum rectum
was in more danger of being wounded."  (pp.  12, 13.)
  In further proof of  the correctness of Douglas's statement, Sharp (a), in speaking
of Rau's operation for the stone, and Cheselden's first mode of proceeding in his
lateral operation of  1730, says:—"After  this unsuccessful trial, Mr. Cheselden
made use  of the following method, which is now the practice of most English ope-
rators.  The  patient being laid on a table, &c.   This (the external) wound must
be carried on deeper  between the muscles,  till the  prostate can be felt, when search-
ing for  the staff, and fixing it properly if it has  slipped, you must turn the edge of
the knife upwards, and cut the whole length' of that gland from within outwards, at
the same  time  pushing  down  the  rectum with a finger or  two of the left hand, by
which precautions the gut will always escape wounding."  (pp. 99, 100.)  And in
contrast with this, speaking of " the old way, in which the urethra only is wounded
about two inches on  this side the  prostate, and the instruments are forced through
the rest of the  passage, which is composed of the bulbous part of  the urethra, the
membranous  part of  the urethra, the neck  of the bladder, and the prostate gland,"
he observes:—" It is pity, the operators do not in the old way always slide the
knife, along the groove of the staff, till they have quite wounded through the length
of the prostate." (pp. 104, 105.)
  The remainder of the operation,  as described in the fifth edition, are Cheselden's
own words:—" And  then passing the gorget very carefully in the groove of the staff
into the bladder, bear the point of the gorget hard against the staff, observing all the
while that they do not separate, and let the gorget slip to the outside of the bladder;
then I pass the forceps  into the right  side of the bladder, the  wound being on the
left side of the perinaeum; and  as they  pass, carefully attend to their entering the
bladder, which is known by their overcoming a straitness, which  there will be in
the place  of the wound; then taking care to push  them no further, that the bladder
may not be hurt.   I  first feel for the stone with the end of them, which having felt,
I open the forceps and slide one blade underneath it, and  the other  at the top; and
if I apprehend  the stone is not  in the  right place of the forceps, I  shift it before  I
offer to  extract, and then extract it very deliberately, that it may not slip suddenly
out of the forceps, and that the parts of the wound  may have time to stretch, taking
great care not to gripe it so hard as to break it;  and if I find the stone very large,  I
again cut  upon it, as it is held in the forceps.   Here I must take notice, it is very
convenient to have the bladder empty of  urine before the  operation; for  if there is
any quantity  to flow  out of the bladder at the  passing in of the gorget, the bladder
does not contract but collapse into  folds,  which makes it difficult to lay hold of the
stone without hurting the bladder, but if the bladder is contracted, it is  so  easy to lay
hold of it, that I have never been delayed one moment unless the stone was very
small, (pp. 330, 31.)
   Douglas also gives  an account of  the dissection of the parts concerned  in this
operation, which, he says,  "I have had several  good opportunities of examining in
dead  subjects, upon which Mr. Cheselden was so  kind as, at my request, to perform
his operation.  I once  likewise opened the body of a patient who had been cut by
him for the stone, in which I found the  parts divided  in  the very same  manner in
(a) Treatise on the Operations of Surgery.  London, 1751.  Sixth Edition. 
THE LATERAL OPERATION (CHESELDEN'S.)         317
 which they were cut in the dead bodies I had dissected."  The parts he cuts are
first, the common integuments of the perinaeum, and a little further back, between
 the protuberance of the os ischium and extremity of the os coccygis.  *  * * Second,
 he divides sometimes the subcutaneous portion of the sphincter ani.  * * * Seventh,
 he divides in a pretty oblique direction, a large portion of the levator ani that lies on
 the inside of the ligamentum pubis transversum, &c."  These are some of the prin-
 cipal parts; but as Mr. Cheselden does not always make his outward wound pre-
 cisely in the same place," they need not be further noticed.  "The internal wound
 is through  the  bladder, prostate  gland, and  urethra.   First,  The  vesica urinaria,
 covered with the membrana cellularis is cut in two places, viz., first, a small portion
 of it a little above the prostate gland ; on the left side, where he enters the  knife
 first into the  groove of his  staff, and  then part of the bladder which lies round the
 orifice upon the  upper part of that gland ; second, the  substance of one-half of the
 prostate  gland  is likewise divided laterally from without, inwards,  in the direction
 of the urethra that lies within it, through the whole length of that part of the canal;
 third, the iter urinae, or canal  of the urethra, is  divided  in two places, and both
 laterally : first, the beginning of it, which runs through the substance of the prostate
 lengthways, at the  same time the  incision  is  made through it, and the urethra into
 the groove of the staff.  The next is  the membranous  part of the urethra, with the
 circular muscle  that surrounds  it beginning  at the apex inferior of the prostate,
 and ending a little beyond the hole in the septum tendineum, under the pendulous
 part of its bulb.  *  * * To  this short enumeration of the parts, one observation may
 be added, which is, that if the operator turns the edge of his knife too far backwards,
 and then raises  it to cut, he can scarcely be able to avoid  wounding the intestinum
 rectum pretty high, some part of the  vesiculae seminales next the prostate,  and the
 verum montanum within  the urethra that runs through that gland,  together with a
 large portion of  the levator ani  anterior and of the  ligamentum suspensorium vesicae,
 that closely embrace it." (p. 21-5.)
   The celebrated Martineau, of Norwich, followed pretty nearly Cheselden's
 operation of 1730, using the knife and blunt-beaked gorget, the latter being em-
 ployed, to use Crosse's words,  "as a conductor, and also as a dilator of the blad-
 der." (p. 75.)   Martineau (a), describing his own operation, says he used "a staff
 in which the groove was much wider and deeper than usual, and therefore more easily
 felt; * * * he  made  his first incision long, deep,  and nearly  in a line with  the
 raphe, which, he thought, facilitated the cure; he then felt for the groove, and  intro-
 duced the point of the knife into it as low down  as he could, and cut the mem-
 branous part of the urethra, continuing his knife through the prostate into the blad-
 der; when, instead of enlarging the wound downwards, and thus endangering the
 rectum, he turned the edge of the blade towards the ischium,, and made a lateral enlarge-
 ment of the wound in withdrawing the knife;  he thus avoided cutting over, and over
 again, which often does mischief, but  can give no advantage over the two incisions,
 which he generally depended on, unless in very large subjects, where a little further
 dissecting may be required.  He then took the staff  in his left hand, whilst he in-
 troduced the blunt gorget with his right, and by thus taking the management of the
 staff and gorget into his own hands, he better directed the latter, and discovered at
 once if it were slipping from the groove; but this will be prevented by depressing
 the gorget while it  is pushing on towards the bladder.   On this depends very often
 the ease and success of the  operation.  * * * After  the gorget was  in the bladder
 he introduced his finger, and endeavoured to feel the situation of the stone, which,
 if found, is a great  advantage in the direction of the forceps to lay hold of it.   He
 never used any other than straight forceps, and it will be found more easy to extract
 a stone whole, by rather large forceps, than with flat  or small ones."  (p. 409-11.)
   Bromfield (b) describes  very fully his mode of  operating  with  the  knife, and
 though not following Cheselden's method, distinctly shows that even he occasion-
 ally cut as  Cheselden did,  and as is stated by Douglas.   " I begin my incision of
 the external integuments,"  says he, "about half an inch  below the commissure of
 the ossa pubis, on the left side of the raphe, and pursue it by a quick stroke, obliquely
 outwards and downwards between the anus and obtuse process of the ischium, ending
 somewhat lower  than  the basis of that process.  As soon as  the integuments  are

  (a) On Lithotomy; in Med.-Chir. Trans.,    (b) Chirurgical  Observations  and Cases,
vol. xi. 1820.                             vol. ii.  London, 1772.  8vo. 
318
CUTTING FOR THE STONE |
thus divided, I introduce the fore and middle fingers of my left hand : with the last
I keep back the lip of the wound next the raphe, and with the index press down the
rectum.  I then make a second incision, almost in the same direction with the first,
but rather nearer to the raphe and anus, and sufficiently deep to divide  the  trans-
versalis penis, and  as much of  the levator ani and  ligamentous membrane as will
make the prostate gland perceptible by my finger; I then, with the index  of my left
hand, feel for  the  sulcus of the staff, which  serves  as a conductor to my knife for
opening the membranous part of the urethra, and afterwards for dividing part of the
prostate; the rectum is likewise by my fingers  kept out of the way of the knife in
the next part of the operation,  which I effect in the following manner.   Hitherto I
hold the blade  of my knife like a pen, between the forefinger and thumb, and resting
on  the middle finger of my right hand,  with the back of the blade uppermost, but
now I take  it between the  forefinger and thumb of  my right hand, with  the handle
towards the palm of my hand  on the inside, the back of  the blade facing the inside
of the  index of the right hand :  I then turn the back of this hand that holds the knife
downwards, and convey the knife to the membranous part of the urethra, by gliding
the under fingers of my right hand on the index of my left hand, which serves as a
conductor of the knife to the gland ; as soon as I perceive that, I feel for the groove
of the  staff with the index of my left hand, with which I  convey the convex edge of
the knife into the membranous part of the urethra, as much laterally as is possible,
and as nigh to  the prostate.  When I am clearly in the sulcus of the staff, I turn the
back of my knife as much downwards as I can, to avoid  wounding the rectum, as I
then push the blade of the knife along the groove of the staff into the body of the
gland, sliding the knife on the convexity of its edge, till it has divided nearly half
the length of that gland; and if I wish to cut a little more of it, I incline the handle
of my knife a little downwards, and towards the left ischium.  The point of the knife
will then drop into the groove of the staff, and by drawing the knife in this situation
towards  me, I  shall certainly make good the wound of the prostate, so as near two-
thirds of it may be divided in the operation.   This last stroke of my knife is what
is generally called  "cutting from within outwards."  I then introduce the beak of
the common gorgeret,  &c." (p. 229-32.)
   " The next step of the operation," says Brodie, " is the continuance of the incision
along the posterior part of the urethra, and the dilatation  of the neck of the bladder.
Some recommend this to be accomplished by means of  the common scalpel, with
which you have made the external incisions;  the point being steadily introduced
along the groove of the staff, with the edge turned outwards, so as to divide the left
side of the prostate.   This was Cheselden's mode of operating.—[Not  his last
mode of operating certainly, as I have shown from his own words.—j. f.  s.]—After
having incised the prostate and neck of the bladder,  Cheselden introduced the blunt
gorget, so as to dilate  the wound still further, answering at the same time the pur-
pose of a conductor for the forceps; and, as far as I can learn, this method was fol-
lowed generally by the English Surgeons up to the  time of Sir Cjesar Hawkins,"
 who  "caused  one side of the gorget to be  ground to a sharp edge, and thus con-
 verted the blunt into a cutting gorget. *  * * I cannot but think that there are some
 considerable objections to it (the cutting gorget.)  The  incision is made as it is
 being thrust into the bladder.   In consequence of the thick wedge-like form  of the
 instrument, the prostate, and  especially a hard  and enlarged prostate, offers to it
 considerable resistance.  A certain quantity of force is_ necessary for its introduction;
 and if that force be not well applied, the beak may  slip out of the groove of the staff
 into the space  between the bladder and the rectum, an accident which is too  surely
 followed by the death of the patient. *  * * Although I have very frequently used
 the cutting gorget, I generally make the incision of the prostate with the knife," of
 which "the blade is broad enough to divide a considerable portion of the prostate as
 it enters the bladder, without its being necessary to increase the size of the incision
 by cutting laterally afterwards^ and instead of a sharp point, it terminates in a beak,
 fitted to the groove of the  staff.  In  ordinary cases, a knife of this kind with a single
 cutting edge is sufficient, but in cases of very large calculi there are good  reasons for
 dividing both  sides of the prostate.   There is no objection to  this being  done  that I
 can discover, and for  such cases I have been for some time in the habit of using a
 double-edged  knife with a beak projecting from its centre.  Having made the open-
 ing into the membranous part of the urethra; you are to insert the beak of the beaked
 knife into the  groove of the staff, you then take the handle of'the staff into the left 
   LATERAL OPERATION WITH THE KNIFE (LANGENBECK's.)    319

hand, depressing it at the same time.  You depress your right hand also, so that the
handle of the knife, which you hold in it, lies in the lower part of the  external
wound.  You are now to push the knife along the groove of the staff into the blad-
der, with its  cutting edge  inclined  outwards, and a little downwards towards the
ramus of the  ischium, if you use a single-edged knife;  but holding it horizontally,
if you use one with a double edge.  Let this be done slowly and cautiously, taking
care that you  do not lose the feeling of  the beak sliding over the smooth surface of
the staff for a  single  instant.  Generally, as the knife enters the bladder, a few drops
of urine escape, but  never any large'quantity.  This being accomplished, you are to
withdraw the  knife along the groove of the staff in the same line in which you intro-
duced it.  Never cut with  it laterally, except you  find it afterwards  absolutely
necessary to do so on account of the  large  size of the stone; for in cutting laterally,
you will find  it difficult to measure exactly the extent of your  incision; and you
may endanger your patient's life in  consequence of your  dividing the parts beyond
the boundaries of the prostate.   The next step of the operation is to introduce your
finger, directed by'the staff, into the bladder, so that you  may feel the parts which
are divided, and determine whether the incision is properly made.   If you operate
on a child, or  on a young and thin person, you may then at once introduce the forceps
into the bladder.   But if you operate on a full-grown person, and especially on one
having a deep perinaeum, it will be prudent for you first to introduce  the blunt gorget
previously to  using the forceps. * *  *  The  gorget is intended to  answer the pur-
pose of a director for the forceps.  But it answers another purpose also; it is  a
dilator of the  wound—the knife divides only a portion of the prostate.  The gorget
splits the remainder as far as its breadth allows it to do so.  Do not for an instant
suppose that  this is any rude or violent  proceeding.  It is  far otherwise.  The
incision of the prostate having been begun by the knife, the extension of it by means
of the blunt gorget  is accomplished with  the  greatest ease. *  *  * You will ask
why not make such a division of the parts by cutting laterally with the knife?  Why
prefer the dilatation of the wound by the blunt gorget?  My answer is, that the
separation of the parts with the latter instrument causes  no haemorrhage ; and that  it
ceases as soon as it reaches the margin of the prostate; that is, as soon as it reaches
the condensed cellular  membrane, which forms what may be called its capsule."
(p. 111-15.)]
   2081.  Langenbeck's knife {a)  is  specially distinguished by its  point
having a cover  or guard, by  means  of which  he passes it more readily
and safely along  the groove  of the  staff.   It is  used in  the following
manner:—When the membranous part of the urethra is  laid  bare; the
nail of the left forefinger is placed  in the groove of the staff, and directed
by it,  the  point of the lithotome perforates, the parts still covering the
staff;  the right hand holding the stem of the lithotome, inclines it towards
the  right thigh, so that its point forms  a right angle with the beak of the
staff, the handle  of wThich is  held inclined towards the right groin, and
with its outer edge a little downwards.  The point of the knife is now
carried a  little forwards in the groove  of the staff, for the purpose of en-
larging the  opening, and  moved up and down in the groove, in order to
open it satisfactorily.  The hand of  the assistant,  and with it the handle
of the staff, is then grasped with the left hand and raised  so as to  bring
its concavity against the pubic arch :  whilst this is doing the point cover
is pushed forwards, the  handle of  the lithotome being firmly  pressed
against the  palm  of  the  hand by the ring, middle, and little fingers, the
point  of the forefinger carried from the back to the side, and the thumb
on the back of  the instrument, so that the  latter  lies fixed  behind the
button of the  point cover, and, as  it  is straightened, thrusts  the cover


   (a) Ueber eine einfache und sichere Methode des Steinschniites.  Wurzb., 1802.  His
alteration of the Lithotome is found intheNeue Bibliothek fur die Chirurgie und Ophthal-
mologic, vol. i. p. 429, f. 1. 
320
CUTTING FOR THE STONE J
 forwards;  the knife  is  then moved  up and down to ascertain that it is
 actually in  the groove  of  the staff.   The lithotome then, with its edge
 towards the extremity of the cut in the skin, is thrust along the  staff to
 its blind  extremity, in doing which the point of the  lithotome is first a
 little sunk  and the  handle raised, till it  has  passed  beyond the curved
 part of the staff, when the handle is sunk and  the point  a  little  raised.
 The knife  is withdrawn in the same direction.
   [Thomas  Blizard, who was a very able operator, after  opening the groove of the
 staff in the usual way, divided the prostate gland, laterally, by means of a narrow-
 bladed knife, about four inches long, and having a beak inclined at an angle towards
 the right side of the blade.  (lam informed by his nephew Stanley, that he never
 lost a patient from bleeding, after this  operation.)  Astley Cooper, #1so, for a time
 used a long-beaked knife, but with the beak projected directly forward; the greater
 number of operations, however, which  I saw him perform were done with the single-
 cutting gorget.  He was, however, as Tyrrell  observes, " fond of variety," and I
 have seen him operate with both single and double cutting  and blunt  gorgets, as
 well  as with the knife.
   Tyrrell always used the straight-beaked knife for dividing  the prostate gland.
 He was a very able and successful lithotomist, and thus describes his operation (a):
 "The staff is first introduced, and. should well  fill the urethra;  the larger it is the
 better, as you have the advantage of a  deeper groove.  The staff is then firmly held
 by an assistant, and the bulb of the penis is made to project a  very little towards the
 left side.   I  now take the double-edged scalpel, make an incision through the inte-
 guments and fascia of the perinaeum on the left side of the raphe, commencing at the
 point just beneath the lower edge of the  symphysis, at the place where the  urethra
 begins to curve under the arch of the pubes, and continue it downwards and outwards
 to opposite the middle  of the anus, between it and the tuberosity of the ischium.  If
 you begin above the place just mentioned, it cannot be of  any service in extracting
 the stone.  I next make an incision into the groove of the  staff, as near as possible
 to its median line, because I think the  danger  of haemorrhage from the transverse
 artery of the perinaeum or any other artery is less in proportion to the  distance you
 are from its origin.  As soon as I have laid  open the urethra and carried the knife
 into the groove, I introduce  the nail of the forefinger  of  my left hand and satisfy
 myself that the knife  is  properly within  the groove, although you may feel pretty
 confident of it by the  sensation produced in rubbing the knife in the staff.   Then
 incline the edge of the knife a little outwards, and carry it on nearly to the prostate
 gland, then I carry it down  deeply into the perinaeum,  in the direction of the first
 incision, to divide the deep muscles there as I withdraw the knife.  I then lay aside
 the scalpel, and  take Astley Cooper's long straight knife in my right hand, take
 hold of the staff firmly with  my left, and then introduce the beak of the knife fairly
 within the groove, keep it well against  the staff, and carry it onwards, following the
 curve of the staff, into the bladder.  The knife having  entered the bladder, I give
 the staff to an assistant to hold steadily  in the same position, and introduce my finger
 on the surface of the rectum, under the point of the knife, which I can then feel in
 the bladder, and divide the prostate, as  I withdraw the knife, in the direction of the
 former incision, letting its probe point rest on my finger, which is at this time pro-
 tecting the rectum from injury.   If I operate on a child, where the perinaeum is shal-
 low, i introduce my finger into the  bladder and feel  the stone, and then withdraw
the staff and introduce  the forceps on  the finger.   But if  the perinaeum is deep, I
introduce the forceps with the  blades  a little x>pen, and glide one blade  along the
groove of the staff, upon which it very readily finds  its way into  the  bladder, and
rests upon the stone, which I then grasp, by deliberately opening the blades of the
forceps, and cautiously withdraw it."  (pp. 637, 38.)  To this account  of Tyrrel's
mode  of operating I may add, that in.introducing and withdrawing the beaked knife,
he did not hold the blade vertical, but with  its sides  inclining a little upwards and
downwards, so that the edge was turned somewhat outwards, and the knife seemed
to leave the wound after dividing the prostate almost flat.—j. f. s.]
(a) Clinical Lectures on Stone in the Bladder; in Lancet, 1823-24, vol. ii. 
LATERAL OPERATION WITH THE CUTTING GORGET.    321
   2082. The cut having been made in one of these ways, the  finger  is
passed  through  the wound  into the  bladder, the staff removed, and, if
the cut be sufficiently large, the forceps are introduced upon the finger,
for the purpose of drawing forth  the stone without much  bruising  and
tearing of the edges of the wound; but if the cut be too small, it must
be enlarged, carefully and  slowly, with the finger, the forceps,  or some
special dilator, or with a button-ended bistoury, according to the direction
of the outer wound.
   2083. This mode of operating is the most  simple of all; the operator
does not depend on the mechanism of his instrument, but can modify its
direction and efficiency at his pleasure.   It is dangerous in unpractised
hands, which, however, is  also  the case with  every operation.  The
entrance of the knife into the groove  of the staff may be difficult; it may
slip from it, and the rectum and  bladder  may be wounded.   Langen-
beck's lithotome allows an easy and  safe introduction  into the groove  of
the staff.
   2084.  The cut into the neck  of the bladder and the prostate gland^ith
a particular instrument, from without inwards.   To this belongs the use
of the cutting gorget, and of Le Cat's bistouri cache.
   2085. In using the cutting gorget, the nail of  the left forefinger, after
the membranous part is laid bare  by  the external cut, is introduced  into
the groove of the staff, and the membranous part of the urethra laid open
to  some extent by the bistoury  carried upon it.    The beak of the gorget
is now entered into the groove  of the staff thus opened, upon the finger-
nail still remaining  there, the  handle of the staff  gfasped with  the left
hand, and, after moving the gorget several times up and down, to ascer-
tain that its beak is certainly in the groove, the gorget is pushed forward
to the  blunt  end of the  staff, the staff removed, and the forceps intro-
duced.
   The cutting gorget, invented by Hawkins (a), in 1753, has undergone various
modifications of which those by Desault  (b), Cline  (c), Astley Cooper  (d),
Scarpa (e), and Graefe (/) are considered the best.
   [Although Sharp (g) states, that Cheselden's lateral operation "is now (1751)
the practice of most English operators," (p. 99,) yet it appears not to have been
pursued for any great length of time, and  perhaps,  not  so largely as Sharp would
seem to infer;  as  if it were practised by others with any thing like similar success
to that of Cheselden himself, it would be scarcely probable that Serjeant Hawkins
should have set about improving the bluntgorget, by giving one of its sides a cutting
edge, which he did between 1751 and 1754, for, "after having mentioned the objec-
tions to the continued incision of the urethra, and prostate gland" in the old way, or
with the apparatus major, Sharp (A) says:—"I shall  observe, that Mr. Serjeant

   (a) A. F.  Pallas,  De variis Calculum   (c) Erlich's Chirurg. Beobacht.j vol. i. p.
secandi methodis.   Ludg. Batav., 1754.—A.  227, pi. iii. f. 2, 3.
Louis et 1 f auuer, Dissert, de Methode Haw-    (dt) Savigny, Engravings, &C*, pi. vi. fig. 4.
kinsiani in calculosorum scctione prasstasitiai    (e) Mem. de l'Institut, vol. ii; p. 1.—Erin-
Paris, 1770.                            nerungen  iiber  Hawkins  sbbneiddendes
   (b) Abhandlung  iiber der S'einschnitt  Gorgeret zur Ausziehung des Blasensteines;
nach der verbesserten HAWKixs'schen Me-  in Salzb.  Med.-Chirurg.  <5eitung,  vo\t  j_  p_
thode; iu Chirurg.  Nachlass, vol. ii. part iv;  31.—Ollivier, above cited, p; 1. pi. 1.
p. 180.—Hausmann, Beurtheilung der Haw-    (/) Bernsteines Prakt.  Handbuch  fQr
KiNs'schen  Methode  der  Blasenstein  zu  Wundarzte, vol.  iii. p. 98.  Fifth Edition.
operiren.   Braunschweig,  1782.—Loder,  Leipzig.
Bemerkungen iiber Hawkins'Methode; in    (g) Treatise bri the Operations of Surgery.
this Journal, vol. ii. p. 348.                London, 1751.  Fourth Edition.
  (h) Critical Enquiry into the present State Of Surgery; London, 1754.  Third Edition
   Vol. hi.—28 
322                    CUTTING FOR THE STONE J
Hawkins seems to have fallen on an  ingenious contrivance, not only for removing
them, but also  giving  the last hand towards perfecting  the lateral operation.—
[Though he should more  correctly  have said, altering the old mode of dividing the
prostate with the blunt gorget, by dividing it with a cutting gorget, which was very
different from Cheselden's operation.—j. f. s.]—This he effects by making his
gorget to  cut on the  right side, so that when it  is introduced upon  the staff, and
pushed  on into the bladder, it necessarily makes an incision on the left side of the
urethra  and prostate gland." (pp. 212, 13.)  As Hawkins's gorget still retained the
form of  the blunt gorget, except as to its cutting edge, it could not divide the prostate
laterally, but upwards and outwards: or, as  Scarpa  observes, "not laterally, but
rather at its upper part, towards the summit of the ramus of the ischium, and the
arch of  the pubes ; an opening of all others, in the perinaeum, the most  confined, and
presenting the greatest impediment to the passage of the stone from  the bladder"
(p. 13;) so that the prostate was really not divided as in Cheselden's operation.
Hawkins's gorget, which  was  pretty much  like  Hildanus's conductor or blunt
gorget, with  the beak in  the middle, had a cutting edge about two-thirds of its
length;  but Else (a) observed,  that  "it should not  cut the  whole length of the
instrument, as it will then do much mischief by wounding the  internal pudendal
artery, which is  pretty large, and  cannot  be easily  secured, therefore the gorget
should not cut more than half an inch in length."   Whether  this restriction of the
length of the cutting edge originated with him,  or with Benjamin Bell I cannot
positively state, as the copy of Else's Lectures I have is without date : but I should
be inclined to think  it did, or it is  probable he would have mentioned the in other
respects variation of shape which Bell's gorget has.  In this  latter instrument, the
shaft is much narrowed, and deep  to within  an inch of the beak, at  which part it
suddenly sweeps out on the right  side  like  a lip, and thence cuts  with  a sharp
rounded edge to  the beak.
  A very slight  inspection of either  of these gorgets will show, that they cannot
divide the side or thicker part of the prostate gland, but that they must cut through
its upper part, making as Scarpa observes, "an opening, of all others in  the peri-
naeum the most  confined, and presenting the greatest  impediment to the passage of
the stone from, the  bladder." (p. 13.)  To remedy this objection, the elder Clink
made a  most important change in the form of the gorget.  Instead  of the beak being,
as previously, in, or nearly in the middle of the end of the instrument, which was
rounded, he placed the beak on  the left side, lengthening that side a third beyond
the right side, by a flat horizontal plate beyond the concavity of the gorget.  In this
way a straight diagonal edge was formed, from the short right to the  long left side
of the instrument; this diagonal was made a  cutting edge, and at  its extremity pro-
jected the beak  about a quarter of  an inch, flattened  on the  sides, and reaching a
little above and  a little below the cutting edge.  The extent of the wound made by
this instrument  depended  upon the width of the  shaft of the gorget, which was
equally wide and moderately deep,  from the hind part of the cutting edge up to the
handle.   The width of the shaft varied from  half an inch to an inch in different
sized gorgets ; for children, the former was usually employed; in adults, generally
one of three-quarters wide, and when the prostate was large, that of an inch.  Such
width was found by experience  sufficiently ample for the division of the  prostate,
but not so as to  cut into the cellular tissue surrounding that gland.   With  this in-
strument I witnessed my highly valued master, the younger Cline, operate  twenty-
six times with the loss of three cases, one of which an elderly man, sunk within a
few hours without  any assignable or discoverable  cause beyond the shock of the
operation, and another, whose stone was triple phosphate, died a few days after, and
was found to have the bladder, now in the Museum  at St. Thomas's, much thickened,
and its  whole interior beset with fungosities.  With the same  instrument my friend
Green  cut about forty (b) cases successively, without losing a case.  Sufficient
proof, it must be admitted, that the  cutting gorget  is not the dangerous instrument,
either as to its immediate or deferred results, which it  has been so much the fashion
to describe it.
   Scarpa objected  to  Hawkins's  gorget, on  the  grounds  already mentioned; and
thought that the alterations of  it  by Bell,  Desault and Cline, rendered it "an
instrument, of all others, least adapted to the performance of  the lateral operation"

      (d) MS. Lectures on Surgery.            (b) Lancet, 1827, 28,  vol. i. p. 61. 
     THE LATERAL  OPERATION WITH THE CUTTING GORGET.   323

(p. 14;) and therefore made an alteration of his own, which diminishing the general
width of the instrument, still kept the two-thirds of the edge nearest the point cut-
ting, as  in Hawkins's  instrument, but widening the  middle third to the extent of
three lines, in a somewhat elliptical form.   His instrument has not, however, found
many admirers in this country.
   Astley Cooper at first used a gorget with a central beak, "and cutting upon both
edges, but he thought it occasioned too much bleeding, and divided  more than was
absolutely necessary for the removal  of the  stone."  He therefore gave it up, and
operated sometimes with Cline's gorget, and sometimes with his own knife; but I
think I saw him more frequently use  the former in his hospital practice.—j.. f. s.
   The directions given by Chelius for the use  of the cutting gorget are not satis-
factory,  for more  is requisite than to introduce its beak into the staff,  and push it
forward.  Sueh, however,  is the too common method of using the instrument, and
hence arises the difficulty and danger with which, in the bands of inattentive per-
sons, it  is beset.
   It will be convenient here first to mention the directions given by Astley Cooper,
for opening the membranous part of the urethra, which are those commonly adopted
in the operation with the cutting gorget.,  " The scrotum  being elevated, the incision
is begun opposite the under part of the arch, of the pubes, and is continued on the left
side of the raphe, along the perinaeumy as far as midway between the tuberosity of
the  ischium and the anus.  The first incision should divide the skin, &c, and expose
the  accceleraior urinx; the second should be carried between the left crus penis and
 the  bulb, the latter being  pressed towards the  right side by the forefinger of the
surgeon's left hand.  A part of the accelerator,• urinae is divided, and  the transversus
perinaei  should be freely cut, as. it forms, a great  impediment to the extraction of the
stone, if undivided.  The next incision should he made into the groove of the staff,
by cutting into the membranous portion of the urethra,-,  for this purpose the knife
must be directed upwards, (that is, its point raised towards the. hand,le of the staff,
—j. f. s.,) and  not horizontally, otherwise the rectum is endangered.  The opening
 made to expose the groove of the staff should be an inch  in length."  (pp. 241*, 50.)
   The membranous part of  the urethra having  been  opened by the  third cut, and
well opened, by moving the point of the knife up and down so as to have it perfectly
bare, the left forefinger-nail should be pressed into it, immediately on the knife
being removed, and there retained,.   Using the nail  as a  guide, the beak of the
gorget (Cline's  with the  single-cutting edge) is  entered upon it  into the groove,
and the  finger withdrawn.   The surgeon then moves the beak of the gorget twice
or thrice up and  down in the groove of the staff, to assure  himself that the beak i§
free, and not entangled witb any cellular tissue, by which, in. his further proceedings
it might be jerked out of the groove.   The body of the gorget should be held hori-
zontal,  and  its  cutting edge inclined a  little  downwards, and  outwards..  The
operator  now, with his left hand, takes the handle of the staff from the assistant,
and brings it down till it form an obtuse angle with the perinaeum—in short, till the
staff, if  it were  straight throughout and thrust onwards, would pierce through the
umbilicus, its direction  corresponding  to the axis of the  pelvis, which Green con-
siders a most important part  of the operation, as  it ensures the proper course of the
gorget.   At the same time that the handle of the staff is sunk, the gorget is pushed
very gently forward, and without any violent pressjure, cutting its way through, and
dividing the prostate laterally, it enters the bladder.  The great point to be remem-
bered is, the depression of the handle  of the staff, so that that part of its groove, on
which the beak  of the gorget rests, face downwards towards the scrotum, and con-
sequently when the gorget is slightly pressed forward it meets no obstruction, and
runs gently  on.   If, however,  the staff-handle  be not depressed, the beak of the
gorget drives directly against the staff, and cannot move forward, the staff-groove
standing ,up  like  a wall against it, and the opposition  is the greater  the more force
is used,  till the operator unwittingly alters the position both of staff and gorget,
depressing the handle of the former, and raising that of the latter, so that its-point
dips, finds less resistance in the now oblique position of the groove of the staff, and
then is pushed on  into the bladder, if the operator have good luck, or  slips out of it,,
and passes between the  bladder and rectum, or between the bladder and pubes, which
may be expected, if he use mueh. force and have  little discretion.   I have seen also,
in more than one or two instances, when the staff-handle has been little or insuffii.
ciently depressed,  so much force used, without getting the gorget to  move-on, that 
324
CUTTING FOR THE STONE ;
the staff was bent, above its curve, and could only be withdrawn with difficulty.—
J. F. S.]
   2086.  All the  cutting  gorgets have  this  objection, namely, that in
pushing forward their beak in the groove of  the staff,  they often merely
push forward the neck  of the bladder, and  do not cut through  it; they
require much greater force than any other instrument;  the inner wound
has not  the  same parallel  direction as  the  outer; on account of the
lateral direction of the inner cut, the pudic artery is mast liable to injury  ;
and if to avoid this, a more descending direction be given to the instru-
ment, there is no  protection against wounding the  rectum.   The  intro-
duction  of the forceps upon the gorget is but a trifling advantage (a).
   [These objections to the cutting gorget are entirely groundless.  No more force
is requisite for introducing the gorget than for dividing the neck of the bladder and
the prostate with the knife.   The instrument neither requires force, nor is force em-
ployed, if the operator k»ow how to use it; and, therefore, whatever mischief is
done is the fault of  the surgeon, and not of the  instrument.  In passing into the
bladder, the cutting  gorget must cut through its neck, and also the prostate  gland.
It cannot push it before it, so long as it remains in  the groove  of the staff, but if it
slip from it, as  is occasionally, though not  often the  case, even in the  hands of an
unskilful operator, without violence, the beak of the instrument more readily slips
between the. bladder and rectum then drives  on the neck of the bladder.  But this
cannot happen, except from carelessness,  without force being employed to  drive the
gorget on, which is never required so long as the instrument takes its. proper course;
and if the gorget will not enter without violence, the surgeon may feel pretty well
assured, in nineteen cases  out of twenty, that he is misusing  the  instrument, and
that he will get into mischief.   The difficulty in introducing the gorget, and  the force
occasionally seen expended on it, depends, as has been mentioned, on  the operator
forgetting to sink the handle  of the staff, so as to place its groove in the line  which
the gorget has to travel; and, consequently, herams the beak of the gorget against
the staff,  which he continues to hold nearly upright, so that till he accidently alter
the position of the staff, or, by dint of force, the beak of the gorget slips down the
curve of the staff, it is impossible for the gorget to pass into the bladder, though easy
enough for it  to slip from the staff, and get between the bladder and rectum.
   The want of parallelism of the internal with the external  wound is  really of no
consequence,  even admitting that it be greater than in division of  the neck  of the
bladder, and of the prostate, with the knife, of which I cannot allow it is.
   The division,, or rather wounding, of the pudic artery, by the introduction  of the
gorget, might be matter of more  serious  objection  against the  employment of that
instrument, were it as frequent as Chelius and others imagine;  but from my own
observations of the practice of others,  as well as my own, I believe it very much
less frequent than generally supposed; and  the free bleeding which occurs  some-
times in  the operation, either with the gorget  or knife, for I have seen it as great
with the use of one as  of the other instrument, depends, I believe, usually on division
or wounding the artery of the bulb, just after it comes off from the pudic artery, and
not from  injuring the pudic artery itself.  The use of the gorget, as a ready channel
for the  introduction of the  forceps, is,  as Chelius observes, of but little  im-
portance.—j. f. s,]
   2087.  Le Cat's  method, which, in recent  times,  has been especially
modified and  employed  by  Panola,  is characterized by the  prostate
gland being in part  only divided,  and  the  enlargement of the wound
being effected by a, peculiar dilator.
   According, to Pajola, the  patient should be laid with his trunk a little
obliquely;  the staff, when introduced, is to be held by  an assistant, with
its  handle so inclined towards the right groin, that its curved part should

  (a) Textc-H, C.,( Ueber die Ursache des Nichtauffindens der Blaseiisteine, nach gernach-
ter  Operation der Lithotomie, p. 22.  Wurzburg, 1816.—Zang,  OperationeD, vol. iii. pt
u\p. 1.77., 
         LATERAL OPERATION WITH COME's LITHOTOME.      32£>

rest between the left side of the raphe and the ascending branch- of the
left haunch bone.  The external cut is  made, as regards its size and
direction, in correspondence to the  prescribed directions, {par.  2078^)
with  the urethrotome, which is held  like a writing-pen, with its  groove
facing towards the patient's left  side.  When the membranous  part of
the urethra  is laid1 bare^ the nail of the left forefinger is  passed into the
groove of the  staff, the bulb pressed  aside, the  urethrotome thrust into
the membranous part close behind the bulb,  and  carried carefully along
the groove of the staff,  so as to divide the membranous part to the extent
of from four to  five lines.  The operator now  keeps the point of the
urethrotome against the staff, brings its handle horizontal, and takes hold
of it with his left hand  in such way that the thumb is on the  upper edge
and the fore, middle, and ring fingers  are upon  the under  edge of the
handle.  The operator-now grasps the  cystotome with his right hand, and
placing his  middle finger in its ring, his third and fourth fingers on the
under, his thumb on the upper surface of its handle, and the forefinger
on the  sheath  of  its   blade* enters  its  beak into the groove  of the
urethrotome, and upon it into that of the staff, and then  takes away the
urethrotome.   When the operator ascertains  by the sensation which the
contact and rubbing together of the two metallic bodies affords, that the
beak of the  cystotome is actually in the groove of the staff, otherwise the
cystotome must be withdrawn, the membranous part at once opened and
the instrument introduced as before, he- grasps, with  his-own left hand!,
the handle of the  staff,  together with his  assistant's hand, carries it in a:
direction corresponding to the white line, raises it beneath  the  arch of
the pubes, so that it forms a right  angle with  the  trunk,  and  pushes the
cystotome, the handle of which he sinlcs a little, along the groove of the
staff,  up to its.blunt extremity.   After  the cystotome  is  withdrawn, the
operator carries the point of his left forefinger upon, the staff and into the
opening in the bladder; the staff is then withdrawn., and'a blnnt gorget,
previously oiled, with  its concavity upwards, is  introduced upon  the
sensible surface  of  the left  forefinger, which serves  as  a  guide.  The
dilator, with its-front blades-closed, is.now* introduced,upon  the gorget,
and after the withdrawal of the  gorget, the wound in.the prostate gland
is gradually enlarged by bringing'together  the hind  branches  of  the
dilator to such an extent as the  size of the stone seems to require.
   For the further description, of this operation, the following Writers, are  referred!'
to:—
   Le  Cat, above cited.
   Kast, (praeside C.Siebold,) Histor^i Lithotomia; in eodem homine bis facta?*.
Wirceburg, 1778.
   Hartenkeil, above cited;
  Loder, Programma Lithotomiae LeCatian^ emendatae Descriptio.  Jenae, 1785.-,
  Koelpin, A., De Calculi Vesicae sectione laterali inprimis Le Catiana; in Opus- '
cula Chirurgica, vol. i.  Hafnia;,.,1799.
  Rudtorffer, F. X., Abhandlung iiber die Operation des  Blasensteines, nach,,
Pajola's Methode.  Leipzig, 1808; with five plates.
   208S. This operation has-partly the same objection  as  the cutting
gorget, that' the parts are  easily pushed  before.it, and not always cut
through to the required  extent;  and that  the  enlargement of the insuffi-
cient  cut with the dilator not unfrequently causes great bruising, and its,
consequent symptoms, especially a permanent weakness  of the neck of
                               28* 
326
CUTTING FOR THE STONE J
the bladder and the like.  Experiments upon the dead body have satis-
fied me that the use of the dilator does not effect a  simple enlargement,
but if the  extension  be great, an increase of the wound by tearing.   In
other respects this operation is more complicated than all the other modes;
it is, however, employed with considerable success.
  2089. The Cut into the Jfeck of the Bladder and the prostate, with a
particular  instrument, from  within  outwards.   To this belongs  Frere
Come's method with the concealed lithotome {lithotome cache.)
  When the  outer cut has  been made  and the  membranous part is
opened, the concealed lithotome is entered into the groove of the staff
upon the nail of the left fore-finger, which  has been previously introduced
into it.   The  operator with his left hand  grasps the handle of the staff,
raises it under the arch of the pubes, satisfies himself that the lithotome
is in the groove, by moving it up and down, and then pushes it on in
the direction of the staff, to its extremity.   The staff is now withdrawn,
after having been  passed  a  little farther into  the bladder, to disengage
the point of the lithotome, with which it must be attempted to ascertain
the size of the stone, and then the instrument  is gauged at a higher or
lower number, in accordance with  the size of  the  required  cut.   The
lithotome is now held with the left thumb and fore-finger on its lock, is
raised under the pubis  arch,, and whilst the handle  is grasped with  the
right hand, and the lever pressed down with the third and fourth fingers
upon the  handle, the blade is  drawn out horizontally,  and inclined
towards the lower angle of the wound.
  The following writers may be referred to on this operation:-
  Journal des Seavans,  1748,  Juki.
  Frere  Come, Recueil  des pieces impartiaJes sur l'Operation de la Taille faite par
Ite Lithotome cache.  Paris, 1735=.  .
  -----„,,.  L,.,; Additions a la suite de Recueil de toutes les pieces qui ont ete pub-
lliees au  sujet du Lithotome cache.  Paris.
  De Preval, Ergo sealpello vagina recondite cystotome lateralis perfectior.  Paris,
1754.
  Cambron, Lettre sur la Lithotome, pour prouver la superiorite du Lithotome cache.
Paris, 1760.
  Nahuys„ Parallele de la Taille laterale de M. Le Cat avec celle du Lithotome
eache.   Amsterd., 1766.
  Chastanet, Lettres sur la Lithotomie, pour prouver la superiorite du Lithotome
eache pour l'Operation de la Taille sur tous les autres instrumens.   Paris, 1768.
  Sabatier, Remarques sur l'Operation de la Taille avec le Lithotome cache, et sur
le Jugement que  PAcademie de Chirurgie a  porte  de cette operation, dans le
troisieme Yolurae de ses Memoires,; in Mem. de l'Institut National de Franee, vol.
iii. p. 341.
   2090. The  disadvantages objected to  the  concealed lithotome are,
wounding the inner wall of the bladder when its blade is gauged at the
higher  numbers; the great danger of wounding the rectum or the pubic
artery if its blade be not  immediately directed towards the ischial tube-
rosity;  and the difficulty of finding the aperture  in the bladder, when the
staff has been withdrawn before the cut is made (a).  It has been attempted
to  do away with many of these  objections, by shortening  and blunting
the blade, so that after the lithotome has  been introduced into the blad-
der the staff should net be withdrawn, but that, without its point leaving

  (a) Memoires de l'Acaderaie de Chirurgie, vol. iii. p. 628.—Scarpa, Dupuytren^Textob,,
 above eked. 
THE  BILATERAL SECTION.
327
the staff, the  lithotome might be drawn out of the bladder, or that the
instrument  should be furnished with a small gorget, or with a sheath  to
its blade (a).   It must  be remembered, however, that with very unruly
patients this instrument can  be used more safely than any other, and  is
always to be  considered as one of the most preferable.
  Boyer (b), who prefers  Frere Come's lithotome to any other, uses it in the fol-
lowing way:—In adults and elderly persons he never gauges the instrument higher
than No. 11, however large the stone maybe, and in general only up to No. 9.  He
prefers enlarging this cut if it be too small.  In drawing out the  instrument, instead
of pressing the shaft up against the pubic arch,  he presses its concave  side on the
branch of the right pubic bone, so that the blade is inclined almost directly outwards.
When he is satisfied by the length of that part  of the instrument which has been
drawn out, and the cessation of resistance that the prostate and the neck of the blad-
der are cut through, he allows the blade to return into its sheath, and withdraws the
instrument closed, by which wounding the rectum and the pudic artery are avoided.
The transverse direction of the inner wound is made  correspondent with the outer
by the introduction of the finger, and does nob prevent the entrance of the forceps.
   2091. In the  same way, as Chaussier and  Beclard (par.  2062) had
recommended cutting into the prostate  and neck of the. bladder  on both
sides, as  being  the more correct  interpretation  of Celsus's text, did
Dupuytren  perform successfully and fully lay  down  this mode' of ope-
rating, the bilateral section,,zs it is called, in the year  1824.
   The patient is  placed  and fastened  in  the  usual way,  and the staff
held by an  assistant vertically and corresponding to the raphe.   The
operator with a  straight-pointed bistoury makes,  at a distance of six or
seven lines from the rectum,  a transverse cut, the slight curve of which
has its concavity downwards, and its middle over the raphe.  The mem-
branous part  being laid bare, is  opened, and  the point of the bistoury
introduced upon the  nail of the left fore-finger into the groove of the
staff, and carried some way along it.   A peculiar lithotome is then en-
tered into this opening, and pushed along the groove of the staff into the
bladder.   The  neck of the  bladder is divided, in withdrawing this
instrument,  by  knives; which project on  both sides,  in  the direction
of the external wound.   A gorget is then introduced, and upon  it the
forceps.
   Dupuytren's lithotome is similar to that proposed by Fleurant for operating on
women for the stone;  the two blades may be separated to a distance of eighteen
lines.  Charriere's improvement consists in the blades projecting obliquely down-
wards.  La Serre's alteration which is inefficient, consists in their acting first in
the horizontal, and then in an oblique  direction.  Astley Cooper cut through the
neck of the bladder on both, sides with a double-edged gorget.
   Upon this subject the following works.may be consulted:—
   Ollivier, above cited, p.. 237.
   Archives Generales des de Medecine* vol. v. p. 159.   1824.
   Repertoire Generale d'Anatomie et de Physiologie Pathologrques, vol. i. p. 240.
Lecons Orales des de Clinique Chirurgicale, vol. ii. p. 381.
   Dupuytren, sur une Maniere Nouve'le de pratiquer l'Operation de la Pierre; ter-
mine et publ. par Sanson et? Begin.   Paris,  1836.
   [Lectures  on  Lithotomy, by Alex. Stevens, M. D., New York, 1838.—
G.  W. N.]
   2092.  Beglard altered his  mode of performing the sectio  bilaterali*
   (a) Beck, R.,  Ueber den Seitenschnitt mit   (6) Traite des Maladies Chirurgicales, vol..
dem  Stromeyer's  chen doppeltgedeckten, ix. p. 391,
Sfeinmesser.  Carls., u. Freib., 1844. 
328                 CUTTING FOR THE STONE ;
from that which he first advised, and proceeded in the following manner:
Leaving the staff, which had  been first introduced, alone,  so  as  not to
disturb  the position of the parts, he made a cut through the  coverings, as
in the  lateral operation, with a knife  similar  to  that of Dubois;  then
opened the membranous part upon the left side  and behind  the bulb,
and passed the knife nearly transversely, with its edge directed to the left,
into the bladder, and enlarged the opening in drawing back the  knife. At
this point of the operation, he raised his hand, and gave  the blade of the
bistoury a direction parallel to the axis of the prostate, in order to avoid
injuring the  seminal vesicles and the base of the bladder with  the point.
If the stone eould not be drawn out through this opening, he enlarged it
with the button-ended bistoury; and if this did'not answer, he made a
second  cut transversely to the right side into the neck of the bladder and
body of the  prostate.
  Senn  (a) proceeded in the same way, exeept that he directed the first cut into the
neck of  the bladder, more obliquely downwards, as in the common lateral operation.
The external tegument need not be cut into in the second  transverse cut, as it is
capable of great extension.
  Le  Dran (b) had already proceeded in a similar way; after cutting into the  neck
of the bladder, he passed his forefinger into the neck and upon it a small bistoury,
and then made upon the right side a cut similar to that on the left.
  Vidal de Cassis (c) has proposed cutting into  the neck of the bladder  in four
directions.  And Colombat has recommended an instrument, (lithotome quadruple,)
in which two blades project upwards and- outwards, and two downwards and out-
wards (d).
  2093. The advantage of the bilateral section is, that it affords a cut of
very large extent  for the removal of a large stone ; without  danger of
wounding the pudic artery; and the rectum may be avoided, notwithstand-
ing the  large size of the cut.  In regard to Dupuytren's semicircular ex-
ternal cut, it may be remarked, that the transverse artery indeed may be
avoided ; but that this cutis difficult for a less experienced operator,  and
a> slight variation  from the prescribed  mode causes  that vessel  to be
wounded.   The bulb is. also easily wounded,  especially in  old persons,
in whom it is large, and juts back  so much that it is not easily pressed
down ;  and  if the knife be sunk deeper to  avoid  it, there  is   danger of
wounding the rectum.  Both, however, may, according to Senn, be more
certainly avoided, if the membranous part be  divided, not  lengthways,
but transversely.  Beclard thought it a particular advantage of this ope-
ration, that the edges of the wound lie  close together, and that the cure
follows more quickly (e).   Souberbielle (f)  consider  that the double
cut should' be so large, that the extraction of the stone  should entirely
separate the middle from, the other parts, of the prostate.
  2094. One of the  most important circumstances, which has the  great-
est influence in deciding on the several  modes of  performing the lateral
operation for the stone, is. the variety of  opinions-  as to the room  which

  (a) Dissert. Recherehessur les differentes  chives generales.de Medecine,  vol. viii. p.
Methodes de  Taille soupubienne.   Paris,  139, 309, 310.
1825.                                  (e) Ollivier, above cited, p. 244—Roter.
  (6) Suite des differente&.manieres de faire  Coli.ard; in Repertoire generate  d'Anatomie
^Extraction de la Pierre.   Paris, 1756.      et de Physiologie, vol. i. p. 507.
  (c) Taillie quadrilaterale These.  Paris,    (/) Journal deMedecine,,vol..&vii. p. 416.
]£28..                               1822.
  (d) Ollivier, above cited, p. 238.—Ar- 
THE EXTRACTION.
329
the cut into the prostate and neck of the bladder can give, and which can be
given with safety.   Many make the  cut so large that the stone  can be
withdrawn without stretching and bruising the parts;  they divide, when
the size of the stone  needs it,  the whole prostate, and  continue the cut
even into the body of the bladder; considering a clean cut less disadvan-
tageous than the tearing and bruising by simple dilatation.  Others  fear
large cuts, as if the whole prostate be divided into the  bladder, infiltra-
tion of urine, abscesses and gangrenous destruction of the cellular tissue
between the  bladder and  rectum, weakness of  the neck of  the bladder,
slow cure, and fistula, may  ensue.
   It is most advisable to cut sufficiently deep into the prostate and neck of
the bladder,  without continuing the cut into the body of the bladder, and
to enlarge the opening in a  gentle and gradual manner with  the finger or
the forceps.   This enlargement may  be carried to such extent that very
large stones may  be withdrawn, and by this  mode of enlarging the
wound the objections  do not apply which for the most  part result  from
the great apparatus, as if the prostate and neck of the  bladder be pro-
perly cut into, the  enlargement  is made in  a very different  way.  To
Dubois' knife, with which I cut into  the prostate and neck  of the blad-
der, as I introduce it, but especially in drawing it out, I give the prefer-
ence above all the other modes  of practice.  If the cut do not correspond
with the size of  the  stone, I enlarge it with the button-ended straight
bistoury, which cuts only to the extent of an inch.
   [Scarpa, as already noticed,  (p.  583,) has well pointed out the extent to which
the prostate should be divided, and the  capability of doing this, to a certain and de-
finite extent, is the great advantage  of the cutting gorget, which  ean only divide the
prostate equal to its own  breadth.  If the prostate be divided with the knife, the ex-
tent of the division must  depend entirely upon the operator, and is liable to vary con-
siderably.—j.  f. s.]
   Upon the matter just considered the following works may be also consulted :—
   Klein, Chirurgische Bemerkungen, p. 1.  Stuttgart, 1801.
   Prak'tische Ansichten der bedeutendsten chirurg. Operationen; part  ii.  Stuttgart,
1816.
   Martineau, in Med-Chir. Trans., vol. xi. p.  402. 1820.
   Cooper, Samuel, Dictionary  of Practical Surgery,—Art. Lithotomy, p. 889.
   Dupuytren, above cited, p. 17.
   Scarpa; in Ollivier, p. 1-40.
   Chelius, Ueber den Steinschnitt; in Heidelb, klinisch. Ann., vol. vi. part. iv.
   2095. The extraction of the Stone is in general accompanied with great
difficulty, and requires the more careful and skilful management, as upon
the proper performance of this part of the operation depends principally
its successful or  unfavourable result.  The left forefinger, and in very
stout persons, a blunt gorget upon it, is passed into the opening of the neck
of the bladder, and upon it the forceps (a), previously oiled, are  carried
in a rather oblique direction from  below upwards into the bladder.   The
forceps  are then  gently turned about in various directions to find the
stone, and when  it is found, the  handle-rings of the forceps are to be
taken hold of with  both hands, widely opened, and  the forceps pushed
farther  into the bladder, or turned  half round with a sweep, so as to bring
the stone between their blades  and to grasp it.   When the separation of

  (a) On the Construction of the various kinds of Stone-Forceps, see Deschamps, above cited
vol. iii. p. 200. 
330                CUTTING FOR THE STONE \
the handles shows.thatthe stone is seized, the thumb and middle finger of
the right hand are put into the rings of the forceps, or the instrument is
grasped with the whole hand, but in either case the forefinger is kept be-
tween its handles, partly to prevent  breaking the stone, and partly to pre-
vent the walls of the bladder catching in drawing out the forceps, which
are to be turned round on their axis, so as to ascertain that the bladder
has pot been laid hold of.  The surfaces of the blades of the forceps are
then directed towards the edges of the wound, the left hand placed on the
joint, and with a continued gradually increasing pull, accompanied at the
same time with waggling movements  obliquely from above  downwards,
the forceps, together with the stone, are drawn out.  If during the  ex-
traction the edge of the wound  be stretched very tightly over the stone, it
must be held back with the finger of the left hand.
   2096.  The obstacles which occur in grasping and drawing out the stone
depend on its position and size, on the  contraction of the wound of the
bladder, on the stone being encysted or adherent, and on its breaking to
pieces.
   2097.  If the stone lie low, it must be attempted by the forefinger of
the left hand, passed up  the rectum, to carry it towards the forceps, or a
pair of curved forceps may be used.  If the stone be very high, or in the
sides of the bladder, it must be tried to change its  position with the finger,
to thrust it down by pressure  on the lower part  of the belly, or curved
forceps  must be introduced ; and in using the latter,  their handles must
always be inclined downwards.
   2098. If the stone be grasped in  an unfavourable diameter, or too near
the joint of the forceps, which is shown  by the very great  separation of
their handles, or if the stone lie with its long diameter transversely within
the blades, which is  discovered  by the slight separation of  the handles,
and the difficulties  in  attempting  the extraction,  the forceps  must be
opened a little, and with the finger, or with a  bouton (a), it  must be
tried to give  it a  better position; or it must be  dropped  into  the
back of the  base of the bladder, and seized afresh.  If the wound be
too small, though the  diameter of  the stone be  favourable, it must be
enlarged, as directed, (par. 2094,) to such an extent as to render the ex-
traction  possible, without much bruising  and injury.  If the  stone he
of such a size that even  with the greatest possible enlargement of the
wound  it cannot be removed, nothing remains but either to break it to
pieces with Earle's (b) stone-breakers;  or if the stone be not  too hard,
the outer layers may be  broken with  a pair of common stone-forceps;
or, what is still better,  Heurteloup's percuteur may be  used; or the
bladder may be cut  into  above the pubes, which proceeding is always
most proper when the stone is  very hard.   Under  these circumstances,
also, the extraction of the stone has been recommended to be made sub-
sequently, {Steinschnitt in zwei Zeitraumen, Germ.;  Taille en deux terns,
Fr.,) when suppuration  has  commenced in the wound ; the extraction,
however, is never thereby rendered easier, and  this practice is in gene-
ral to be rejected.   Small stones may also lie so between the  blades of
the  forceps,  that the  handles  are  not  separated, and  the  operator

      (a) An instrument like the stilette of a catheter, with a ball at its extremity.
      (6) Med-Chir. Trans., vol. xi. p. 69. pi. iii. 18. 
THE  EXTRACTION.
331
thinks he has  not grasped the  stone; in withdrawing and accidentally
turning  of the forceps, such stone may remain  concealed within them,
without  the operator being aware of it, as I myself have observed.   The
gush of urine, after cutting into the neck of the bladder, may also throw
out a little stone.   Small  stones  can  often  be well seized with a pair of
dressing-forceps, or with  flat-bladed stone-forceps.

   Campana (a) considers the extraction of the stone more easy and less injurious, if
it be grasped by its largest diameter.
   [If after the entrance of the gorget into the bladder, the urine do not immediately
flow out, as it usually does, though less frequently when the internal wound is made
with the  knife only, it does not gush  forth  suddenly as soon as the forceps are intro--
duced; "not  impelled," says Brodie, "by muscular exertion, but by  its own
gravity and the pressure of the viscera.  Under these circumstances, when you in-
troduce your finger into the bladder,  " you find the muscular tunic  relaxed, and the
mucous membrane hanging in folds ; and  in consequence they  are not likely to  be
ruptured.  In other instances, the patient voids his urine immediately after the ope-
ration, or perhaps during the  introduction of the staff.   Here, the urine having been
made to  flow by  the patient's own efforts,  the muscular tunic is contracted; it offers
a considerable resistance to the opening of the forceps,  and is liable to be ruptured,
if the blades are  opened rudely and incautiously." (pp. 317, 18.)   A case of this
kind Brodie mentions, in which " the bladder (as he supposed) was in a contracted
 state, and the surgeon, in opening the forceps, observed a resistance, which suddenly
 gave way, as if a ligature had been broken." *  * *  On the third morning after the
 operation, he died, and  on examination, it was  "found that the mucous membrane
 and muscular tunic of the bladder had been  ruptured to the extent of three quarters
 of an inch." (p. 304.)  I have, very recently, in operating on a child of nineteen
 months,  been inconvenienced by the  violent contraction  of the bladder which Brodie
 mentions, and to a degree of  which  I had no notion.  I had operated with the cut-
 ting gorget, and  introduced  the forceps with perhaps  a little  more difficulty than
 usual, and immediately found the stone; but on attempting to open their  blades, I
 found it impossible without  using force, which was not justifiable.  I passed the
 blades farther in, drew them back, gave them a quarter turn, each time endeavouring
 to open  them, but in vain; they were as firmly closed as if they had been tied  to-
 gether, and a momentary thought passed  through my  mind, that they might have
 escaped  from the gorget, and slipped between the bladder and rectum ,• however, feel-
 ing the stone distinctly, again and again, I was convinced that could not be the case,
 and that the blades were fairly in the bladder. I continued making gentle attempts to
 open them, and full  five minutes elapsed  before they would move at all ; they then
 began slowly to open, and at last sufficiently toallow the stone to get between them,
 when it was extracted, though not before it had slipped once  or twice, as I could
 only at  first catch hold of the edge, the principal  part of the stone seeming to have
 been lodged in  a fold of the bladder, from  which I could not disengage it.  Now,
  had  I violently attempted to open  the forceps in this case, I should undoubtedly
 have torn the bladder, as in that mentioned by Brodie ; but using only gentle
 efforts,  the bladder  yielded   slowly,  and the operation was  safely completed.—
 j. f. s.]

    2099.  When the stone is enclosed by a  diseased  contraction of the
 bladder, attempts must be made to free it by introducing the finger, or a
 pair of stone-forceps, the blades of which  must be opened in different
 directions before  the stone, so as to  separate the  walls  of the bladder.
 For this  purpose, forceps with several arms, capable  of being applied
 singly have been proposed (b).   If the stone' cannot in  this  way  be
 grasped, its extraction must be given  up, and the spasm attempted to be
 removed with antispasmodic remedies, fomentations, and the like.

             (a) von Graefe  und von  Walther's Journal, vol. v. p. 171.
             (b) Deschamps, above cited, vol. ii. pi. i. fig. 14, pi; vi.  fig. 8, 9i 
332                 CUTTING FOR THE STONE J
  2100. If the stone be encysted, the  operator carries his forefinger to
the stone, and endeavours, if the encystment be not considerable, to set
it free.   If this be not possible, on account of the opening of the cyst
being very small, a  narrow blunt-pointed bistoury, or a bistoury con-
cealed in a sheath and $ little curved, must be  passed in upon the left
forefinger, and in its passage  attempts must be made to lay open the
cyst to such extent as may be necessary for setting the stone free, which
if its position allow, may at the same time be raised by the introduction
of an assistant's finger into the  rectum.
  Stones which lodge in the ureter and project into the bladder must be
loosened with the finger, carefully seized with the forceps, and attempted
to be freed by gentle pulling;  as  every violent pull is extremely painful
to the patient, and drawing the stone towards the neck  of the bladder
troublesome, however large the wound may be.
  If the  stone  lie in a hollow, formed by the protrusion  of the lining mem-
brane between the fibres of the bladder, it must be attempted to enlarge the
opening of the communication by  introducing a pair of small forceps, and
then to draw out the stone.   The difficulty in doing this will depend upon
the  nearness or distance of the  stone from  the wound.  If the stone be
covered with the inner coat of the bladder, in which case it has been thrust
between the membranes at the orifice  of the ureter, nothing can be done
except  proceeding as with a  partially encysted  stone, or  it may be
grasped with the forceps, and drawn out with careful movements.
  When a stone is covered with fungosities, the finger is to be carried
between it and the wall of the bladder, their connexions  separated, and
the  stone pulled out by moving it in different directions, and if the  con-
nexions be very firm, it must be attempted to loosen the  remaining part
by frequent injections, and by shaking the  patient, and afterwards to ex-
tract the stone (a).
  2101.  With  a  brittle and easily-breaking stone, it must be endea-
voured, by the introduction  of  the forefinger between  the handles of the
forceps, to prevent them being too firmly  closed, to avoid breaking the
stone ;  and for this purpose various apparatus, as forceps with a bag to
catch the stone, and so on,  were  formerly proposed.   When, however,
the  stone has been broken, the  larger pieces must be removed with the
forceps,  the smaller with a scoop, and the little pieces by repeated in-
jections, with warm water from a clyster-syringe, the pipe of which is to
be passed into the bladder on the forefinger.  Klein (b) advises that, in
this case, as also  when numerous little  stones have been removed, the
bladder should always be  examined with the sound some days after, for
the  purpose of  ascertaining  that nothing remains behind.  If the stone
break when it has been brought into the  outer wound, it must be pressed
out by the left forefinger in the rectum..
  2102. When the operation is finished the perineum  must be cleaned,
the  patient freed from the ligatures, and several turns of a bandage passed
round above and below the knees, to keep the thighs together.  He must
be kept in bed$ lying on one or other side, or on his back, with the thighs
drawn, up and the knees supported.   A moist sponge is applied to the
wound, and oiled silk or folded cloths laid to prevent  the fouling of the
bed by the urine: which flows out.
  (a) Klein ; in Loder's Journal; v6l. iv.  p. 564.       (b) Above cited, p. 380. 
BLEEDING.
333
  2103. The accidents, besides those already mentioned, in the extrac-
tion of the stone which may occur during the operation and require par-
ticular treatment are, bleeding, injury or prolapse of the rectum, convul-
sions,  and fainting.
  2104. Bleeding may happen from the superficial perinasal artery or its
branches, from the transverse  perinasal artery, from the inferior or  from
the internal  hcemorrhoidal artery, from the  internal  pudic artery,  from
wounding the bulb of the penis, and from  the posterior or inferior vesical
arteries.
  The branches  of the superficial perinseal  artery can  only produce an
alarming bleeding in those cases where it  is  unnaturally large.   The
transverse perinseal  artery lies so near the  ramus ischii  that it cannot
easily  be wounded, if the  cut  be  made at the proper  height (par. 2078.)
The inferior heernorrhoidal artery is sometimes injured when it is further
forwards than  usual, or the cut is  continued beyond the line from the
anus to the ischial tuberosity.  The branches  of the internal hasmor-
rhoidal artery spreading between the neck of the bladder and the rectum
may bleed.  The internal pudic  is  wounded when the cut  is made too
far to  the side.   The vesical arteries may be wounded  if the prostate be
complelety cut through, and the body of the  bladder  itself cut into.
   The  bleeding from the superficial vessels of the perineum  may be
stanched by tying them ;  but  that from the deeper vessels requires cold
applications, and if these be insufficient, compressipn  must be made with
a silver or elastic tube, open on both sides, and with a linen bag attached
to its front part {canule a chemise.)   The  front  end having been pushed
into the bladder, lint  is passed between  the tube and the linen bag, till
 sufficient pressure is made on every part of the wound, and the other end
 of the tube is fastened externally with a T bandage.  Erard (1), Dupuy-
 tren  (2), and von Graefe (3), have recommended  particular compres-
 sors for this purpose.
   The injury  of the internal  pudic artery  may  cause  so considerable
 bleeding that the extraction of the stone  must be deferred;  pressure, in
 the way prescribed,  will,  however, always be successful in stanching the
 bleeding.  It has been also advised to keep up pressure with the finger by
 relays of assistants, or to  tie  the artery by means of  a  particular kind of
 needle  (a), or with Deschamp's- (6) artery-needle.   According to my
 own experience, however, the continued  and efficient application of cold
 is the best mode of stanching  bleeding after cutting for the stone ; I have
 succeeded with it when pressure had been used in vain (c).
   (1)  Erard's (d) compressor consists of a canula, at  the vesical end of which are
 two wings, which jut against the inner wound, whilst a plate furnished with com-
 presses is pressed against the perinaeum with a  screw.
   (2)  Dupuytren's (e) compressor has two branches,  flat on their inner, convex on
 their outer surface, and by their elasticity capable of separating from each other like
 the branches of common dissecting forceps.  The branches are covered with leather
 and agaric, the latter upon their convex  surface.  The instrument is to be passed,
 closed, into the wound, the one branch put against the seat of the bleeding vessel,
 and then the branches allowed to  open.   If the bleeding stop, the instrument must

   {a) Zang, Operationen, vol. iii pi.  ii. f. 5.    (d) De l'Hemorrha?ie a. la suite de  la
   (b) Bovkr, above cited, p. 435.          Taille, &c.   Paris, 1822.
   (c) Heidelberg klinish. Annalen  vol. vi.   (e) Memoire acheve etpubl. par Sanso.v et
 part iv.                              Begin, p. 50.
      Vol. hi.—29 
334
CUTTING FOR THE  STONE ;
be left there; but if otherwise, its position must be altered till the bleeding vessel is
fully compressed.
  (3) von Graefe's (a) compressor resembles Weiss's speculum, and consists of
four branches, the  outer surface of which is covered with  agaric: it is introduced,
closed, into the wound, and then  the branches opened by a screw, so that the regular
pressure is made on every part of the wound.
  Shaw (b)  has described a case of fatal bleeding, in operating for  the stone, from
wounding the dorsal artery of the pern's, which was given off as a large branch from
the hypogastric artery in the prostate gland, and was continued under the pubic arch
to the pern's.   He  has found this variety of the artery frequent, as has also Tiede-
mann (c) and Burns.
  [With regard to the  loss of  blood during the operation for the stone, Brodie
says :—" I have sometimes heard it observed, when a patient has lost a good deal of
blood at  the time of the operation, that he has lost no more than it will do him good
to lose."  I have, however, great doubts whether even in the case of the strongest
man, the losing much blood adds to his chance of recovery, and it is evident, that in
the case  of a person of originally weak constitution, or of one whose bodily powers
are  exhausted by his previous  sufferings, or who labours under disease of the kid-
neys, or  other organs, ihe loss  of a considerable quantity of blood in the operation,
is likely to make all the  difference between its success and failure."  (p. 335.)
  As to  the bleeding which occurs during the  operation ; though free, it often ceases
almost immediately after the patient is unbound, and the legs brought close together,
and requires  nothing further.   But if it  continue, and the patient become faint and
pallid, it will be necessary to.put a stop to it, otherwise the bleeding will be  fatal.
Brodie mentions the case of an elderly man with an enlarged prostate and deep
perinaeum, in whom " the  blood  seemed  to proceed from  the  neigbourhood of the
neck of the bladder, and what was remarkable, it was venous.  He was foiled  in all
his  attempts to restrain the haemorrhage, and the patient survived the operation only a
few hours."  (p. 335.)   I have also known a case or two in which the bleeding was
fatal: but such instances are rare.
  When the bleeding continues after the operation, the wound must be gently opened
and carefully examined.   If any vessel can be seen, it should be taken up and tied ;
But if, as is more commonly the case, the transverse perinseal artery, or the artery of
the bulb, which I believe is far more frequently the bleeding vessel than the pudic,
which lies so protected by the ramus of the ischium, that  it is scarcely possible to
be injured with the gorget, though it  may be  cut through with the knife, be cut off
close to  its  origin  from  the internal  pudic, there is not room to apply a ligature
around either of the former; and with regard to the pudic, it is next to impossible
to get at it at all with a needle.  In such cases the best and safest proceeding is to
pass the finger into the wound, and press the artery steadily against the ramus  ischii
till  the bleeding.cease.   This will require to be continued for several hours, and will
need a relay of assistants. • I have seen two cases so treated successfully.  The first
case was under my care during my dressership, and the pressure was  kept up un-
interruptedly for fourteen hours, and with very little inconvenience to the patient.
Attempts had been made both  to tie the vessel, and to cut it across, so that its ends
might retract, as it was  supposed to have been  merely wounded, but they  were
quite fruitless.  In the other case, fouror five hours were sufficient to put the patient
in safety.  Under these  circumstances the surface of the wound generally sloughs,
and the cure  is retarded.
  Sometimes, the blood  instead of escaping by the outer wound, flows back into the
bladder,  and forming a clot, prevents the passage of the urine either by the wound or
by the urethra.  I have known this happen in a few instances, without the bleeding
however, being serious,  or affecting the constitutional powers.   If the patient do not
pass water in the  course of a few hours after the operation,  if he become  restless,
and  if there  be fulness and uneasiness, or pain about the region of the bladder, it
may be suspected,  that  blood has flowed into the bladder and clotted.  It is then
necessary to pass the finger gently through the wound into the bladder, and imme-
diately this is done the urine escapes and  clots of blood with it.  Should the bladder

  (a) Journal von Graefe und von Walther,    (6) London  Med. and Physical Journal,
vol. xxii.  p. 65.                            vol. Iv. p. 2.  1826.
                        (c) Tabulro Arteriarum, pi. xxx. f.  2. 
SECONDARY  BLEEDING.
335
be found much distended with blood, it is well to wash it out gently with a syringe
and warm water, which may be  repeated once  or twice at intervals, according to
circumstances.
  Plugging the wound, or other of the appliances mentioned by Chelius,  I do not
think at all proper.
  Secondary bleeding, in rare cases, follows at an  interval of several days after a
patient has been cut for the stone.  Brodie mentions one •if a child in the second
week, which occurred under his own care, and*though the  boy was excessively
lower by the bleeding, he recovered.   Also a case of Earle's, which bled on the
seventh or eighth day, and  was stopped " by introducing through the wound into the
bladder, a tent composed of a quantity of lint wrapped round an elastic gum catheter."
(p. 335.)   The first case of this kind which I witnessed was under my care during
my dressership in  1816, and  had been operated on by the  elder Travers.  At the
time of the operation much  blood was lost, but it soon stanched.   On the fourth day
there was a sudden bleeding from the wound, to  the  amount of  a pint and a half,
which was stopped  by pressure with the finger.   On the following day the bleeding
returned twice, and he lost another pint of blood ; pressure was again made for five
hours; the bleeding was not repeated, and  he recovered.  A similar case occurred
to Green, in a boy of thirteen.   He became excessively faint very soon after the
operation, and there was a little bleeding throughout the whole of the afternoon and
day following, which was  checked by the introduction of the finger, with  pressure
on the pudic artery  for about half an hour at a time.   No farther bleeding occurred
after the second till the ninth day, when he  became very restless, and there followed
a very free bleeding, both from the wound and from the urethra; several clots were
passed during the afternoon and evening, the finger having been introduced into the
wound  several times  to favour their escape. There was no recurrence of clots or
bleeding after this day.  He was kept low for  some days, but no cold  application
used, and he recovered.
   The following fatal case  of secondary bleeding happened to me in 1839 :—Ihad
operated on a  lad of thirteen  years of age with  the gorget, and in opening the staff
had cut through either the transverse perinaeal or the artery of the bulb, from which
there was very free bleeding, but it soon ceased.  On the evening of the second day
he had pain in the region of the bladder and  in the left groin, with tenderness and a
good deal of constitutional  excitement.  Leeches were applied to the bfelly.  The
symptoms continuing, calomel and opium were ordered on the following day, and he
was so much improved the fifth day that the mercurial was left off, there remaining
only a little tenderness in the left groin.  His urine was now quite natural in colour.
On  the sixth  day, up  to which  time  he had passed water plentifully both by the
wound and  by the urethra,^ thin slough about the size of the finger-nail came away,
and he seemed doing very well; but about noon he had some pain at the lower part
of the belly, which was immediately followed by a small motion, accompanied with
much straining;  and as the urine  passed  by  the wound, a quantity, as much as
fill both hands, of  very offensive dark-coloured  clotted blood escaped with it.  He
then became easy, but was very faint  and pallid, and it was necessary to give  him
some brandy.   On the next  day he was tolerably well, free from pain, and did not
seem affected by the  occurrence of yesterday.   It was thought that the  clot dis-
charged  might have depended on bleeding back into the bladder, and that this had
been the cause of the irritation on the second evening.  On  the seventh  evening he
had a good  deal of straining, and passed by  the wound about  three table-spoonfuls
of clotted blood in several lumps, with plenty of water.  On the following  morning
he passed some bloody urine  after straining, and the napkin was slightly tinged with
fresh florid  blood ;  he was  pallid, his pulse small and quick, and the countenance
rather anxious.  The same  evening, with much straining and a little motion, he
passed a clot of four ounces, another an inch and a half long, and  as thick as the
finger, and a third and smaller clot, at three  several times.   On the morning of the
ninth day, about half-past seven, with much straining and a little motion, he passed
about four ounces of cldt with urine by the wound, and a little blood, but no water,
from  the urethra.  He then became very faint and squeamish, and  yawned con-
tinually, his countenance bloodless, and his  pulse very weak and quick.  I carefully
examined the  wound, and found it clean but pale, with a small layer of coagulated
blood on the left side, which being disposed to  stick, I thought best to leave alone.
Between this time and three in the afternoon his bowels were  sparingly moved five 
336                   CUTTING FOR THE STONE;
times, and he had passed plenty of water, but neither blood nor clots.   On consulta-
tion with my colleague, Green, it was determined that the finger should be intro-
duced into the bladder, and any clot there detached and broken to pieces, and cleared
out by injecting warm water, that the bowels should be quieted with opium, and his
powers supported with  egg and wine.  This  was accordingly done; I introduced
my finger, but could not ascertain any thing unusual;  no water, but a small portion
of clot, not  larger than half a sixpence, followed its  withdrawal.  I then passed a
catheter  by  the urethra, and with* my finger  in  the wound, introduced  it  into the
bladder,  and injected by it  some warm water twice, the first passed by the wound
slightly  tinged, but the  second was colourless; and the catheter when removed had
no appearance of having been  in any clot.  He slept during the rest of the day, and
neither  had  any more straining  nor passed blood, though the napkin was  a little
stained.   About eleven  he  threw up  some beef tea  immediately after taking it,
as well also porter and  brandy and water, which were  given  at intervals, and then
dropped  asleep.   At four o'clock on the  morning of the tenth day his bowels were
freely moved without any clot, and soon  after he took and kept down  an egg and
some tea.   In the course of the forenoon he passed plenty of water, accompanied
with  a very offensive discharge, as if  from  a slough, but without any blood, and
seemed  better though  very languid.  As he  was fully under the influence of  the
opium I  directed its omission,  thinking it might be perhaps  the  cause of the sick-
ness.  At noon he was seized with shivering and seemed to be passing'his  water;
the wound was looked to, a small  clot found in it, which being removed, the urine
escaped  readily, and the shivering ceased.  During the day he took  some beef tea,
porter, and egg, which he enjoyed, and was constantly dozing.  He had one  motion
with  much  straining, but unaccompanied with bleeding or clots.  On the fifteenth
day he continued improving, except that the straining continued, for which an opium
injection was  given with advantage,  and he has taken plenty of nourishment, to
which first port wine was added, but  afterwards changed for sherry.  The  wound
bas become  more florid  and suppurates freely,  and there is a plentiful discharge of
7?iMct<sfrom the bladder.  Every thing seemed doing welt, and the quantity of mucus
diminishing up to the  twenty-first morning at five o'clock, when the napkin was
found stained with bloody urine, and a little bright red blood ;  he passed more bloody
water and a little bright blood  several times.   At nine o'clock a small clot passed,
at ten another and soon after a  motion, and about two table-spoonfuls of clot, and he
began to feel  faint.   Clots and water continued passing at intervals till  eleven
o'clock, and between that time and noon about six ounces  more.   Soon after he
passed another clot from the wound, and some  bright blood by  the urethra.  He then
became very pallid and cold and his pulse very small and quick.  I passed acatheter
and washed  out the bladder; the first water was  tinged with blood, but the second
was clear; under these circumstances  I thought it best to introduce the finger into
the wound and compress the pudic artery, which being found efficient was continued
for  twenty-one  hours, a very small clot or two only passing when the finger was
withdrawn for relief.  Brandy  and beef tea and a few drops of laudanum were given
during the day, as he had become very restless.   On this evening (the  tu>enty-second)
he was attacked with  some bronchial irritation, which continued increasing,  not
having been relieved by the application of mustard poultice or blister,as he was too
weak for any more active means.   He continued  sinking, and died on the afternoon
of the twenty-fourth day, but  had not had any recurrence of the bleeding. The
examination of this  case was most unsatisfactory, as  the parts which had been
removed  that they  might be carefully examined, were cut to  pieces in the  neigh-
bourhood of  the pudic artery, which was the most important of all.  I was therefore
unable to ascertain whence  the bleeding had originated; but I cannot help thinking
it must have been  from  tin origin  of the transverse perinseal artery, and that had I
made pressure on it at first, as  I-did at last, the boy might have been saved.  This
plan I should certainly adopt under similar circumstances.   At the  time I did  not
recollect  the occurrence  of after-bleeding in a case of this kind, and when the bleed-
ing ceased for  a time and the  child again began to improve, I had  hoped that the
danger had passed away.   The case is deeply interesting, and I believe not unde-
serving the full report I have given of it.—j. f. s.]

  2105. Wounding  the  rectum may happen in various  ways j First, at
that step of the operation when the  operator having made the  outer cut, 
AFTER-TREATMENT.                    337
carries the point of the knife into the groove of the staff' for the purpose
of opening the membranous part.  If the handle of the knife be then too
much raised, its point sinks into the  rectum.   This opening is in general
very small, a mere puncture, through which only the intestinal gas and a
small quantity of faecal matter escapes into the wound.   Second, when in
withdrawing Frere Come's lithotome or the common bistoury, the wound
first made, is  still  increased.   The pain  which accompanies  cutting
through the neck of  the  bladder often  excites  the patient to strain vio-
lently, and thereby force the intestines violently into the  pelvis,  so that
the rectum lies  as a  fold  before the prostate.   In old persons there is
sometimes an enlargement of the rectum, so that'the prostate is usually
lodged in a hollow of the gut, which also  surrounds the neck of the blad-
der on both sides.  In such  case the rectum must be almost necessarily
wounded in the withdrawal of Frere Come's lithotome.   If the gut receive
the prostate only on  one side in such  hollow,  it is advisable to operate
on the  right side, and with  great care (a).   Third, the rectum may be
wounded in drawing out a large angular stone; if the wound be small,
and near the m. sphincter ani, and the patient young, strong, and healthy,
the opening frequently closes of itself without symptoms.   Sometimes a
fistulous opening remains after the wound in the neck of the bladder, and
the membranous part of the urethra has closed, and communicating with
the gut like a common rectal fistula, is to be treated in the  same manner.
Occasionally, the  external wound -closes, and there still remains  a com-
munication between the neck of the bladder and the rectum, which, how-
ever, is in general so contracted, that but little  urine passes through the
rectum, and only a small quantity of fsecal matter by the urethra.  De-
sault and Dupuytren have  in  such cases divided the rectum from the
wound with  success.  The  common practice is  to introduce an elastic
catheter  into the  bladder.   According  to Kern {b), in a  wTound of the
rectum, corresponding  to the body of the bladder, the  buttocks  should
be raised, frequent injections of warm water, and drawirg off' the urine
several times a  day with the catheter, should be practised.
   The bladder is placed higher in children than in adults; therefore, as the parts are
cut through from  without inwards, or from within outwards, a  direotion  must be
given to the instrument, corresponding to a line supposed to be drawn from the navel
to the haunch-bone, so as more certainly to avoid injuring the rectum (c).
   [Wounding the rectum in performing the  operation for the stone is, as far as I
know, of rare occurrence. I have seen but two cases in the course of thirty-three
years; one was done in introducing the gorget, and the other in making the, second
cut with the knife before the gorget was  introduced.  Th© surgeons under whose
care they were, wisely left them alone, and treated them as if no accident had hap-
pened.  A little faeculent matter passed  by the wound in. the perinaeum for a few
days, after which  the rectum scarred, and  no farther inconvenience ensued.  I have
never seen any instance in which division of  the sphincter ani was  requisite, and I
doubt whether in England such ever occurs.   Should I  ever meet with a recent case
of the kind, I should advise leaving it to nature.—j. f. s.]
   2106. When the rectum is protruded  by the  patient straining during
the operation, it must be pressed back and retained by an assistant with
a pad upon the  right side.
   Convulsions and fainting require the  operation to be quickly finished

       (a)  Deschamps, above cited, vol. iii.  p. 8.       (b)  Above cited, p. 233.
                      (c) Dupuytren, above cited, p. 28.
                                 29* 
338
CUTTING FOR THE  STONE ;
and if that be not possible, and the patient's danger great, the extraction
of the stone must be put off.
   2107. The-after-treatment in general consists of cooling and mild re-
medies.   The patient should take an opiate after the operation, and must
preserve the most perfect rest  of body and mind; for drink he  should
take a little almond milk, and for food only a little  broth, for the  first
few days.  The sponge on the wound should be frequently changed, and
the neighbouring parts kept clean.   In  general the urine begins to flow
partially by the urethra the first day after the operation;  when the urine
is mostly voided by the urethra, the wound should be covered with wad-
ding, which is to be fixed with a tightly drawn T bandage, and towards
the end of the scarring the wound must be touched with caustic to pro-
mote its  healing.   The cure  of the wound is often complete in three or
four weeks; sometimes it occupies a month; but in rare cases the wound
closes by quick union in from nine to fourteen days (a).   I have twice
seen the wound healed by agglutination on the  fourth  day (6).
  The continued application of cold by means of a large sponge dipped in very cold
water, is obviously the  most efficient remedy to prevent  bleeding and severe trau-
matic reaction.
  [The dextrous performance of the operation for the stone is  not all that is neces-
sary for the well-doing of the patient, and instances have occurred within the remem-
brance of many, in  whieh, though ably and quickly performed, and with as  little
suffering to the patient as possible, and every hope of a favourable result when they
were removed from the operating-room, yet have  they terminated fatally.   In hos-
pital practice, I  have no doubt this  has arisen from stone-patients having been, in
most instances, placed in a ward with other patients, where sufficient quietude could
not be preserved, and where the sister having only occasionally a single case, had
no chance of obtaining sufficient experience in the conduet of a case, which  mainly
depends on her  constant attendance and ability, almost as much, indeed, as upon
the good  performance of the operation.  In consequenee of so much being intrusted,
of necessity, to the sister, and so little which might attraet attention being done, few
students, on leaving the  hospital, know more of a stone-case than the performance
of the operation and its result, unless any thing very remarkable should occurduring
the course of the cure;  and therefore, when  settled in practice, and called upon to
operate for the stone, although they may perform  the operation extremely well, yet
they are at a loss to know in what way the after-treatment, under common circum-
stances, should be conducted ; and are therefore unable  to give directions, or to exert
such eontrol over the nurse as may assist to bring about a favourable  termination of
the case.   I am not aware that either in any Lectures on Surgery, or other published
works, that these seemingly trifling, though, in reality, very important points in the
after-treatment of stone-operations have been noticed, the attention only having been
drawn to  after-bleeding,  peritonaeal inflammation, and some  other  more striking
circumstances of such cases.
  To fill  up this serious gap in the after-treatment, I  shall  now relate the practice
whieh certainly for the last forty-six years, and I have little doubt for a mnch longer
period, has been adopted at St. Thomas's Hospital.
  When a patient is ascertained to have the stone, he is placed in a small ward, con-
taining only half-a-dozen beds, and which, during the first part of the after-treat-
ment, is kept private and extremely quiet.  Here he remains under the watchful
eye of the sister, an experienced woman, to whom all the  stone-cases are assigned,
and who is capable of giving the surgeon a full and sufficient account of the patient's
symptoms and sufferings during his absence, and to note any little peculiarity about
him, which a nurse unaccustomed to such cases would  overlook.  Great  care is
taken in  first instructing these women, who  usually remain long in this ward;
indeed, in thirty-six years the sister has been replaeed only thrice since the death

  (a) Textok, above cited, p. 34.—Graefe    (6) Chelius, TJebcr den  Steinschnitt; in
in Bernstein, p. 100. .                   Heidelb. klin. Annulcn, vol. vi. part iv. 
AFTER-TREATMENT
339
of the sister who had the ward when I first entered  the  profession, and who spent
twenty years there: a  sufficient proof of the experience  which such persons must
acquire.
  The patient usually remains for ten days or a fortnight, to accustom him to the
place and to his attendants; and it is rarely requisite to pay more than ordinary atten-
tion to his diet and habits, if he be in good health, excepting his immediate com-
plaint.  If his sufferings be severe, an occasional hip-bath is used, which has a very
soothing effect;  and is often extremely serviceable  if the preparatory soundings
increase, as they will occasionally, his sufferings.   I have rarely known it neces-
sary to employ blood-letting  or other depleting means, though such necessity may
possibly occur, but in  ordinary cases they are unneedful and  improper.   An occa-
sional clearing of  the bowels is,  however, requisite;  and if the  patient have been
accustomed to take gin and water,  for promoting the  action of the kidneys, a prac-
tice, with regard to young stone-patients  especially, very prevalent, it will be well
not to deprive him of it at once, or he will become fidgetty and  uncomfortable, but
to diminish it slowly, or even to continue its use.
  Under ordinary circumstances,  a  stone-patient should not be operated on, except
his health be otherwise good.  His  sufferings from  the  disease itself will call for
the performance of the operation.  The  state of the  atmosphere should, as far as
possible, be considered.  Temperate weather is the  most  favourable; for if it  be
very hot, the patient, in the weak state he usually is after the operation, suffers much
from its depressing effects; and if it be very cold, he is liable to chill in the neces-
sary frequent uncovering to which he must be  subjected to  keep him dry during the
after-lreatment.
  On the day previous to the operation, a dose of castor oil should  be given to clear
the bowels, and the diet restricted to rice pudding and milk, with plenty  of barley
water or gruel, but the former of the two is most preferred.  If the motions be hard
and lumpy, castor oil is added to  an injection of gruel, which must be thrown up on
the morning of the operation, but if not,  a simple injection of gruel is sufficient for
the purpose of completely relieving the. lower bowel.
  Immediately after the operation, the patient  is put to bed, with his  legs straight
and close together, by  which the  surfaces of the wound are brought gently together,
and any slight disposition to bleeding checked.  A napkin  is passed round the
pelvis, and brought up  between  the legs, in the same way as healthy infants are
commonly clouted.  As it is  of great importance that the patient should be  kept dry,
the napkin is changed  every  time any urine passes  by the wound, and attention is
paid to this through the whole course of the treatment.  On the evening of the ope-
ration day, or the following morning, if there be no bleeding, a piece  of lint,  folded
 on the end of the finger, is introduced  into the wound, and pressed up the depth of
 the perinaeum; this is also  replaced every time the  patient wets, and is  continued
 till the wound heals; its object is to ensure the  healing of the wound from the bot-
 tom, so as to prevent, as far as  possible, the  production of any fistulous passage,
 which, under this treatment,  is of very rare occurrence.   A handful or two of camo-
 mile flowers thrown into a basin, are sprinkled with  spirits of wine, well mixed, so
 as  to be equally moistened, and then put into a thin flannel bag,  and having been
 well heated  on a warming-pan, are applied over the  belly as hot as the patient can
 bear, on the evening of the operation day, if there be no bleeding; and this is con-
 tinued for a  week or ten days.  If, as sometimes happens, on the second day the
 wound be swollen, and the urine do not  flow through it,  no lint is  introduced, but a
 bread-and-water poultice  applied, and, as the  swelling subsides, the  water escapes
 by the wound.  Such is the usual mode of proceeding, and neither is the bed guarded
 with oiled silk, nor cold sponge, nor any other cold applied even though there were
 bleeding.   Rarely,  except  under  particular  circumstances, is  any opiate given
 throughout the cure.   The diet for the first two  or three days should consist merely
 of  rice or sago pudding, biscuit,  toast and tea, or arrow root and milk, with a plen-
 tiful  supply  of barley  water.  As the bowels had been  freely relieved, it is unne-
 cessary to give any medicine before the third day, and then only a little castor oil
 to act gently.  But if there  be pain in the belly, or sickness, then the oil must be
 given earlier, and usually it subsides when the bowels  are moved.   The urine at
 first passes frequently by the wound; but usually about  the third or fourth day also
 comes  by the urethra; and  as more continues to pass  by the latter, so  does less
 escape by the former, and, in about a week or ten days, the wound of the prostate 
340
CUTTING FOR THE STONE J
having healed, the water passes only by the natural passage; and when this hap-
pens, the wound  is dressed with wax and oil upon the lint introduced, as before.
In one instance I have known the water cease to pass from the wound after twenty
hours, but this is a rare occurrence.   Generally, when the water does not at first
flow from  the wound, the  patient becomes irritable and uneasy, and it  is well to
introduce the finger, so as to break up any little  clot which may stop up the wound,
after which it usually escapes freely.  Occasionally it may be necessary to resume
the gin and water, if the  patient flag, which, however, the surgeon himself will
attend to in reviewing the  state of the health.   The patient should  be kept in bed
some days after the water has ceased to flow by the wound, or, in other words, till
it is nearly healed to the surface.  If a small sinus should continue open, it is well
to twist up a little piece of lint corresponding to its size, which  should  be dipped
in a solution of sulphate of copper, and  gently screwed up to its bottom; but, in
most cases, a simple dressing of wax and oil is all that is needed.   Commonly, in
from three weeks to a month, the cure is perfected; the diet having been gradually
improved, and porter or wine added according to circumstances.—j. f. s.]
   2108.  When, after the operation, there  is reason to fear active inflam-
mation, it must be sought to prevent, it by general and local  blood-letting,
and by the constant use of cold  applications to the perineum.   If inflam-
mation arise, which commonly   spreads  over the  perineum, it must be
met with corresponding antiphlogistic treatment (1).   It most commonly
depends on the escape of urine into the  cellular tissue of the  pelvic cavity,
when  the capsule of the prostate has been opened by a large cut, or by
tearing.  Old persons, in whom the walls of the bladder are thickened,
or otherwise  diseased, often die without any active inflammatory symp-
toms coming on.  Opiate  clysters and  blisters to the belly are  proper in
these  cases  (a).   In an  erethetic state, which shows itself by a  very
great degree  of general uneasiness, by  great wearisomeness  of the whole
body,  by dull pain in the loins, and depression of the powers, with small,
contracted, faltering pulse, cooling and mild treatment must be first em-
ployed, together with warm  bathing and  oily mixtures,  and if any one
organ  be specially affected, leeches must be at the same time applied to
it  (b).  Spasmodic symptoms require  antipasmodic remedies  alone, or
in connexion with antiphlogistics, if there be  accompanying inflammation.
A painful discharge of urine  by the urethra, or its complete obstruction
may be caused by  spasm, by swelling of the wounded parts, or by  a
collection of clotted blood.   According to  the variety of the cause, the
remedies must be  either antipasmodic or antiphlogistic, and  the urine
must be emptied through the  wound by a female catheter passed into the
bladder.
   [(1) "It is a prevailing opinion," says Key, " that stone-patients die of peritonitis
brought on by the injury done to the bladder  during the operation, a mistake which,
though not leading to any serious  error in the after-treatment, is so far attended with
mischief inasmuch as it misleads  the surgeon from the true cause of the fatal event.
I will not venture the assertion,  that inflammation of the peritonaeum  is never a
sequela of lithotomy, but that it is  an extremely rare occurrence, and still more rarely
the cause of death, examinations post mortem  have fully convinced  me. During the
ten years I have been at our hospitals, I  have never yet seen an unsuccessful case,
examined  after the  operation,  in  which inflammation of the peritonaeum could be
regarded as the cause of death; and as invariably I: have found that one circumstance
was uniformly present, namely, suppurative inflammation of the reticular texture
surrounding the bladder.  *  *  *   Inflammation spreading rapidly through these
cells will quickly effect a surface much greater than that of the peritonaeum, and I

    (a) Samuel Cooper, First Lines of Surgery, p. 775.  Seventh Edition.  1840.
    (b) Zang, above cited, p. 239. 
AFTER-TREATMENT.                        341
have witnessed," says he, "symptoms as acute, pain as severe, and  the  peculiar
depression attending peritonitis, as marked  in the reticular inflammation as in  the
most acute and fatal case of inflammation of the abdominal cavity.  *  *  *   la
the inspection of those who die after lithotomy,  it is not sufficient to look  into the
peritoneal  cavity, to open the bladder, or to examine the state of the  wound;  the
peritonaeum lining the lower part of the abdominal muscles should be stripped off,
and  the source of evil will be then laid open.  The finger will enter a quantity of
brick-dust coloured pus  in  the  cellular substance around the bladder, and if con-
siderable force has been used in  the extraction of the stone, will readily find its way
towards the wound  in the perinaeum; the barrier between the adipose  structure of
the perinaeum and  the reticular texture of the pelvis being broken down,  the sup-
purative inflammation spreads rapidly along the latter, and may be traced,  in some
cases,  between  the perinaeum and abdominal muscles  as high as the umbilicus, in
one case I have seen it extend to the diaphragm." (p.  18-21.)
   "All that I have been able to observe  for many years past," says Brodie, "has
confirmed  me in the opinion, that an incision of  the prostate, extending  into  the loose
cellular texture surrounding  the neck of the bladder is replete with danger to the patient.
Such a division of parts is never necessary where the calculus is of moderate dimen-
sions ; but it cannot be avoided where it is of very large size; and hence the extraction
of stones  of this description can never be accompanied without a great probability of
the patient not surviving the operation.
   "The symptoms which arise in these cases are not well marked in  the first
instance.   There is some heat  of skin, and  generally an absence of perspiration;
there is usually an abundant flow, of urine  through the wound.   The pulse, as to
frequency, is somewhat above the natural standard; and the patient, although  free
from suffering, has no disposition to sleep.  This state of things continues for
twenty-four or even forty-eight hours after the operation; then the more characteristic
and alarming symptoms  show  themselves.  The pulse  becomes  more frequent,
rising  to  90, 100, and at  last to 140  in  a minute; the heat of  skin becomes still
greater, the tongue dry,  the countenance anxious.  Afterwards, as you count the
pulse, you find every now and then a beat weaker than the rest, and then there are
complete  intermissions.   At first the intermissions are not more than one or two in
a minute; by degrees they  become more frequent, until they occur  every  third or
fourth  beat.  There is an occasional hiccough;  the  patient complains of some de-
gree of tenderness in the lower part of the abdomen, especially in the left groin;  the
belly becomes tympanitic, that is the stomach and  intestines are  filled with air, the
distention of  the belly increases, the  hiccoughs are more frequent, the pulse con-
tinuing to intermit, becomes weak and fluttering.  In some  instances, the patient
retains his understanding even to  the  last; while in others he falls into a  state of
low delirium  previous to  death.  Occasionally in  the progress of such a case, the
patient has a  severe rigor, and sometimes he  complains of a pain in the loins.
Where these symptoms begin at an early period, he may die within forty-eight hours
from the time of the operation; but in other  cases,  death may  not take place for four
or five days, or even  for a week.   On dissection  you  find the cellular membrane
round  the neck of  the bladder, and between the prostate and the'rectum, bearing
marks of inflammation, infiltrated  with lymph and serum, and to  a greater or  less
extent, converted into a slough.   If death has taken place at an early period, the in-
testines are found distended with air, and there is a very slight effusion of serum in
that part of the peritonaeum, which distends into the pelvis.  But if  the patient has
laboured   under these symptoms  for  many  days  before  he  dies,  the  peritonaeum,
where it is reflected from the bladder to  the rectum,  is  seen of a darker colour than
natural, and incrusted with  lymph ; and at a still later period there  is"the appearance
of inflammation, to a greater or less extent, throughout the peritonaeum generally.
But the  peritonaeal inflammation  is evidently not  the primary disease; it is  the
inflammation  and  sloughing  of the cellular membrane  of the pelvis, which  has
induced inflammation of the adjoining  portion of the membrane.  Something also is
to be attributed to the tympanitic distention of the intestines, which, if continued for
a considerable time, is always liable to be attended with tenderness of  the abdomen,
and  some degree of peritonaeal inflammation.  It is important that you should not fall
into the error  of regarding such cases as I have just described,  as cases of simple
peritonaeal inflammation;  for the remedies which would be useful in the latter case are 
342             CUTTING FOR THE STONE, THROUGH
injurious here.  The abstraction of blood, or even the operation of an active purgative,
will cause the patient to sink more rapidly, tending only to hasten his death.  The
proper system to be pursued, is the opposite to that of depletion.   The patient should
take such nutriment as his stomach is capable of digesting. The bowels may be
kept open by injections, or by the exhibition of some very gentle  purgative; and
ammonia, wine, and brandy are to be administered, when  the state of the general
system indicates that stimulants are necessary." (p. 327-30.)].
  2109. The bleeding  -which occurs at various periods after the opera-
tion, requires a different mode oftreatment according to its  degree.   If
slight it may be considered useful as  a  local  blood-letting, and as tran-
quillizing the patient.   A severe bleeding, when  coming  on soon after
the operation,  if  it do not yield  to the use of cold  applications, requires
the ligature, if the  seat of the bleeding vessel will  permit it, or pressure
as already directed.  In this case, as well as when pressure is also applied
after the operation, the instrument used  must be continued in its proper
place, as long as seems necessary for the certain obliteration of the vessel.
Bleeding from the vessels of the bladder requires, besides strict rest and
a  cooling  treatment, cold  applications  to the belly,  and in  cases of
necessity injection of cold water, or solution of alum.
  In persons whose blood  is thin and watery, their eyelids puffy and semi-trans-
parent, who are often attacked with  bleeding from  the nose and gums ;  a constant
bleeding often comes on after the operation, which is nearly always fatal, and like
any parenchymatous bleeding, must be treated with tonics  (a).
   2110.  Abscesses sometimes form about the neck of the bladder, which
must be encouraged to discharge their pus.   If fistula  should remain, it
must be  treated  as already  directed (par. 2105); frequently it is in-
curable.
   Incapability of holding the urine and impotence,  which rarely continue
after the lateral operation for the stone,  depend upon the great bruising
and gangrenous destruction which  the neck of the  bladder has  suffered'
from the large size  of the  stone  and  the  violence of the extension.
Strengthening remedies, internally and externally,  as in ischuria paraly-
tica, are the alone means which may here perhaps  be useful.
   2111.  If the disposition to form  stone continue after the  operation, it
must be counteracted  by  either of  the already prescribed  rules  (par.
2011-13).
  An instance  of remarkable disposition  to form stone is mentioned by Chari.es
Phillips (6), in Vhich in the space of six years, on lithotomy and four lithotripsies
were required.
  To the works already referred to on the lateral operation  for the stone, the follow-
ing may be added:—
  Mery, J., Observations sur  la maniere de la tailler dans les deux sexes pour
l'Extraction de la Pierre, pratiquee par Frere Jacques.  Paris, 1700.
  Morand, S., Opuscules de Chirurgie. vol. ii. p. 51.
  Garengeot, De l'Operation  laterale corrigee.  Paris, 1730.
  Gunz, De Calculum curandi viis, quas Foubert, Garengeot, Perchet, Le Dran
et Le Cat reperierunt.  Lipsiae, 1740.
  Pallucci, N.  J., Nouvelles Remarques sur la   Lithotomie, &c.  Paris, 1750.
8vo.
  Albin, R. S., Dissert, de variis Calculi secandi methodis.  Ludg. Bat., 1754.
  Camper, Demonstrationes Anatom. pathologicae,  lib. ii.
  Pouteau, Sur l'Operation de la Taille; in Melanges de Chirurgie, p. 197.  Lyon,
 1760.

  (a)  Deschamps, vol. iii. p. 29.           (b) Gazette Medicale, vol. ii. p. 534.  1834. 
        THE PERINEUM INTO THE BODY OF THE BLADDER.    343

  Seiller, Dissert. Cultrorum ceratotomorum etcystidotomofum historia. Witten-
berg, 1805.
  Dorner, Uber  die Wahl einer Steinschnittmethode; in von Siebold's Chiron,
vol. i. part i.
  Thomson's John, M. D., Observations on Lithotomy, &c.  Edinburgh, 1808. 8vo.
  Cooper, Samuel ; in Med-Chir. Trans., vol. viii. p. 206.
  Richerand, Memoire  sur l'Hemorrhagie apres l'Operation de la Taille laterale;
in Mem. de  la Soc. d'Emulation, vol. i. p. 145.
  [Dudley, B.  H., On Nature and Treatment of Calculous Diseases.
Lexington, Ky., 1836.   8vo.
  Bush, Jas. M., Observations on the operation of Lithotomy, illustrated
by cases from the practice of Prof. Dudley, in  Transylvania Journal of
Medicine for .1837.—g. w. n.]
  2112. Incidental to the history of the lateral operation for the stone,
are the methods of  opening the body of the bladder from the perineum,
which originated in  the  attempts made  by  Bamber,  Cheselden Le
Dran, Douglas, and Morand, to  discover Rau's operation, which was
wrongly believed to  consist in  opening the  body of the  bladder (a).
Foubert proposed  a particular  mode of  operating, in  which,  after the
bladder had  been largely  distended by drinking, by injection, or by hold-
ing the water,  a long grooved trocar was  thrust horizontally  into the
bladder in  the middle of the space between the m. erector penis and m.
accelerator urine, from two to three lines from the ischial tuberosity and
an inch from the anus ;  and after withdrawing the stilette a little, with  a
peculiarly formed knife carried along the groove of the trocar, the open-
ing into the body of the bladder from below upwards, and in withdraw-
ing the knife the outer wound was  dilated.   A gorget was then intro-
duced on the groove of the trocar, with which, if necessary, the wound
was farther enlarged,  and upon it the forceps passed (b).
  Thomas (c) made the cut from above downwards by means of an instrument re-
sembling Frere Come's lithotome.
  2113. The danger of bleeding,  the difficulty in extracting the stone,
the wounding the rectum, and the other accidents, and their consequences
which frequently accompany the lateral operation for the stone, have led
to the practice  of cutting for the stone  through the  rectum  (Lithotomia
recto-vesicalis.)   This operation was first proposed by L. Hoffmann {d),
who gave reasons for its preference over the others, although the proposed
operation is  more uncertain  in  its  results.  Sanson (e) claims it as his
own discovery, and describes his mode of proceeding.  It is in especial
favour with  Vacca  Berlinghieri  (f) and others, and performed with
success.
  (a) Douglas, above cited.—Le Dran, Pa-
rallele des differentes  mmieres  de tirer la
Pierre horsde la Vessie, p. 109. Paris, 1730.
  (,b) Foubert, Nouvelle  Methode de tirer
la Pierre de la Vessie ; in Mem. de l'Acad.
dc Chirurgie, vol. i. p. 65, pi. i.-viii.  Kes.
seluing,  Dissert  Historia et examen Me-
thodi Foubertiani pro extraciione Calculi.
Halte, 1736.
  (c) Thomas ; in I.ouis, in Mem.de l'Acad.
de Chirurgie, vol. iii.  p.  653. Dkschami's,
alove cited, v>l. ii. pi. v. f. T2.
  (d) Von einer  neuen Methode den  Stein
zu schnciden;  in Vermischten  Schriflen,
herausgegeb. von. H. Clavkt. Miinster, 1791.
vol. ii. p. 511.
  (e) Des M >yens de  pnrvenir a la Vessie
par le Rectum, avantages et inconveniens
attaches a cette  Methode pour tirer lea
Pierres  de la Vessie.  Paris, 1817.  4to.
  (/) Sanson, l)es Moyens de parvenir a la
Vessie par le Rectum, &c, suivie d'un Me.
moi^e snr la  Methode d'extraire la Pierre de
la Vessie nrinaire par la  voie de 1'Intestin
Rectum, de And.  Vacca  Berlinghieri, tra-
duite de  l'ltal. par Blaquiere. Paris,1821.8vo. 
344                   CUTTING  FOR THE  STONE,
   Martin (a) lays claim to  the discovery of this operation: he made his first ex-
 periment on the dead body in  1786.  But Hoffmann lectured on the subject in 1779.
 That the first notion of the operation of cutting for  the stone by the rectum  cannot
 be ascribed to Vegetius (b), as the Editor of the  Article Lithotomie in the Diet.
 des  Sc. Medic,  vol. xxviii. p. 421, imagines, Vacca Berlinghieri has  sufficiently
 proved (c).
   [" In the case of a thin person, with a stone of so large a size, that the extraction
 of it by the usual method, would be either impracticable, or attended with the great-
 est risk to the patient's life," Brodie says, ''it may be a question, whether there is
 not a better method of proceeding (than the high operation) in the recto-vesical ope-
 ration; in which the incision of the perinaeum is made to extend through the tunics
 of the rectum and the sphincter ani muscle.  Here  the parts which afford  the chief
 resistance to the extraction of a large stone are divided; and, although  the incision
 of the neck of the bladder extends beyond the boundaries of the  prostate, the ill con-
 sequences arising from the escape of urine  into the cellular membrane, are  likely to
 be in great measure obviated in consequence of the free opening which has been made
 into the rectum."  Brodie  performed this  operation on one occasion in which  the
 stone was supposed to  be very large, but did not so turn out, and the  patient, who
 had suffered from stone more than twenty years, died in about three weeks  with ab-
 scesses in the kidneys, and on one side of the pelvis, (pp. 347, 48.)  In another case,
 a  man between sixty and seventy, whom he operated on with Blizard's knife, and
 on whom  with much constitutional excitement, the abdomen was tense and  swollen,
 and there was great danger, Brodie cut through the rectum with a probe-pointed-bis-
 toury on the fourth day,'and the patient did well.
   Solly,  one of our assistant surgeons, also  performed  this recto-vesical operation
 in a case  where the stone was presumed  to be very large; but  it was not  large.
 The case went on well, and recovered without any untoward circumstances.—j. f. s.]
   2114.  Sanson has proposed two different modes of penetrating through
 the rectum into the bladder.   After previously dividing the m.  sphincter
 ani  and  the lower part of the  rectum,  in the  direction of the raphe,
 towards the root of the penis, the prostate, and part of the lower  wall of
 the bladder is  laid bare, and then  upon the groove of a staff introduced
 into the  bladder, the  prostate is to be divided in its  mesial line; or the
 knife  may be passed behind the prostate through the wall of the  bladder
 into the groove of the staff and the base of the bladder divided to a certain
 extent.
   The latter method is fully described  by Sanson; the former is rather indicated.
 The staff when introduced  is to be  held upright, the left forefinger, with its volar
 surface upwards, is  to be introduced into the rectum, and  upon it the blade of a
 straight bistoury laid flat; its edge is then turned up, and with a single cut the outer
 sphincter muscle, together with the lower part of the rectum, is cut through in the
 direction of the  raphe.   The  groove of the staff is now sought for with the  finger
 behind the exposed  prostate, the point of a bistoury  introduced upon it, and as it is
 pushed along the groove, a cut is made in the  lower wall of  the bladder, which
 commencing behind its neck, passes in the mesial line to the  midst of the  space
 between the two ureters,  through which the  stone is extracted.  Vacca Berling-
 hieri has specially defended the first mode, and  has fully set forth his preference of
 it  both by  reasoning and  experience, so  that  his essay may be considered  the best
 guide for recto-vesical lithotomy.
   2115.  The patient must be placed  and  bound  as for the lateral opera-
tion ;  a staff is passed  into the bladder, and  given  to  an assistant, who
holds  it firmly  and perpendicularly so that its  groove corresponds to the
 mesial line of the urethra and the raphe.  The operator then takes a
straight bistoury with  his  right forefinger and thumb, where  the blade

  (a) Nouvelle Methode de faire l'Operation    (ft)  Mulomedicina, cap. xlvi. lib. i. Basil.
de la Taille; in Revue Medicale, vol. ix. p.  1574.
225.  1822.                                (c)  Above cited, p. 72. 
                       THROUGH THE RECTUM.                  345

meets the handle, and lays its blade flat  on the volar surface of the left
forefinger, in  such way that both its edge and  point  are covered; the
finger and knife are then passed into the rectum, and carried upwards ten
or twelve lines, the dorsal  surface of the finger  corresponding to the
hollow of the sacrum.   Whilst the operator presses the hind wall of the
bladder with  this finger, he turns with his right hand  the edge of the
bistoury upwards, and with the forefinger pressing its back, he thrusts its
point through the front wall of the rectum, and as he withdraws the knife,
cuts through the rectum, the external sphincter  muscle and the cellular
tissue covering the urethra.   The operator now  leaves the bistoury with
the left forefinger, turns the dorsal surface of this finger towards the left
and its cubital surface upwards, carries its tip into the wound of the
sphincter, and places  his nail (which in this operation  should be always
done) in the groove of the staff, which can be  felt  through the wall  of
the urethra.  Guided  by the nail of the left forefinger, the point of the
bistoury,  with its edge downwards, is Carried  through the wall of the
urethra into the groove of the staff,  and supported on the nail, is pushed
forwards  in a corresponding direction to the raphe, by which the neck of
the bladder and the prostate are  divided to a greater or less extent, ac-
cording to  the presumed size of  the stone.  The  staff is now removed,
and the finger passed through the wound  into  the bladder, by  which is
ascertained whether the wound be sufficiently large, or whether it require
enlargement,  which may be easily done with a common or button-ended
bistoury introduced on the left forefinger.   The forceps are passed in upon
the same finger, and  the stone extracted according  to  the rules already
given.   After the wound has  been  Cleansed, the patient is to be put in
the  same  posture  as  after the  lateral  operation.   Any dressing of the
 wound is objectionable.
   Cutting into the prostate with Frere Come's  lithotome, introduced into  the  groove
 of the staff after the membranous part is opened, as Dupuytren and others do, is
 less convenient than with the bistoury.
   Geri's (a) mode of introducing a gorget an inch and  three quarters broad at its
 base, three inches and a  half up the rectum is objectionable, as straining and purging
 may occur during the operation, and as the rectum is only widened at the expense
 of its length, and is therefore short and folded, and the peritonaeum approaches  the
 neck of the bladder, so is the peritonaeum the more liable to be wounded, and  certain
 parts of the rectum must be left undivided.  Vacca Berlinghieri mentions the case
 of a child operated on by Geri, which died  twenty-four hours after, and  both these
 accidents had happened.
   These objections apply still more to the method of Sleigh (b), who widened  tfi6
 sphincter and the rectam with Weiss's speculum am, found the hind edge of  the
 prostate with the tip of  the left forefinger, and  then without touching the gland, cut
 through the wall of the rectum and bladder with a convex scalpel, concealed in a
 spring sheath, upon the  groove of a  staff first introduced.
   2116. The after-treatment has the same object as in the lateral opera-
 tion.   The patient should take an  opiate; he should use mucilaginous,
 diluting drinks; at first should  take  exceedingly little food ; and, by a
 proper treatment, it  should  be  endeavdured  to keep  off inflammation,
 which is more necessary in this  than in  the lateral operation, because it
 is accompanied with very little loss of blood.  When suppuration comes

                (a) Rep. Med.-Chir. de Turin, No. 11, p. lfio.
   (b) An Essay on an improved Method of cutting for Urinary Galculij or the Posterior
 Operation of Lithotomy*  London, 1824.  8vo:
   Vol. iii.—30 
346               CUTTING FOR THE STONE ;
 on, usually about the seventh  day, it is  necessary to touch  the wound
 with  caustic at every part of the cut in the rectum; for this purpose, the
 edges of the wound are drawn apart a little, and a wooden canula, having
 a bit of caustic in it, is passed up, by which  the cure is promoted.
   2117.  The advantages of cutting for the stone through the rectum are
 stated to  be, first, that the patient is in no danger from bleeding; second,
 that the bladder is reached through the least thick parts;  third, that the
 stone is most easily found, grasped, and pulled out, even when of large
 size, because the wound corresponds to the  largest space of the pelvis;
fourth, that  no infiltration of urine follows.
   Geri {a) and Scarpa (b), the most  violent  opposers of this  practice,
 bring against it, first, that the wound and irritation of the rectum produce
 intermitting, irregular, febrile action after the operation; second, that one
 or both the vasa deferentia  may be wounded, and by the pulling and
 stretching in the removal of the stone, are so much injured, that inflam-
 mation, swelling, wasting of the testicle, impotence from the destruction,
 adhesion or contraction  of the mouths of the vasa deferentia may ensue;
 third, that the neighbouring parts are irritated by the use of the caustic;
fourth, that  by the entrance of the faecal matter into the bladder, there is
 fear of its internal  coat  being destroyed, of dangerous irritation, and of
 fseco-urinary fistula; fifth, the recovery is more tardy.  Scarpa considers
 this operation even  more imperfect than that  of Celsus.
   2118.  These objections  are not all of equal weight.   The intermittent
 fever is, according to Vacca's observations, in but very few cases directly
 connected with the  wound of the rectum.   The injury of one of the vasa
 deferentia, and the consequences based  thereon, Scarpa has not supported
 by cases; this wound may scar or remain fistulous, and its orifice may
 still perform its functions; besides, the operator can even avoid this injury,
 and also  in  the lateral  operation the vas deferens  and even the vesicula
 seminalis may be wounded.   The irritation of the neighbouring parts may
 be prevented with caustic  by Vacca's method.  The entrance of  faecal
 matter into the bladder can only happen by cutting through its base, and
 not by Vacca's proceeding, as it is prevented by the valve-like protrusion
 of the wall of the bowel cut into below ; and still more as the excrement,
 in consequence of  the division  of  the sphincter, meets with less obstruc-
 tion  from the natural  passage.  Fistulas indeed not unfrequently remain
 after this operation, but they communicate  only with  the membranous
 part  of the urethra; a little stool is passed rarely by the urethra, and  but
 little  urine  by the rectum, and nothing gets into the bladder.  On this
 point Wenzl's (c)  remark is  important,  that the external cut should
 always be made sufficiently large, by which in  part, during the operation,
 the sphincter causes less obstacle,  but  it  especially prevents the external
 wound contracting more quickly  than the inner.   The cure is indeed
 tedious in many cases, but in others has been observed to be as quick as
 in the lateral operation.   As to the other  objections, for instance, if  the
 stone be very large, that the whole prostate must be cut through,  the
 peritoneum  may be wounded, the  introduction of the  instruments is  not
                 (a) Repert. Med.-Chif. de  Turin, No. 11-18.
   (b) Sag-gio  di Os?ervatione sul Taglio   (c) Geschichte eines Steinschnittes durch
 Reito-Vesicale per l'Estrazione della Pietra die vordere rectovesical  Methode; in N.
 della  Vesica Orinaria.   Pavia, 1823, fol.     Chiror., vol. ii. p. 181. 
THROUGH THE RECTUM,—"WHEN PREFERABLE.
347
easier, and the pain in the glans penis after the operation is very violent;
these, under corresponding circumstances, apply to the lateral operation,
and in regard to the complete  division of the prostate, it must not be
overlooked that here, perhaps, infiltration of urine is less  to be feared
than in the lateral operation, because the cut being in the bottom of the
bladder, the urine more readily escapes (a).
  2119.  If recto-vesical lithotomy be considered in  reference to the re-
sults  obtained to the present time, it is found  to  vary considerably with
different operators.   Some consider it  more successful, some less suc-
cessful, than the lateral operation.   It has indeed its weak  points, and in
general must be put after the lateral operation, but it has twro indisputable
advantages, to wit, the slight  danger there is to life, and that the bleed-
ing is not dangerous.   Therefore, in particular eases, and where, on ac-
count of the size of  the  stone, the cut above the pubes is required, and
the walls of the rectum are healthy, it appears preferable to the high and
lateral operation, as also in old persons, and  those who have little blood,
with a more than moderately-sized stone.
  The following writers may be also referred to on  this subject:—
  Noethig, Ueber die verschiedenen Methoden des Blasensteinschnittes, besonders
fiber den Steinschnitt durch den Mastdarm nach Sanson.  Wurzb.,  1818.
  Riberi; in Repertorio Medico-chirurgico de Turino.  No. 31-33.
  Vaca Berlinghieri, Memoria sopra M  metodo di estrare  la Pietra della Vesica
orinaria per la via dell' intestino retto.  Memoria terza.  Pisa, 1823.
  Farnese, Essame delle osservatione sul Taglio retto-vesicale dal A. Scarpa.
Milan, 1823.
  Compte-Rendu Medico-Chirurgical dies  Observations recueillies a. l'HcVpitai'de la
Charite de Lyon.  Sec.  patrie, 1823..
  Sanson, Compte-Rendu  de la Pratique  Chirurgicale die I'Hotel Dieu de Lyon—
Archives  generales de Medecine, vol. vi. p* 83.
  Scarpa; in Annali Universali de Medicina, vol. xxx. p. 125.  1824.
  Thomson, Will., A Probatory Essay on the Extraction of Calculi from the Uri-
nary Bladder.  Edinburgh, 1825.
  Koenig, Ueber einigen  Methoden Harnsteine aus der Blase zu ziehen;  in von
Graefe und von Waltber's Journal, vol. viii.  p. 530.
  Journal Complementaire du Dictionnaire des  Sciences Medicales; Barbantini,
vol. vi. p. 79.—Williaume, vol. x. p. 180.—Camoin, vol. xii. p. 19.—Dupuytren
et Sanson, vol. xv. p. 86-87.—Pezerat, vol. xviii. p. 128.
  Heinecke ; in Journal von Graefe und von Walther, vol. v. p. 305.
  Gustorf ; in same, p. 510.
  Behre ; in Heidelb. Klinisch, Annalen, vol. i. p. 453.
  Royer Collard, Clinique Chirurgicale de I'Hotel Dieu ; in Report, gen. d'Anato-
mie et de Physiologie pathologique, etc.,  vol. i. p.  234.
   2120. Vacca Berlinghieri's (b) most recent practice  still remains
to be noticed, which without having the disadvantages, of the recto-vesical
operation, unites all the  advantages, and resembles the coup de mailre
proposed by Marechal  in the  great  apparatus (par. 2066.)   The first
cut, from twenty to twenty-two lines long, extends from the edge of the
rectum,  along the raphe to the  scrotum,  divides the skin, the fibres  of the
m. levator ani  and  transversus  perinei, which with  the  m..  accelerator
urine, the urethra, and the m. erector penis form a sort  of triangle in the
perineum.   The left forefinger introduced into the front of the wound,
seeks for the groove of the staff, which is held upright, passes the  knife
  (a) Journal Complement, du  Diet, des Sc.  tiquer l'Operation  de  la Pierre, publ. par
Med.,  vol.  xvii. p. 128. 1823.—Dupuytren,  Begin et  Sanson, p. 13.
Memoire sur une Nouvelle Maniere de pra-    (b) DellaLitotomia nei due Sessi. Quarta
                                     Memoria. Pisa, 1825. 
348            CUTTING FOR THE STONE IN WOMEN,
into it, and therewith cuts into the urethra to the extent of the outer wound.
A knife with  a  blunt beak, about two lines long, is inserted into the
groove of the staff, at the lower part of the wound;  the staff is then raised
towards the pubic arch, slightly inclined towards the operator, and then
pushed about an inch deep into the bladder.  Without changing the posi-
tion of the staff, the handle of the knife is to  be raised a little towards the
scrotum, by which its back is jammed against the groove of the staff, and
in drawing it out, the neck of the bladder, the prostate, the membranous
part and the cellular tissue beneath it are cut through.  If the wound be
not  sufficiently large, it  maybe easily enlarged in the usual  way.  In
withdrawing ihe stone, the blades of the forceps should  be directed to-
wards the angles of the wound.
  L. Balardini (a) has given an  account of eight cases  treated in the  same man-
ner.
  According to Pantaleo (b), the  oblique cut in  the direction of the outer wound
should be made with a  double-cutting bistouri cache, through the upper and lower
part of the prostate.
  Here also must be mentioned Dupuytren's proposal, which he pursued very suc-
cessfully, but has not made known publicly.  He made a cut into the raphe opposite
tfie staff held vertieally, then with the bistoury penetrated the groove of the staff, and
passed upon it into the bladder Frere Come's bistouri cache, then turned the edge of
the instrument upwards, for the purpose of dividing  the neck of the bladder as the
bistoury is withdrawn (c).
                B.—Of Cutting for the Stone in Women.,

  Louis, Sur la Taille des Femmes; in Mercure de France.  Decembre, 1746.
  Masotti, La Litotomia delle Donne perfezionata.  Firenza, 1764.
  Platner,  Progr. Historia  literario-chirurgica Lithotomiae Mulierum.  Lips.,
1770.
  Cronenberg, Historia Lithotomiae in muliere factae.  Halae, 1811.
  Behre, Dissert, de Lithotomia muliebri.   Kilias, 1822.
  Behre, Versuch einer historisch kritischen  Darstellung de Steinschnittes beim
Weibe.  Heidelberg, 1827.  8vo.
  v,on I£ern, above cited, p. 149.
  2121. The various methods and modes of proceeding in the operation
of cutting for the stone in females may be most conveniently brought to-
gether under the following heads:—
  First. The cu,t below  the  arch of the pubes, with the divisions of the
urethra and neck of the bladder.
  a.  The cut made as in the lateral operation.
  6.  The horizontal cut on one or both sides, with or without dilating.
  c.  The vertical cut upwards.
  d.  The vertical cut downwards.
  Second.  The cut below the pubic arch, without division of the urethra.
  a.  The vestibular cat of) Celsus and Lisfranc.
  b.  von Kern's method.,
  c.  The vagino-vesical operation.
   Third.  The cut above the pubic arch.
  [It  may be well to notice, here  Astley Cooper's observation, that women suffer
more from stone in the bladder than men, and that " in addition to  the symptoms

  (a) Annali  Universali di Medicina, vok    (c) Sanson, above cited, p. 48.—Salzburg
alvi. p. 23a  1828.                     Med.-Chir. Zeitung, vol. i. p. 285.  18ia—
  (J$ Lancet^ X833-.4, vol. ii. p. 557.       Royer-Collard, above cited, p. 500. 
BY THE LATERAL OPERATION.                349
observed in the male, as the irritability of the bladder increases, the pain during
micturition is excessive, and there is agonizing suffering after the discharge of
the urine from bearing down of the bladder, uterus, and rectum, with a sensation of
their being forced through the lower opening of the pelvis.  The retention of urine
becomes imperfect, and the person is always wet, and smells offensively of urines
The sufferings of the patient at length renders her incapable of moving from her bed."

  Brodie observes, that "in women, calculi of a small size are expelled as they are
in the male sex, without ulceration or other injury to the  urethra, and without the
patient suffering  any inconvenience afterwards.  Calculi of very considerable size
occasionally escape from the female bladder; but the natural cure in these cases is
effected by a less simple process."  In one case he mentions "a large calculus was
found  in the vagina, which was extracted with the fingers, the urethra and  vagina
had ulcerated, and the calculus had passed through the  ulcerated opening." (p.
350.)   A similar case is mentioned^by Astley, Cooper, " in' which the stone" was
placed half in the urethra and half in the vagina; the extremities of the stone were
large,  and connected by a narrow portion which passed through an ulcerated, open-
ing in the under part  of the urethra."  (p. 298.)]
   2122. Cutting for the stone in women by the  lateral operation  is per-
formed in the following manner:—
   After  the patient  has  been  bound and properly fixed' in the same-
position as in operating on the male,  the labia, are separated from each
other, the operator passes a straight  staff  through the urethra into the
bladder, holds it with his left hand in such way that the groove may be
directed outwards  and downwards, and its convexity pressed against the
lower edge of the pubic arch, and passes on it a common bistoury, or the
knife  used in  the lateral  operation^  or  even a  gorget  with the edge
directed downwards and  outward's, between the vagina and; the ascend-
ing branch of the  haunch-bone, up< to the closed  end of the staff.  In
withdrawing  the bistoury,  its point  must  be sunk for the  purpose of
enlarging the cut.
   If Frere  Come's  lithotome be-used, it must be introduced  closed:
through the urethra into the  bladder,  after setting it at a number corres-
ponding  to  the size  of the stone, pressed  against the pubic arch,  and;
withdrawn,  whilst the blade is projected, in such direction  that the
urethra and neck  of  the bladder may be divided obliquely downwards,
and outwards, as when the bistoury, is employed.   The forceps are then<
introduced on the  finger  or on,  a  gorget,  and  the stone  drawn  out
according to the rules already laid  down.
   In  this mode of operating there is  danger of wounding the vagina or'
the pudic artery ;  and in removing a  large stone, there is fear of irritating
the cellular  tissue attaching the urethra and of palsy of the neck of the'
bladder, in consequence of the bruising and dragging which it suffers {a).
   2123.  In the horizontal cut on one (usually the  left) or  on both sides,,
the cut is made either with a narrow  blunt-ended^  bistoury, with a com-
mon  stone-knife, with a cutting gorget upon a staff, or  director,  of which',
the groove is directed towards the side ; or with Frere Come's lithotome,.
or with a proper, single or. double-cutting  instrument, and  its  enlarge-.
ment  effected with  the  gorget,  the  finger, the forceps, or the  dilators.
In this  mode  of  cutting,  the  vagina indeed is- safe  from, injury,  but
damaging the pudic artery is  more to  be dreaded.

   (a) Klein, Prakt. Ansichtcn u. s. w., partii., p. 1.—Schreger, CJiirucgiscke. Versuche,,
vol. ii. p. 132.
                                   30* 
350              CUTTING FOR THE STONE IN WOMEN,
  Le Cat's method with the grooved staff.—Horn's dilating lithotome.—Franco's
cutting forceps.—Louis and Flurant's double-edged lithotome cache.—Le  Blanc's
single-edged lithotome, and the like.—Compare also Behre.
  [Liston employs the horizontal cut, but not to the extent here mentioned.  He
says:—" The best mode of extracting foreign bodies from the bladder is to widen
the  urethra gradually by means, of the screw-dilator, then by the introduction of a
straight blunt-pointed knife to notch the neck of the  bladder slightly towards each
ramus of th© pubes, so as to divide the dense fibrous band'eneircling it;  the dilata-
tion is continued, and in a few minutes the finger can be admitted; the stone can
then be readily grasped by a pair of forceps, and it is astonishing how large a body
may be removed  by these means.   Incontinence of urine may follow the operation
from the distention of the  sphincter of the bladder; but in a few weeks this will
generally cease.  The mode  of proceeding above recommended is  by much to be
preferred over the mere dilatation, as being less painful and more rapid in execution;
and' looking to the after-consequences, it is undoubtedly preferable  to extensive
incision of the neck of the bladder with or without wound* of the. vagina." (pp. 525,
26.)],
  2124. In the vertical cut upwards-, formerly advised' by Colot (a), and
recently-by Dubois, after  the patient has been properly placed, a staff is
introduced  into  the urethra with  its  groove  upwards; and whilst  the
operator holds it with his  left hand^, he presses its back against the lower
wall of the urethra,  by which its canal is expanded for the purpose of its
more ready  division.  A  narrow-pointed single-edged bistoury, with its
edge a. little directed- to the left so  as to  avoid the clitoris,  is now passed
in,  and whilst  the  two  instruments  form  an angle, the point  of which
corresponds to the neck of the bladder, and the base of the perineum,
the canal of the urethra and the neck of the  bladder are divided.   After
the knife has been withdrawn, a gorget is introduced on the groove of the
staff,and  upon it the forceps  (b).   Richerand (c) and  Dupuytren em-
ploy for thjs operation Fre^e Come's lithotome, which having been  intro-
duced, through the  urethra into the  bladder  with its edge above, and
gather inclined to the side, is withdrawn, whilst its blade is projected.
  [Brodie  performed  an  operation which  is a modification of  the vertical cut
upwards.  He says,  he " was, informed it, had been adopted by  an eminent pro-
vincial surgeon, and had not been followed by the usual incontinence of urine.  " I
introduced," says he, "a bistouri cache into the urethra, having previously fixed the
screw in the handle of the instrument, so that the cutting edge could not be made fo
project more  than to  a very  small extent; perhaps to about  one-sixth of  an inch.
Then, drawing out, the bistouri, with the- cutting  edge turned directly upwards, I
endeavoured  to divide the membrane of the  urethra immediately below the sym-
physis  of the pubes, without- allowing the incision to extend into the  contiguous
cellular structure.  The next step of the operation was to introduce Weiss's dilator,
and-dilate the urethra, so as to allow of the introduction of the finger, and afterwards
eftthe forceps, into the bladder.  As the urethra now offered no resistance, this dila-
tation was. readily effected in the course of a, few  minutes, and thus the stone  was
extracted,  The  patient did not,suffer from actual  incontinence after.the operation;
she could not, however, retain it for so long a time as before the disease existed; I
believe not longer  than two  hours,   But I  have performed  the same operation in
several other cases, with a still more favourable resulu'* (p. 354.)]
    2125. This  operation has the following advantages:—The lower part
 of the urethra  has not any bone beneath it,  it- is very supple and  yields
 below.  .After  the  operation, the uninjured lower wall of the urethra
 forms a groove over whieh the urine  flows out  without disturbing the

   («) Ambr. Parei, Opera,  edit. Guille-    (b) Dupuytren, Lithotomie, 51.
 Weau, lib, xvi. cap. xlvii. p. 506.              (c) Nosograpbic  Chir.,  vol.  iii. p., 558.
                                      Fifth Edition. 
BY THE VERTICAL CUT DOWNWARDS.            351
cure of the wound above, the healing of which may be assisted by the
pressure of a sponge introduced into the vagina.  Further, the trunk and
large branches of the pudic artery are preserved from, injury, and in the
event of any of its minute terminal branches bleeding, they are readily
stanched  by pressure against  the arch of  the pubes.  Great as these
advantages are, it must, however, be remembered,  that large stones can-
not  be  withdrawn  without considerable bruising of the neck of the
bladder, and tearing  the natural connexions of the urethra, the conse-
quence of which is incurable incontinence of urine (a).
   2126. The vertical cut downwards may be made on  the groove of a
male staff, held upright, and its concavity  pressed against the aroh of
the pubes, with a common bistoury; or. Frere Come's lithotome may be
preferred, with  which the urethra, the neck  of  the bladder, and the cor-
responding wall of the vagina  may be  cut through downwards in their
mesial line.   This method corresponds to the recto-vesical operations on
the male; by it a sufficiently large wound may be made without danger
of bleeding, and the largest stone may be extracted with ease, as experi-
 ments on  the  dead,  and successful  results  on  the living, have satisfied
 me.   That incontinence of urine is to be feared with a free cut, and that
 the  danger  of  a vesico-vaginal fistula  is  greater than in the  common
mode of cutting the bladder and vagina is refuted,  at least by my experi-
ence, which especially determines  me  to consider  this, as the most
preferable mode of operating {b).
   Falconet (fc)>rfieretofore recommends this practice.
   Bromfield (d) mentions that he saw a surgeon introduce one blade of a pair of
 button-ended scissors into the urethra and the other into the vagina, and  divide the
 under part  of the urethra, up to the entrance of the vagina, to the extent of an inch
 at least. According to Bromfield, such a cut could never again unite, the contrary
 of,bwhich my observations  prove; but he says, as the neck of the bladder had the
 major part  of its sphincter: muscle not divided* the patients in general kept their water
 pretty well.
   2127. The cut below the pubic symphysis, without dividing the urethra
 and the neck of the  bladder, is the method of Celsus.   The stone must
 be  pressed against  the neck of the bladder in; girls by the -finger in the
 rectum, and in women by  the finger in the vagina, and the stone cut on
 in the one on the under arid left side, andin the  other between the urethra
 and the arch  of the  pubes.   The  great objection  to this method is self-
 evident;  the pudic  artery, the vagina, and even the rectum,  are exposed
 to injury, on which  account this,operation-is generally discarded (e).
    2128.  Lisfranc's vestibular cut is to be considered as a modification
 of Celsus's operation.  After the patient  has- been placed in  the usual
 posture and bound,  two assistants^ draw the labia apart:.   The operator
 standing  between the legs of the patient, introduces a common male staff
 through the urethra into  the bladder with its  convexity upwards.  An
 assistant  then grasps the handle of the staff, and draws.the  urethra  and

   (a) Bf.hre, p. 129.                    endus  apparatus lateralis ?  Paris, 1744.—
   (b)  Chelius, Ueber den Steinschnitt beim in Halleri Disput. Chirurg., vol. iv., p. 208.
 Weibe; in  Hcidelb. Klinisch. Annalen, vol.   (d) Above cited, vol: ii, p. 279.
 vi. part i. Sichereu ; in  Wurtembergischen   (e) Mery, Observations sur la Maniere
 Correspondenzblatt, July, 1*43.  No.22.   de tailler les Deux Sexes pour TExtraction
   {c) An educendo.oalculo  casteris antefer- de la Pierre, pratique© par Frere Jacques.
                                     Paris, 1-7U0. 
352            CUTTING FOR THE STONE IN WOMEN,
vagina downwards.  The operator, after having assured himself of the
position of the pubic bones, and of any variety of the  pudic artery, by
the introduction  of his  finger into the  vagina, places the left fore  and
middle finger upon the  points where the cut is to begin and end,  and
with them stretches the cellular tissue.   Then holding a straight bistoury,
as a pen, he makes a semi-circular cut through the external membrane,
and the stretched cellular tissue of the vestibule, which is to  begin on
the right side at correspondent height with the orifice of the urethra, runs
within the pubic  arch at the distance of a line, and terminates on the left
side at a  similar  height to its beginning.   The  cellular tissue is  then
divided layer by  layer in the  same direction  till the front of the bladder
is cut through, in doing  which all pressure against the bladder must be
avoided.   The left thumb is now introduced into  the vagina, and the
left forefinger into the wound,  and the wall of the  bladder therewith
made tense and pressed forwards.  A longitudinal or transverse cut is
now made into the body of the bladder with the bistoury, or if this seem
to be  unsafe, the cut is to made on  the groove of the  staff, or a  dart
sound may be used^ upon which the bladder is  opened, and the fore-
finger  being passed into  the wound, it is to  be  enlarged either lon-
gitudinally or transversely with the knife (a).
  2129.  This proceeding of  Lisfranc's is objectionable on very many
grounds.   The cut is-made into  the bladder where there is least space,
consequently the  extraction of even a moderately large stone is difficult,
and accompanied with bruising; the pudic artery, the position of which
cannot be well determined by the examination before  the operation, may
be wounded; the front of the bladder is  easily separated from its cellular
connexions; the vascular net at the seat of the cut, often much developed
in stone-patients, may be  injured, and  the wound  in the  bladder  may
slip from the external  wound,  in consequence  of which there will be
infiltration.   It is difficult to understand how in using the dart sound, at
least with  its usual curve, the dart can be protruded some  lines above
the neck of the bladder {b).
  Piers Uso Walter (c) has practised Lisfranc's vestibular cut successfully in a
woman of forty-five.
  2130." von. Kern's practice, which he has successfully followed, is the
following.   After the patient  has been  properly placed and the staff in-
troduced into the bladder, an assistant standing  on the right side, holds
the staff with his  left hand and sinks it a little towards the patient's right
groin, and-places thefore and middle fingers of the right hand near the
orifice of the urethra at its under part, which he draws down tightly, at
the same time separating the labia with the thumb and other fingers.
The  operator then, finds  the hinder  extremity of  the urethra with the
left thumb-nail near the neck of the bladder, places the nail  upon the
right edgeof the  staff, penetrates the stretched urethra with the lithotome,
and enlarges the Gut by carrying the scalpel forwards in the groove of

  (a) Memoire sur une Nouvelle Methode   (ft) Baudrv, L., Dissert, du meilleur Pro-
de pratiquer l'Operation de la Taille chez la  cede a employer pour  l'Operation  de  la
Femme ; in  Revue Medicale, vol.. x. p. 1.  Taille chez la Femme.  Strasb., 1823.
1883.—MeresseI Dissert,  sur  la Lithoto-   (c) von Gkaefe  und  von Walter's
naie, chez la Femme.  Strasb., 1823.       Journal, vol. xviii. p. 285. 
BY THE YAGINO-VESICAL  CUT.                353
the staff, and at the  same time presses it  on  with the thumb until the
opening is  of sufficient size (a).
   2131. The vagino-vesical cut has the closest resemblance to the recto-
vesical; it  is performed most safely  in  the following manner.   After
placing the patient  in the position for the  lateral operation, a  staff is
passed by the urethra into the bladder,  and a wooden gorget with its con-
cavity upwards is introduced into the vagina.   Both instruments are
brought together so  as to form a larger or smaller angle, in proportion  to
the cut to be made.   Tb,e gorget is to be well pressed downwards, so that
the front wall of the vagina can be got at.   A straight, pointed bistoury
is to be held like a pen in the right hand, its point passed into the groove
of the  staff behind  the canal of the  urethra, and then by  thrusting it
forwards, an opening is, made corresponding to the size of the stone.  Its
extraction  and after-treatment are conducted  according to-, the ordinary
rules.
   2132.  The advantages of this  mode of operating are great.   There
is no bleeding, no incontinence of urine, and the largest stone maybe  in
this way removed.   The production of a vesico-vaginal fistula, which
may be objected to this  operation, cannot, at least from present experi-
ence,  be considered as the  usual consequence.  If this  operation be
restricted only to the extreme cases of very  large stones, it has however
there undoubted preference over  cutting into  the bladder above the pubes,
as the patient's life  is never endangered,  and at  the utmost there is the
inconvenience of a fistula.   The objection  made by some, that the scar
produced by  this operation would cause difficulty in child-birth, is  con-
trary to experience.
   Upon this subject the following works may also  be consulted:—
   Fabricius Hildanus, De Lithotomia, p. 149,
   Ruvsch, Observationes Anatomico-pathologicae, Obs. i.
   Mery, above cited, p. 28.
   Louis, above cited.
   Bussiere ; in Philosophical Transactions, vol. xxi. p.  100.  1699.
   Lister, Iter  Parisianum, 1697.
   Gooch, Cases and Practical Remarks in Surgery, vol. ii. p. 182.  London, 1758.
8vo.
   Michaelis, Etwas iiber den Blasenschnitt, p* 57.  Marb., 1813.
   Dupuytren, above cited, p. 55.
   Flauber et Clemont ; in. Sanson,  above cited, p. 23.
   Vacca Berlinghieri, above cited,  p. 110.
   -------------------, Del Taglio vagino-vesicale, Pisa, 1825.
   [In all the previously described operations, incontinence of urine is a very trouble-
some consequence and often incurable.  Astley Cooper, indeed, says:—"In all
cases of this operation  which I have performed or'witnessed, the urine has not been
afterwards retained ;  but I would not  deny that a patient might recover the retentive
power.  As the loss of retention is  a greater evil than I can describe, producing
excoriation and a very ofTensive state, I shall in any  future operation of lithotomy,
try what may be effected by employing a suture  to bring the divided parts together."
(p. 303.)  Brodie's  operation (par. 2124) seems to have been partially successful;
but Liston (par. 2123) seems to think  that  his mode causes only a  temporary in-
continence.  Most surgeons however are, I believe, sadly perplexed with this tire-
some result, and the  patient necessarily still more so.  Very recently  I have  seen a
woman, who was cut with the gorget about twenty years ago; she cannot retain her
water at all, but it is constantly dribbling away, and she is in a very pitiable con-
fa) Above cited, p. 154, 
354                        COMPARISON OF
dition.   To avoid this untoward result, Hey (a) made use of a cylindrical linen tent
two inches long and one broad, which he passed into the vagina, for the purpose of
bringing the edges of the wound together without obstructing the urethra, and the
plan succeeded.  Brodie tried the same method, but unsuccessfully;  though per-
haps it may have depended on the child's irritability.  I am not aware that Astley
Cooper's suggestion of sutures has yet been tried.
  The  large size of stones which have been passed spontaneously, as related by
Heister (b), Middleton (c), Colot, (d), Molineux (e), and Yelloly (/), as well
as the earpicker-case mentioned by Thomas (g), which was removed by dilating the
urethra with sponge tent, led  to the proposal of dilating the urethra either with
sponge, or with an instrument corresponding in form to a speculum  ani.  These
methods have, however, been generally  followed by incontinence, if the dilatation
have been made to any great  extent.  Brodie says, indeed,  that " none" of the
Cases to which he  refers  "suffered from actual  incontinence of urine; but one of
them, in whom the calculus was of large size, could not retain more than two or three
ounces of urine in the bladder afterwards."  And hence he concludes, that "the
method of dilatation is not to be recommended, except in cases of moderate size."
(pp. 351, 52.)  I think, if I should be called on to operate for stone in the female,
I should be disposed to perform the lateral cut with the gorget or knife, it would not
matter much which, and adopt the method recommended by Hey.—j. v. s.]

  2133.  Opening the bladder above  the pubic symphysis has been  particu-
larly recommended in women, because, in drawing out the stone by the
outlet  of the pelvis, injury of the vagina or of the  pudic artery is feared ;
large stones  cannot at all  be extracted, and  incurable incontinence of
urine remains as the frequent consequence of this operation.   The pro-
ceeding is conducted exactly as in the male, and  the escape of the urine
from the wound above can be more readily prevented, by the introduc-
tion of a catheter through the urethra.
         COMPARISON  OF LITHOTOMY AND LITHOTRITY.

  2134. In  considering the advantages and disadvantages of lithotrity,
as compared with  those of lithotomy, it  must be first remarked, that
many of the  objections properly made to its earlier mode of performance,
as the  difficulty of introducing  the instruments, its tedious operation,
especially when the stone is hard and the like, have lost  much of their
importance,  or  are entirely removed, by the great degree of perfection to
which lithotrity has of late attained.   The time has  not, however, yet
fully arrived, nor are the  results yet in  such  condition,  that a positive
opinion can  be  given on this point.   The  hitherto-furnished statistics of
the results  of lithotomy and  lithotrity afford  no  decisive  clue, because
stone-patients  must,  in  reference  to this point, be divided into three
classes; first, those which are  favourable, for the effectual crushing;
second, those in which the crushing may be  attempted, but cannot  be
completed;  third, those in which, on account of various circumstances,
lithotrity must from the first be considered inapplicable.   It is therefore

  (a) Practical Observations on Surgery, p.    (d) Traite de 1' Operation de la Taille.
560.  Edition of 1810.                   Paris, 1727,  8vo.
  (6) Chirurgie. Niirnberg, 1719.—Trans-    (e) Philosophical Transactions, vol. xx. p.
lated as, A General System of Surgery.  11.  1698.
London, 1757.   Sixth Edition.               (/) Med.-Chir. Trans.,  vol. vi. p. 577.
  (c) A Short Essay on  Lithotomy above    (g) Ibid., vol. i. p. 123.
the Pubes.  London, 1727. 4to. 
LITHOTRITY AND LITHOTOMY.
355
clear that if  only simple  and slight cases fall within  the compass of
lithotrity, and that to lithotomy the other two unfavourable classes belong,
therefrom the results of both must necessarily be judged.   In the collation
pf such results, in great number and for a length of time, the progressive
improvements in the operations of lithotomy and lithotrity must be also
well considered.   Only in reference to these different circumstances can
it be comprehended, how the results which  have been  collected from a
great number of cases  of lithotomy, have been more favourable than
those of lithotrity  (perforation);  and  how  the  results of percussion,
(Heurteloup,) though by far more favourable  than  those exhibited by
the  earlier ones of perforation, and of cutting, have nevertheless  been
surpassed by the  results which individual operators  have obtained with
the knife.
   2135.  If the possible  evils which may occur in and after lithotomy and
lithotrity be compared, they are found to have a certain degree of equality
as to their number and  danger;  only that in lithotomy,  the wound  espe-
cially gives  rise to  symptoms which in  lithotrity are absent, whilst the
latter  occasions considerable irritation  of the bladder, and dangerous
symptoms resulting therefrom.
   The  possible evils resulting from lithotomy are bleeding, wound of
the rectum, of the seminal vesicles  and their excretory ducts, and of the
deep pelvic  aponeurosis;  subsequently, bleeding, infiltration  of  urine,
extravasation into the scrotum, inflammation of the cellular tissue of the
pelvic  cavity, inflammation  of  the peritoneum, of the  bladder, of the
prostate and  of the  veins, urinary fistula, impotence,  and incontinence of
urine.
   The  possible evils from lithotrity are violent pain and nervous symp*
toms, especially in  very  sensitive persons, inflammation of the urinary
passages,  of the prostate, and of the testicle; in rare cases,  tearing of the
mucous membrane  of the bladder, perforation of the bladder, inflamma-
tion of the veins; further,  retention of urine, infiltration of urine, urinary
fistula, breaking of the instruments  in the bladder (1), and recurrence of
stone (2).
   [(1) In the event of lithotritie instruments being broken or bent in the bladder, so
that they could not otherwise be removed, Liston says :—"I had determined, should
I meet with any case of the kind, to pull forward the instrument as far as possible,
so as to bring the sliding blade (of the percuteur) into close contact With the ante-
rior walls of the bladder, and  these with the anterior aspect  of the symphysis, then
to push down the penis upon  its stalk, and  protect the glans with a piece of split
card or strong  leather; the instrument was then to  be seized with a hand-vice, and
cut through as low as possible, by the use of good files; this can be done within
two inches and a half of the curve.  There would then be no difficulty in pushing
the blades containing the stone back into the bladder and  commencement  of the
urethra, and cutting them out together." (p. 502.)
   (2) "It  may be said," observes Brodie,  "that hemorrhage is one of the  incon-
veniences attendant on the  operation of  lithotrity.   It may arise from the forcible
introduction of the lithotrity-forceps through  the hfeck of the  bladder, where the
prostate gland  is somewhat enlarged, or from the dilatation of the prostate and urethra
in the act of withdrawing the forceps, when the blades are charged with a conside-
rable accumulation of the crushed calculus matteh   The loss of blood, for the most
part, does not amount to more  than a few drops;  but in some instances, I have
known it to be sufficient to discolour the urine for one or two days afterwards. * * *
The occurrence of rigours is another ill consequence of lithotrity, in some instances.
I have already mentioned, that a rigour is usually produced by the stretching of the 
356                      COMPARISON OF
 urethra, at the time of the forceps being withdrawn from the bladder, and that, in
 most instances, it may be prevented by the exhibition of a dose of opium immedi-
 ately after the operation.  This symptom, however, may arise from other causes;
 as, for example, from a fragment of calculus finding its way into the urethra, which
 is too large to be expelled by the pressure of the stream of urine.   And it sometimes
 happens, that the effect of a dose of opium is, not to prevent the rigour altogether,
 but to cause it to be deferred till the following day.  The liability to rigours, how-
 ever, where due precautions are used, is seldom such as to  interfere in any great
 degree with the process necessary for the patient's cure and his ultimate recovery."—
 (pp. 370, 71.)]
   2136. If  these various  circumstances in lithotomy and lithotrity be
 compared  in regard to their cause, to wit, the wound in lithotomy,  and
 the injury of the bladder in lithotrity, it must be presumed  that pain  and
 nervous symptoms  may be equally present in both, but their  frequent
 repetition in lithotrity is of importance;  that bleeding, wound of the
 rectum, injury  to the peritoneum, which  are very much to  be dreaded in
 lithotomy, cannot happen in the modern practice of lithotrity; that infil-
 tration of urine,  so  frequently fatal after lithotomy, is almost impossible
 in lithotrity; that phlebitis  and peritonitis are observed not unfrequently
 after lithotomy, but very rarely after lithotrity, which also applies in like
 manner to the  continuance of fistula;  that, on the other hand, inflamma-
 tion of the bladder, inflammation and abscess of the  prostate are more
common after lithotrity than after lithotomy.  Brdising or tearing of the
 mucous membrane of  the bladder, as also  breaking of the instruments
in the bladder, is at the present time scarcely possible, with  the improved
 instruments.
  Many of the evils mentioned are principally dependent  on the operator;  this
 remark, however, applies as well to lithotomy  as lithotrity.
   2137. Further, if lithotrity be considered in reference to  the condition
of the  urinary organs,  the age, sex, and  constitution  of the  patient,
and  the nature of the stone, it follows, that a diseased change and swell-
ing of the prostate, purulent catarrh, great sensibility, and contraction of
the bladder, render lithotrity quite impossible, or considerably increase
its danger.
   Although lithotrity was formerly considered inapplicable to children,
and  numerous experiments by Civiale, Amussat,  Leroy, and others,
have proved its practicability in little Children; yet, however, the result
of lithotomy at this age is  so  favourable) and the employment of litho-
trity so difficult, that  lithotomy should  undoubtedly  be preferred.  In
advanced age, on the  contrary, the results of lithotomy are  far more un-
favourable than those  of lithotrity.  In females, the less difficulty in  the
introduction  of instruments (par.  20-57)  is  compensated  by the diffi-
culty of keeping  the bladder distended; but lithotrity, although lithotomy
in woman is much more rarely fatal than in man, has this  great advan-
tage, that no incontinence of urine remains after it, an infirmity, the im-
portance of which in  women cannot be too  seriously  thought of.   It
must finally be remembered * that for very stout persons,  who are always
the most unfavourable subjects for lithotomy, lithotrity is by far less dan-
gerous.
  In reference to the nature! 6f the stone,  it must also be considered, that
with the improved new instruments, even large stones may  be broken to
pieces, and  that  no stone, from its hardness, can easily withstand their 
LITHOTOMY AND  LITHOTRITY.
357
 effect; but the frequent repetition of the operation, which in such cases is
 necessary, causes danger, partly from the frequent irritation of the urinary
 organs; partly, and especially, from  the repeated febrile excitement, and
 the inflammation of other  organs thereon dependent.   The same also
 applies to stones in large number.   Such  stones as are  of moderate size
 and round or oval  form, are.best for  crushing; flat stones are difficult to
 grasp and break up.
    2138. If now, after the consideration, founded  on experience, of the
 advantages and  disadvantages of lithotomy and lithotrity, the particular
 cases in  which the one  or  other  practice  is  specially indicated, be re-
 viewed,  it follows  that lithotrity appears preferable, first, in small stones
 or those  of  no great size;  second, when there are two, or several little
 stones;  third, in stones of moderate  size,  and when they can be easily
 broken,  and if in  all these cases the bladder be healthy, or only in a
 trivial degree affected.   These indications  are more important, when such
 cases occur in old  persons,  in females, or in very stout people.   On  the
 other hand, lithotomy is decidedly to be  preferred; first, in childhood ;
 second, with large and hard, and especially mulberry stones ; third, when
 there  are several large stones; fourth, when large  stones  entirely fill, or
 are completely locked in by  a contracted and  unextensible  bladder;
fifth, in  diseased prostate, or se-vere  affection of the bladder;  sixth, in
 very great sensibility of the bladder,  so that the patient can bear neither
 its distention, nor the motion of the instruments; seventh, with stones, of
 which the nucleus,  as, for example, when it is  a bullet or the like, cannot
 be destroyed by the lithotriptor.   It is also not to be overlooked, that in
 the general employment of lithotrity,  the patient should be  subjected to it
 early, by which its results are more certain, and its use will become more
 easy and general.   On the other hand, however, it must not be unnoticed,
 that  under directly the same circumstances,  which are favourable  for
 crushing, does cutting for the stone, if performed with ability, lose much
 of its danger.
   Strictures of the urethra are  only temporary contraindications for lithotrity, and
 equally applying to lithotomy, they must be'first got rid of.  Palsy of the bladder
 neither coniraindicates lithotrity, nor renders its performance difficult.  Should the
 fragments of the stone indeed be discharged more  slowly or with  difficulty, this may
 be easily overcome by injections; and  experience has shown that  the palsy of the
 bladder has been relieved, and even removed,  by  the  effect of the lithotriptic opera-
 tion, which, however, has also been several times noticed after lithotomy.
   [" Since commencing the practice of lithotrity, I have found," says  Key, "that
 more than half the number of adults who  have cOme under my care have been fit
 subjects for the  operation ; and that in the majority of persons afflicted with calculus,
 it has decided advantages  over lithotomy.  One among the principal advantages
 which  lithotrity has conferred on surgery, is the early application which patients are
 induced to make for the relief of their disorder.   Formerly * *  *  the disease was
 associated in their minds with a most painful and dangerous operation, that must be
 had recourse to, asa last remedy, when palliative measures failed to afford Telief to
 their sufferings.  The dangers and sufferings  of lithotomy, magnified as they were
 by the patient's  fears,  often deterred him from applying for medical assistance when
 the pains of stone first came upon him, by  the dread  of having his worst fears con-
 firmed.  Even if the presence of a stone in his bladder were  ascertained, it was, in
 too many instances, allowed to  remain  undisturbed, in the vain  expectation that it
might not  increase in size, and that the severity of pain  might continue to be miti-
gated by the  medicines that so  often had  been  found to assuage his pangs.  The
operation was  thus procrastinated until  the stone acquired a large size, often until
trie bladder had become diseased, and the patient's health undermined by protracted
   Vol. iii.—31 
358                          COMPARISON OF
 sufferings. * * *  Nor has  lithotrity been without  its influence  on the surgeon.
 Formerly, when a patient first consulted him for symptoms of dysuria, followed by
 pain, he was content to palliate  the malady by sedative and  alkaline medicines, re-
 gardless whether they were  caused by prostatic affection, stone, or any other local
 disturbance.   The  use of the sound was deferred : that could be used at any time:
 and, usually, it was first  introduced  into the bladder when the patient's sufferings
 had become  severe and protracted. * * *  The  operation  of sounding was also con-
 ducted in a slovenly manner.  If the stone were not discovered when small, it would
 be when large, and no advantage was gained by operating in the early stage.   Now,
 the surgeon examines the bladder with great care,  knowing  the importance  of dis-
 covering the calculus at the earliest perind, he no longer leaves its existence a matter
 of doubt, but proceeds at once to examine the  bladder, and determines its presence;
 or by a skilful  searching of every part of the viscus, ascertains that a stone does not
 exist.  * * * The  early  symptoms  of the disease  are  thus watched  with more
jealousy on the  part of the surgeon, and are not so  scrupulously concealed  by the
patient.  The advantages of  an  early knowledge of the existence of a stone, and of
prompt measures for its removal, are known to both.  The result of  this is, that
patients apply for advice when the stone is small,  the bladder uninjured by its pre-
sence, and the kidneys free from disease.  In three out of four persons who apply for
advice, for symptoms of calculus, the size of the stone  and the conditions of the viscus
render lithotrity an easy and  safe operation.  Within the  last three or four years, I
have marked  the very early  application  that  patients make for  advice, and the
small size of the stone when  first discovered, compared with  those of former years.
In private practice, I have not extracted, by either operation, a calculus larger than a
good-sized mulberry, except in three  cases, in one  of which  the stone  was of un-
usually rapid formation."  (p.  13-16.)
   " The size of the calculus," observes Key, " forms of itself no objection to litho-
trity.   A  large  stone presents, however, several considerations for the  surgeon^'to
weigh  before he undertakes the operation.  As the  stone cannot be  entirely crushed
at one  sitting, a patient with an  irritable or unsound  bladder, becomes  involved in
most serious  danger by the operation being hastily adopted.   A large stone broken
up into many irregular fragments,  all crowded by the contractions of the bladder
against the irritable and inflamed  cervix, causes excessive efforts to void the urine,
and even inflammation of  the  mucous surface.   Under such circumstances, the re-
petition of the operation becomes  impossible,  or highly dangerous; and the patient
has to  struggle through the stages of inflammation, with  a bladder irritated  by the
lesser fragments.  But if  the  bladder be free from disease, and not very irritable, it
will bear the number of sittings required to break up a large stone, without much suf-
fering  to the  patient, and with  very little danger.   The success of lithotrity, like that
of most surgical operations mainly  depends on its subject. If the constitution be good,
and the power  of  endurance great, difficulties of most unpromising nature may.be
overcome.   We should therefore  pay more regard  to the general  condition  of the
patient, and of his  bladder, than to the size of the  stones;  and inquire minutely
into the several  circumstances likely to have an  influence on the result of the  opera-
tion. * * *  I know  of no limits  to  the size of a  calculus removeable by lithotrity
but the power of the lithotrite.   If a powerful instrument can be brought to embrace
it, and the organ be healthy, the  operation may, as far as my experience  goes, be at-
tempted with propriety.
   " The differentnges of  patients to be submitted  to the  lithotrite or the knife, are
remarkably contrasted with  one another.   Whilst  to youth and advanced age the
latter is more suitable, the former is found generally better  adapted to the middle
period, between puberty and  the  decline of life.  We have seen, in speaking of
lithotomy, that  persons whose sexual organs are  completely developed, are .more
 liable  to the  accidents attending the  use of the knife than children, whose  organs
 are not yet evolved ;  or than  the aged, whose irritability is on the wane.  The lull-
 grown healthy adult, on the contrary, presents all the conditions most favourable for
 crushing the calculus.  The canal is sufficiently large to admit an instrument efficient
 from  its  size;  the  prostate  gland is usually healthy, and free from the enlarge-
 ment of age ; thus rendering the neck of the bladder  a part so important in the ope-
 ration, little  exposed to the dangers of inflammation.   When there is a normal pros-
 tate gland, the operator may  manipulate his instrument without risk of  bruising, or
 otherwise injuring this most sensitive of  all the parts concerned  in the operation. 
LITHOTOMY AND LITHOTRITY.
359
The urethra of such patients being more free, the fragments are expelled with less
difficulty, and cause less pain in  their expulsion, which  is also materially assisted
by a sound and vigorous bladder.  At this age also, inflammation, should it super-
vene, is more easily controlled than in the aged  subject,  who cannot well bear de-
pletion.  The warm bath  and free venesection, speedily arrest the inflammation,
of the mucous membrane of the bladder; but the old are soon depressed by  the dis-
eased action, as well as by the measures required for its suppression.  Inflammation,
however, is less liable to occur  in such healthy subjects, where the parts  are not
mechanically injured by the operation, and when the patient has been  prepared by
dietetic and other  prudential measures.  The aged  subject, however, is not less
adapted to the operation than  the younger  adults, if he  be  free from  the common
accidents of age, as an enlarged prostate, accompanied with an irritable state of the
bladder.   If the parts in the aged are  sound, the operation is especially  successful
in them;  as there is less irritability in the organs of generation, and less excitability
of the general system.  The ur&thra also is usually larger, and if  the  neck of the
bladder be free, it allows fragments of extraordinary size  to pass. * *  *  In the old
subject, however, difficulties often present themselves, in consequence of the change
which the parts about the neck of the bladder undergo, and the unsound condition of
the bladder itself consequent on these changes.   The operation in such  persons is
rendered dangerous by the  inflammatory disposition  of  the organ, and by the diffi-
culty with which the fragments make their way through  the prostatic portion of the
canal.
   " The  state of the bladder is, perhaps of all the circumstances that the lithotritist has
to consider, the most important;  and one on which the propriety of performing the
operation will mainly hinge.  Three conditions of this organ are necessary, and  these
must be ascertained by preliminary observations and trials, before the operation is de-
termined on : first, it must  be capable of holding a  sufficient quantity of water to
facilitate the working of the  percussor; second, it must  be free from  that  extreme
irritability that often attends the latter  stages  of calculous disorders;  and, third, not
prone to  inflammation from slight excitement.  In healthy persons, the bladder, even
under the irritation of a stone, will allow several ounces of water to be  injected into
its cavity, without sustaining more thana slight inclination to eject  it.   Its retentive
powers are not impaired in the early stages of the disorder; patients  will go for many
hours without any desire  to empty the bladder, the  only  early symptom  being  a
smarting, when the  bladder contracts on the  calculus.  It is therefore  rare  to  meet
with any difficulty  in injecting water sufficient for  the purpose of giving space for
the operation, amongst those who apply for advice soon after  the symptoms  have
begun to declare themselves.  Even when, from the long-continued presence of the
stone, the bladder becomes  morbidly affected, and able to contain  but  three or four
ounces of urine without an irresistible desire to expel it, much may be done by treat-
ment to assuage the irritation of the mucous membrane, and tranquillize the muscu-
lar excitability.   When the stone has been  long resident in  the  bladder,  and has
produced a change  in the mucous membrane, and a copious discharge of phosphatic
mucus, signs of extreme irritability come on, and almost seem-to forbid  any expecta-
tion of lithotrity being practicable.   The desire to void urine is renewed every two
hours or oftener; the urine  not only deposits a large quantity of dark-coloured mucus
but is cloudy, and loaded with small flakes of adhesive matter, the result of inflam-
mation of the mucous lining; the pain in expelling the last few drops of mucus is
intense.   Such continued suffering affects the general health; and would seem, I
say, to forbid  the operation  altogether.  Frequently, however, will  these formidable
symptoms yield to a system of diet and medicine, and the patient by degrees be un-
expectedly brought into a condition to bear-the operation." (p. 23-36.)
   "Those who have irritable bladders usually experience some form of irritation
after moderate distention with water and examination with  the catheter.   It gene-
rally assumes the form of rigour, occurring once or more in the twenty-four hours
after the examination has been made, and followed by severe pyrexia,  that  lasts for
several days.  The rigour  of itself indicates the degree of irritation produced by the
sound ; and if not followed  by the hot stage of fever,  it indicates nothing more; but
the presence of pyrexia is evidence of inflammation taking place, and such a state is
most unfavourable to lithotrity.  A distinction, therefore, is to be drawn between
these two states ; the occurrence  of a rigour need  not deter the surgeon from  com-
mencing the operation—it often attends the first examination, and may  never recur» 
360
COMPARISON OF
 but the indication of inflammation, drawn from a continued state of pyrexia, should
 at once induce him to defer the'operation, until by withdrawing all stimuli, he has
 brought the bladder into a tranquil state.  The disposition to inflammation is often
 kept up by improper food, especially drink; and  is indicated by a plethoric condi-
 tion of the system, and a flushed countenance.  Sueh a condition maybe overcome;
 arid is unlike that state  of bladder which is the effect of commencing disorganiza-
 tion, and often associated with diseased kidneys,  (p. 37.)
   "One principal source of irritability of the  bladder is a morbid condition of the
 cervix, or of the prostate gland.  The structure about ihe neck of the bladder, above
 all others deserves the especial attention of the lithotritist; as it is here that he will
 ever meet with the most difficulties, and will  also find the chief source of danger.
 The extreme susceptibility of this part of the bladder is not unfrequently evinced in
 severe rigour and inflammation following the introduction of a sound in patients who
 complain of dysuria connected  with an enlarged prostate.  These persons, often
 highly disposed  to  inflammation, have  a severe  attack  brought  on  by the casual
 introduction of an instrument for the purpose of ascertaining the eause of their ail-
 ments.  When the morbid condition  of the  gland is combined with calculus, the
 risk of inflammation, and the danger of its consequences, become greatly increased;
 and the hasty performance of lithotrity in persons not prepared for  the operation, has
 been known to induce a fatal cystitis."  (pp. 38, 9.)
   "It would be a great error," says Brodie (a), " to represent lithotrity as prefera-
 ble on  all occasions to  lithotomy;  but it is so in a great many instances.  I shall
 endeavour to explain by what signs you  may distinguish from each other the cases
 to whieh it is applicable, and those to whieh it is not.   In boys  under the age  of
 puberty, lithotomy is so simple and so generally successful, that we ought to hesi-
 tate before we  abandon it for any other kind of operation.  There  is also a manifest
 objection to  lithotrity in these cases,  on account of  the small size of the urethra,
 which is such  that it would not admit of the introduction of instruments of sufficient
 strength to crush a calculus of more than moderate dimensions.  In the female sex
 the extraction  of a calculus from the bladder  by the  ordinary methods is  attended
 with little danger;  while the operation of crushing is rendered difficult  inconse-
 quence of the short and wide  urethra, allowing the water which has  been injected
 into the bladder to escape by the side of the lithotrity-forceps before the operation is
 completed.   In cases in  which the calculus has attained a very large size, it is often
 difficult to seize- it with the lithotrity-forceps ; the operation of crushing requires to
 be  repeated a  great number of times,  so that many weeks may elapse before the
 cure is accomplished ; a large quantity of fragments is left in the bladder, of which
 the necessary consequence is a great liability to inflammation of the mucous mem-
 brane;  and of  course the inconvenience  produced by the passage of the fragments
 along the urethra is multiplied, as compared with what happens when the calculus \s
 smaller.  These  circumstances form a sufficient objection to the operation  of litho-
 trity in these cases.   It is true that they are unfavourable cases for lithotomy also;
 but I have little doubt that the latter method is the safer of the two. It admits of a
 question, whether in such cases the two modes of operating may not be advantage-
 ously combined,  the calculus being crushed into three or four pieces first, and ex-
 tracted  by the  usual  incision afterwards.  The operation of  lithotrity is not well
 adapted to those cases of enlargement of the  prostate gland, in which the patient is
 unable to empty the bladder by his own efforts, unless the calculus be of small size,
 so that  there may be no difficulty in crushing the minute fragments into which it
 has been crushed out of the bladder through a large catheter.   There is also another
 objection to the operation in  some cases of enlargement of the prostate, namely, that
 the tumour which projects from it into the cavity of  the bladder,  makes it difficult
 to elevate the handle of the forceps sufficiently  to seize the stone easily in the usual
 manner.
  "I have described the dangers which attend on lithotomy in those cases in which
 a calculus of the bladder is complicated with  disease  of the  kidney.   One of the
principal of these is connected with the loss of blood, which that operation  must
always occasion to some extent, and not (infrequently to a great extent, in spite of
 the best exertions of the surgeon to prevent it.  I have no doubt that in such cases,
 the operation of crushing is the safest method of proceeding;  but a small shock  to
(a) Above cited. 
LITHOTOMY AND LITHOTRITY.                 361
the system will sometimes destroy the life of a patient who labours under renal dis-
ease, and it will be often more prudent to trust to  the means which we possess  of
palliating his sufferings, than to run the risk of shortening his life in the endeavour
to obtain a cure.  *  *  *  With the exception of such cases as those which have
been enumerated, there  are few to which this method of treatment (Lithotrity) may
not be advantageously applied.  It may be said that the exceptions are numerous ;
but they are the result chiefly  of delay.   If a patient seeks the assistance of a com-
petent surgeon within six or even twelve months after a calculus has descended from
the kidney into the bladder, the urine having remained acid, it will rarely happen
that he may not obtain a cure  by a single operation, and with so small an amount
of danger, that it need scarcely enter into his calculations.  As time advances, the
facility with which he can be relieved diminishes, and after the lapse of two or three
years, especially if the  urine has become alkaline, it is probable  that the calculus
will have attained  such  a size  as to render the old operation (Lithotomy) preferable,
and that the access of disease in  the bladder or kidneys may render any operation
hazardous.  It would be absurd to say, and it would be unreasonable of humankind
to expect, that an operation which has for its object to relieve them of a disease so
terrible as that of a stone in the bladder, can be always free from inconvenience, and
difficulty, and danger.   Nevertheless, from what experience I have had, I am satis-
fied that the operation  of lithotrity, if  had recourse to only  in  proper cases, is not
only much more successful than that of lithotomy, but that it is liable to fewer ob-
jections than almost any other of the principal operations of Surgery." (p. 375-79).
   "The operation of lithotrity," says Liston (a), " is applicable  to patients above
the age  of puberty, when the symptoms have not endured very  long; when  the
foreign body is ascertained to measure six or seven lines, or even more perhaps, say
as large as a,chestnut;  when the bladder and urethra are in a tolerably healthy and
normal condition,—as indicated by the power to  retain the  urine comfortably for
several hours, and to pass it in a tolerably free stream; and when the viscus admits
of injection and a  careful exploration.   That the stone may be seized readily, and
acted  upon without danger to  the lining membrane, the bladder should contain at
least five or six ounces  of fluid,  (pp. 500, 501.)
   " When the stone is  much  larger than above indicated,  and when there is reason
to suspect that the bladder, in consequence of the  endurance of the irritation,  has
become contracted, fasciculated and irregular on the surface, presentingthe rudiments
of pouches, it  will be absolutely impossible to make sure of removingall the detritus.
Nuclei must be left, and very shortly the patient will have five or six stones perhaps
substituted for the original one formed upon these.  The suffering and danger, more-
over,  endured by the patient at each sitting, when these  are often repeated', in  an
unsound bladder, for removal of the fragments of a large concretion, are much greater
than those resulting from a speedy and well-conducted safe operation for its removal
entire  and at once.   When lithotomy is well performed,'the excited state of the
bladder is relieved by the removal of all source of irritation, by the viscus being put
at rest, and its functions suspended, and by the loss of blood from the neighbouring
vessels.   In lithotrity,  on the other  hand, when  the stone  is large, considerable
fragments are often left, and the irritation is thus greatly increased.  The pain
experienced in passing fragments, is often extreme, and not unattended wiuYdanger;
for difficulty is often  experienced in dislodging portions from  the urethra.   Then
retention follows,  perhaps, with inflammation of the bladder.  * *  *  Blood too is
often lodged in the bladder and removed with difficulty.  The excited action which
follows  is perhaps at first slow and weak, but it  soon  becomes lighted up by the
continued irritation resulting from the frequent contraction of the viscus, and contact
with  the angular pieces  of the concretion.  Unless a very correct judgment is
exercised in determining upon the practice in particular cases, and great gentleness
observed in the manipulations, fatal results must very often follow.
   "The operation of  lithotomy must jet continue to be performed on children, and
on those of mature age who are so ill informed or foolish  as to permit the stone to
attain an inordinate bulk.  * * * Of late years, in point  of fact, I have scarcely been
obliged to have recourse  to lithotomy at all  in private  practice.   At the hospital,
patients yet present themselves with large stones and bad bladders.   Then lithotomy

                             (a) Practical Surgery.
                                     31* 
362
STONE IN THE URETHRA.
is both a less painful and much more safe operation, as already propounded.   During
the period of the  last six years, twenty-four patients  have been cut, and all have
recovered without accident; these patients have been of all ages, from two to eighty
years, and some of them not over favourable subjects.  So that, after all, there is
not much to find fault with as regards this ' cruel and bloody operation,' when care-
fully set about."  (p. 503-505.)
   I do not propose to offer any opinion of my own as to the preference which should
he awarded to lithotrity, or  lithotomy, as I have had  little practical experience in
regard to the former, and am not therefore qualified to give  one.  But I may he per-
mitted to say that the results of the practice of lithotomy, both with gorget and knife,
and by various operators on patients of all ages  and under various circumstances,
during the course of a long series of years at our Hospital, have been so favourable,
as to afford little cause for making it give place to lithotrity.  I think it is proved
that lithotomy, when properly conducted, is  not the dangerous operation  it is too
commonly held to be; and it is no trifling advantage it  possesses, that the patient is
relieved at once, with a few minutes' suffering,  sharp  indeed  it must be  acknow-
ledged to be, instead of being  subjected to  several operations, which, the more fre-
quent in  their repetition, become, as  generally admitted,  greater  in severity, and
occasionally leave the necessity for resorting to the cure by lithotomy.  I may also
here add the  testimony of some patients who have undergone both operations, that
the suffering during lithotomy was less than in  lithotrity,  and that knowing both,
they would, if needful,, prefer undergoing the former.   It is well, however, that we
have the opportunity of employing lithotrity in cases where patients are too fearful
to submit  to the knife; but I  am by no means  sure that  under all circumstances,
lithotomy  is not at least as free from danger as lithotrity, and certainly more speedy
as regards the cure.—j. f. s.]
   Upon the relations of lithotrity'to lithotomy, the following  writers may also be
consulted:—
   Blandin.
   Velpeau in Doubovitzkt.
   Wattmann.
   Hecker.
   Longhi, A., Sulla Cistotomia e Litotrizia.   Pavia, 1839.
   King, Thomas, M.D., Lithotrity and Lithotomy compared.  London, 1832.  8vo.
                  V.—PF STONE  IN THE URETHRA.

(Calculus Urethralis, Lat.-;  Steine in der Harnrbhre, Germ.;  Calcul dans le Canal de
                                VUre.tre, Fr.)

   2139.  Stones which  enter the  canal of the urethra, as  well as foreign
bodies which have been introduced from without, may be fixed at different
parts, may more or less hinder, or entirely prevent (1), the flow of urine,
and cause inflammation of the urethra and of the whole penis, ulceration,
and gangrene  of the urethra, urinary infiltrations, fistulas, and the like.
If the stone or foreign  body be angular or pointed, the earlier will these
symptoms be produced  (2).
   [(1) A stone may sometimes exist for some time in the urethra, and prevent the
flow of urine by the stream forcing it tightly into the front of that canal, which is too
narrow to permit its escape.   An instance of this kind occurred to Travers in 1829,
in a man of sixty years, under his care  in St. Thomas's Hospital;"he had  been in
the habit of passing small  stones from childhood, during which he had been cut by
the elder Cline for stone in the bladder, and, when fifteen years old, a stone block-
ing up the urethra, immediately in  front of the scrotum, had  been out  upon and
removed, but left a fistulous aperture.   When he  came under Travers's care, he
had a sto/ie about, four inches down the urethra, and this,  when desirous of  making
water, he pushed back towards the fistulous opening, so that there was then room for 
STONE IN THE URETHRA.                  363
its passage.   At night his urine constantly dribbled away.  This stone was removed
by cutting through the fistula into the urethra, and lifting it out with a scoop.  The
aperture, however, did not perfectly heal (a).
  A good example of retention and consequent mortification from the complete
blocking up of the urethra by a stone, is Everard Home's  case in the College Col-
lection (b), of two stones  from a man of sixty years old :—" The large calculus was
situated in the membranous part of the urethra, the smaller about three inches from
the external orifice, the urethra being dilated into a cyst at each of these parts.  The
patient supposed  himself to have laboured under strictures of the urethra for ten
years! at last there was complete retention of urine; the urine became effused behind
the smaller calculus, and mortification of the skin of the penis and scrotum took place
to considerable extent, and the man died."  (p. 121.)
  (2)  A curious instance is recorded byLiSTON(c), of a  person who, "when a boy,
had pushed a small brass  curtain-ring over  the penis till stopped by the scrotum, in
order to prevent the urine  passing off during the night.  The  swelling that ensued
prevented its removal; he kept  the occurrence secret; the tumefaction gradually
abated, and the ring disappeared.   But the hardened mass which remained increased
in size; and latterly the functions of the parts, which had previously been very well
performed, began  to be disturbed.  The foreign body was cut  upon and removed,"
by Liston,  " when the man was approaching fifty years of age."  On making a
section of it, the greater part of the ring was found forming the nucleus.  The con-
tinuity of the erectile tissue, which had been cut through  gradually by the foreign
body,  was perfectly re-established." (p. 520.)]
  2140, If the  stone lodged in the neck of the bladder, it will, if small,
produce only  the common symptoms of stone in the bladder, but if it be
large, it  will cause  more or less  complete  retention, and if angular and
not completely  enclosed by the neck of  the  bladder, incontinence of
urine.   The patient usually suffers urgent pain, a  sensation of weight and
pressure in the perineum and  rectum,  and a constant burning in the
urethra,  especially at the glans.  A stone of any considerable  size  may
be distinguished by the  ringer  in the rectum, but most  certainly by a
metallic  sound  introduced into the urethra, which  is  either stopped by
the stone,  or passes near it into the bladder.
  2141. If it be  not  possible,  after the previous enlargement of the
urethra with large bougies passed down  to the stone, to grasp it with
Hunter's or Cooper's forceps, or Civiale's instrument, in doing which,
the introduction of one  or  two fingers into the rectum,  so as to press
against the stone,  prevents its being pushed back  into the bladder, and
then extract or  thrust it  back into the bladder, {par.  2052,) it must be
removed by a cut. .  If a staff can be introduced  close to the stone, into
the bladder, a cut  must then be made, as in the lateral  operation, into the
prostate  and part of the neck of the bladder, its situation ascertained by
the finger, and  the size of the cut increased as may be necessary.   The
staff  must now be removed, and with the finger  passed into the rectum,
it must be attempted to press the stone out, or at least prevent it getting
back  into  the bladder, so that  it may be removed with the forceps, or
with a scoop.   If the staff cannot be passed into the bladder, it must be
carried down  to the stone, the  membranous part of the urethra opened
upon  it, and a director tried to be passed into the  bladder, upon which
its neck  is to be sufficiently cut into.  If the staff  cannot  be introduced
into the  bladder, its  neck  must be divided up to the stone, which must
be pressed up from the rectum, and  even cut upon.  After the removal
of the stone, the finger or the  sound should always be passed into the

  (a)  Clark's Case Book.      (b) Taylor's  Catalogue.      (c) Practical Surgery. 
364          STONE IN THE URETHRA ; TREATMENT.
neck and body of the bladder, to  ascertain whether there be any stones
remaining.
  If, during the examination with the sound, the stone be forced back into the blad-
der, it must be crushed.
  [When a stone is found lodged in the urethra, and more especially if it be far
down that canal, the greatest care must be taken that it be  neither pushed back by
the sound, nor allowed to slip back in the handling; as if this happen, it will be ne-
cessary either to cut into the bladder, or to attempt crushing, as  Chelius recom-
mends, which places the patient unnecessarily in a very unsatisfactory condition.—
j. f. s.]
  2142. If the  stone lodge in the membranous part  of  the urethra, it
may increase on account of the yielding of the urethral wall, and easily
destroy it by ulceration and fistulous  openings.  If the stone cannot be
removed by the  use of lukewarm baths, by the gradual enlargement of
the urethra with  bougies, by gentle pressure, or by the already-mentioned
forceps, it  must  be  taken out by a cut, in which case the stone should be
pressed against  the perineum  by the  finger  in the rectum, and  then cut
upon in  an oblique direction,  from the raphe to the ischial  tuberosity.
After the removal of the  stone, a thick elastic catheter should be intro-
duced into  the bladder and the wound closed with sticking plaster.
  2143. If the  stone be situated  in the spongy part  of  the urethra, it
may most commonly be  got rid of by  the  use of soothing baths, by the
enlargement of  the urethra, by pressing it forwards, or by means  of the
forceps already mentioned,  or by a loop'of wire.  If these means be  in-
effectual, or the  symptoms  urgent, a cut must be made  on  the  stone,
which should be fixed with the fingers of the left hand, and  then pulled
out; after which a catheter is  to be introduced, and the wound carefully
closed.  If the stone have been long retained,^and the walls of the urethra
be much distended  and changed,  an incurable fistula very easily occurs.
If the cut  be requisite in  the  region  of the scrotum, which should  be
carefully avoided for fear of urinary infiltration, it must be made through
the skin  made tight, but  not  dragged out of place, sufficiently behind,
and  care taken  for the  due passage  of the  urine  by the inlying of a
catheter.
  2144. If the stone be stopped in the fossa navicularis,  and cannot be
removed on account of the narrowness of the orifice of the urethra, the
orifice must be slit towards  the frenum.
  In rare cases the whole urethra has been  so filled with stones to its mouth, that
even the smallest  sound could not be  introduced.   Under these circumstances  the
urethra must be opened at several parts, and if vesical stones be present, a cut made
even into the bladder itself (a).
  [If a stone be any where in front of the scrotum, it can most commonly, and should
be extracted without  cutting; for, as Liston very justly observes, "owing to  the
thinness of the coverings, it will be found  a most difficult matter to close entirely
any opening anterior to the  scrotum."  (p. 520.)   I  have frequently succeeded, by
following the advice of the younger Cline, in getting out a stone so lodged, though
at first the attempt seemed very unpromising, by a very simple  contrivance, but
persevejred in with patience.  This consists, in first nipping the urethra tightly be-
hind the stone, so as to prevent it slipping backwards, and then introducing an eyed
probe, with its eyed end a little bent, so as to form a sort of spoon or loop; it is to
be gently insinuated between the wall of the urethra and the stone,  till its point
have got completely behind the  latter.   Then pressing the stone forwards with  the
thumb and finger, which grasps the urethra, the probe is gently and by little jerks
(a) Klein, in Neuen Chiron., vol. i. p. 78. 
    URINARY STONES EXTERNAL TO THE URINARY PASSAGE.  365

to be drawn forwards, bringing with it the stone, which is  to be closely followed
with the thumb  and finger of the other hand.  By thus proceeding with patience,
the stone is after some time brought up to the glans, and if the lips of the urethra be
there too narrow to allow its passage, the urethra may be cut through by the side of
the fraenum with a lancet, and the stone is immediately set free.
  Should I meet with a case of this kind in which I was  foiled, I am  inclined to
think that, rather than cut on the stone from without, I should pass a phimosis-knife
down the urethra to the stone, and cut through its lining membrane into the spongy
body of the penis sufficiently to enable the stone to move forwards, running the risk
of infiltration of urine, which I should not much dread, by passing a catheter occa-
sionally during the day to draw off the urine, or leaving it in,  so that the water might
flow away constantly.  If infiltration did not ensue, there would probably be some
temporary narrowing of the urethra, which might be cured by perseverance in  the
use of bougies.  Any thing is better  than an urinary fistula, which  becomes  the
more serious in proportion as the urethra is opened near the front of  the scrotum, in
consequence of the readiness with which the  urine will  escape into the loose cellu-
lar tissue of that part, causing troublesome abscesses and even gangrene.—j. f. s.]
  [Dickson, On  Urethrotomy in the N.  Y. Journ.  of Med.  and  Surg.
No. 7.—g. w. N.]
 VI.—OF URINARY STONES EXTERNAL TO THE URINARY PASSAGE.-

   2145., Stones which  are found  external to  the urethra, in the neigh-
 bouring cellular tissue of the  perineum, {perineal stones,) or in the scro-
 tum, {scrotal stones,) are either such as  have been deposited in the cel-
 lular tissue by the destruction  of the walls of the urethra, and have grown
 by the continual deposition of the phosphates, or have been produced by
 the penetration of the urine into clefts of the urethra, into fistulas, wounds,
 and the like, into  the cellular tissue itself.   If the  urine penetrate into
 several spaces of the cellular tissue, several  stones may be formed at the
 same time.   Such stones  are  easily distinguished by hard, nearly pain-
 less, frequently very large, swelling; often by the introduction of a sound
 into  the  urethra,  when they  partially  project  into it.   They frequently
 cause suppuration and fistulous passages, through which a metal sound
 easily finds the stone.   They are not  rarely discharged by suppuration,
 in  consequence of which  incurable fistulas remain, if the wall of the
 urethra have been destroyed to any great extent (1).
   By the destruction of the walls  of the vagina in women, and of the rectum in men,
 vesical stones may lodge in these cavities and be discharged.
   [(1) A very remarkable instance of a large collection of perinseal stones occurred
 to Vincent (a) in St. Bartholomew's Hospital in 1843.  A young man, twenty-
 three years of age, suffered from incontinence of urine during the ten previous years,
 in  consequence of having received at that time a kick on the penis from a horse; for
 this he had constantly worn a yoke.  Four years  after he had  bleeding from the
 urethra, which was  followed  by a swelling behind the scrotum, and this, at the pe-
 riod of his admission, had acquired the size of a goose's egg.  Upon this Vincent
 cut, "and gave exit to a hundred  and forty-six calculi of various figures and sizes,
 the largest being about the size of a horse bean.  After the pouch had been emptied,
 there were several in that part of the urethra next the bladder which were removed,
 and two of the number came  away the next day. The cyst consisted of a  dense
 and tough membrane like pa'rchment.  It communicated with the urethra its whole
 length, and graduated into it, so as to offer no abrupt nor partial connexion with it,
 and appeared to be formed by its dilatation.  After the operation the patient retained
 his urine, passing it voluntarily through the wound.' The stones consist of the
fusible compound mixed with thin alternate layers of urate of ammonia, which are
            (a) Taylor's Catalogue of Calculi, above quoted.  Appendix. 
366
PROSTATAL  stones.
more abundant at the centre of each calculus; the urate, however, does not constitute
a distinct nucleus." (pp. 137, 138.)
  In the College Collection there is also another very curious case of Vincent's:—
" Numerous small calculi, which with about two hundred others, were removed from
between the prepuce and glans penis of a very old man.  The patient had congenital
phimosis, the orifice of the urethra scarcely admitting the introduction of a common
probe.  From the presence  of the calculi, the prepuce was distended to the size of a
large pullet's egg, and retention of urine was  finally produced.  On  dividing the
prepuce, one of the calculi was found  completely blocking up the orifice of the
urethra.  The glans penis was in a state of ulceration, and a large portion of its sub-
stance had been absorbed.   The patient had, during many years, occasionally expe-
rienced great pain and difficulty in making water, and laterally he had a constant
stillicidium.  The calculi are composed principally of the fusible compound ; most
of them have a small nucleus of uric acid ;  their  external surface is varnished oyer
with urate of  ammonia.  From the  composition of the nucleus,  there  can be no
doubt but that the greater number of these calculi had passed from  the urethra into
the sac of the prepuce; and their irregular form and  close adaptation to each.other,
proves that in this situation they had increased considerably in size by the deposition
of the earthy phosphates."  (pp. 39, 40.)]
   2146.  These  stones may be removed by sufficiently cutting on the
parts containing them ; and if the  stone  be in the perineum and deeply
lodged, attempts should be  made from the  rectum to press it through. If
the cavity in  wdiich the  stone lies, be  very large and hardened, it may
be  advisable to  remove  part of its walls.   The after-treatment must  be
conducted according to  the rules laid down for urinary fistula.
  Further notice of this subject may be found in
  Louis, Memoire sur les Pierres hors des voies naturelles de l'urine; in Mem. de
l'Acad. de Chirurg., vol. iii. p. 332.
  Ilse ; in Medical Observations and Inquiries, vol. v. p. 336.
  Walther; in Salzburg Med.-Chir.  Zeitung, vol. ii. p. 253.  1812.
  Klein ;  in neuen Chiron, vol. i. p. 16.
  Graefe, Ueber Scrotal-Steine; in his Journal fiir Chirurgie und Augenheilkunde,
vol. iii. pt. iii. p. 400—pt. iv. p. 695.
  Chelius, Ueber Scrotal-Steine; in Heidelb. Med. Annalen, vol. i. pt. i.
                   [VII.—OF PROSTATAL STONES.

   Stone is occasionally formed in the prostate gland.   This, " though
not of urinary origin," remarks Prout {a), " is very liable to be mistaken
for such, from the situation in which it is formed.  Of this there seems to
be two varieties.   The first   variety is  usually formed in the natural
cavities of the  gland  before it becomes much disorganized.   They are
generally small, and more or less rounded in shape, and of  a yellowish-
brown  colour.   The  second  variety seems' to  be generally  found in
abscesses  of that  gland, where they are sometimes  met with in great
numbers.  These are usually of much larger size than the first variety, and
have a  highly polished porcelainous appearance.  The composition, how-
ever, of both varieties  is essentially the same ; that is to say,  they consist
chiefly  of  the phosphate of lime; a substance which appears to be never
deposited  in  an  unmixed  state  by the  urine.  Hence the prostatal
calculi can be always readily distinguished from those of urinary origin."
(p. 94.) Astley Cooper (6) says, the largest he has seen " are not bigger
(a) Inquiry above cited.
(b) Surgical Lectures, vol. ii. 
PROSTATAL  STONES.                     367
than a pea, and they seldom are so large but their numbers are sometimes
very considerable." (p. 295.)   In a  preparation of this disease in St.
Thomas's Museum, the prostate is studded with little stones  like pins'
heads of various size.  Astley Cooper mentions, that in a case under
his care, " these  calculi had produced not only painful feelings in  the
perineum, but a degree of  irritation which kept the patient in  continued
mental excitement  bordering on  insanity." (p. 296.)  They are usually
accompanied  with  difficulty  in  passing the  water;  may be felt as the
catheter  passes over them into the bladder, and  by the introduction of
the  finger into the rectum.
   These prostatal stones  must be  removed by cutting through the peri-
neum into  the prostate  gland, and picking them out.
   [I am  doubtful whether the following is  to be considered as a prostatal stone, or
merely a stone encysted  close to the gland, but it has much practical interest, and
may be conveniently mentioned here.  A  man  about middle age applied  several
years since to my friend Green, labouring under symptoms of stone in the bladder.
He was sounded, and a stone  felt obscurely; but was sounded again at some interval,
and with the same result; the operation was therefore deferred,  and a few months
after he died of some other complaint.  On  examination no stone was found in the
bladder,  although sounding  immediately  before had  given the same indistinct
sensation.  The bladder, penis, and neighbouring parts were therefore removed for
closer inspection, and it was then found that there was a long narrow stone embed-
ded in a cyst before and below, but in such way that had  the lateral operation  been
performed, and the prostate divided in the usual way, the forceps would probably
have  entered the  bladder without detecting the stone in their passage,  and conse-
quently the operator would have had the vexation of supposing the patient had been
operated on without really having a stone; although as the sound passed  over it had
received the indistinct  impression before mentioned.—j. f.  s.]
                  Mote on Constitutional Stone-Solvents.

  I have to thank my friend  Travers  for the following interesting case which
fell under his own immediate observation, and which  is the best authenticated
throughout of any case I have heard of.  The fragments of the stone are in his pos-
session.
  A tailor who had long laboured under symptoms of stone was sounded  by Tra-
vers a few years since, who detected a hard calculus of  some size, and counselled
immediate operation.  The man being afraid to incur the risk  of the proceeding, put
himself under the care of a person at Henley-in-Arden, who  administered a consti-
tution water to the extent of two or three pints per diem.
  The patient  soon began  to pass fragments in quantity, as  after the operation of
breaking, the act being attended with acute pain,' both before and during micturition.
The pain and discharge oT fragments  continued for many months; both subsided at
last and at the same time.  The patient on one occasion showed him a box full of
fragments, for the most part reduced to a powder.
  This man  was examined  after death by Dr. Charles of Putney, and no  trace of
stone was discovered in the  bladder.
  Dr. Prout stated the basis of the  " drink" to be carbonate of soda and potass,
with a little nitre, in the following proportions :—

                     Sodae carb......gr. x.
             ,       Potass, carb......gr. viij.
                     ------nitrat......gr. ij. 
[  368   ]
SATISTICAL ACCOUNT OF THE OPERATIONS FOR THE STONE IN
              ST. THOMAS'S HOSPITAL, from 1800 to 1846.

  The following is the account of operations for the stone which have been performed
in St. Thomas's Hospital since 1800; and I have to  thank my friend Nash for the
kind assistance he has rendered me from the steward's office books, which unhappily
are, but with few exceptions, the only records kept before  1820.  I have also used
Green's case-books, some of which are missing,  Clark's, and my own books, the
ward books, and the lancet from which I have derived great assistance.
  In the first table are the gross number of cases operated  on in each year.  In the
second table I  have given the dates and the results, with the circumstances of the
cases where important, as far as I have  been able  to obtain them.   I am  sorry,
however, that the reports are so meagre, but still they  are highly important, as show-
ing that the lateral operation  is neither so dangerous, nor so much to  be dreaded, if
the after-treatment be  well attended to; and  also that the  cutting gorget does not
deserve the obloquy which of late years  it has been the fashion so freely to  heap
upon it.
  In the cases recorded in the second table, the gorget was always used by the elder
Travers, Green, Mackmurdo, the younger Travers, and myself; Tvrrell, Solly,
and Clark operated with Blizard's knife, its beak, however, being straight.

                               TABLE I.
Gross Number t)F Operations for the Stone, from 1800 to 1846.
1801	12	1813	7	1825	4	1837	10
1802	12	1814	2	1826	5	1838	7
1803	1	1815	8	1827	7	1839	1
1804	6	1816	5	1828	13	1840	7
1805	11	1817	2	1829	9	1841	6
1806	4	1818	7	1830	10	1842	4
1807	3	1819	8	1831	6	1843	7
1808	11	1820	8	1832	4	1844	6
1809	4	1821	4	1833	5	1845	2
1810	2	1822	7	1834	5		---
1811	15	1823	11	1835	5		295
1812	4	1824	10	1836	8		
                              T AB L E  II.
  Yhe Initials under the Surgeon's column mark the operator.  Up to 1837, the
elder Travers, Green, and Tyrrell, alone operated;  but in that year,  whilst
Assistant Surgeon, was my first operation.  After.the retirement of Travers, and
my appointent as Surgeon, in 1841, Mackmurdo, Solly, and the younger Travers,
became  Assistants; and on the death of Tyrrell, in  1843, Mackmurdo took his
place, and Clark became junior Assistant.  This notice is necessary, as a key to
the Table.
	Age.	Admit'd	Cut. 1 Cured.		Surgeon.			Remarks.
1S22.								
(Seven.) James Townrnw.... (Ward Book.)		May 30	June 7	July 4		G.		
Elizabeth Dnnthorne (Ward Book.)		June G	July 12	Aug. 22		G.		
Robert Brown....... (Ward Book.)		Aug. 1	Aug. 23	Sept. 2b'		G.		
Charles Johnson.... (Ward Book.) (a)		Aug. 24	Oct. 15	Nov.l 2		G.		
(«) The names of tlr remaining patients cannot be. ascertained; but the total number is obtained from
                         the Steward's report in table I. 
STATISTICAL ACCOUNT OF OPERATIONS FOR THE STONE.    369
	Age.	Admit'd	Cut.	Cured.	Surgeon.				Remarks.
1823.									
(Eleven.)	6	Oct. 30	Nov. 7	Dec. 13	Tr.				Stone as large as pigeon's egg.
(Lane, vol. i.)									
	39	Nov. 22	Nov. 28	Dee 22	Tr.		•		Stone rather larger than
(Lane, vol. i.)									crown-piece, not very thick.
									Uric acid. Had slight bleed-
									ing on same evening, but it
									was soon stanched.
		Sept. 4		Jan. 4,		G.			
(Ward Book.)				1824.					
(a)									
1824.									
	3		Feb. 13				Tyrr.		Two stones removed'.
(Lane. vol. ii)									
		April 28	May 21	July 15		G.			
(Ward Book.)									
	3	Nov. 4,	Mar. 12	April 29	Tr.				Stone not found at operation^
(Lane, vol. ii.)		1823.							but afterwards in a clot on the floor, size of a pea and oblong. Soon after his ad-mission a small stone was extracted from opposite/r<E-num. Afterwards an abr scess formed behi nd scrotum-•which was opened, and Ave days after another triple-phosphate stone was re-moved from this part of the urethra. Severe symptoms of stone continued; the child was sounded, stone felt and the operation per-formed as above stated.
	6*	April 8	April 23	J*une 3			Tyrr.		Stone very soft,, and smashed-
(Lane, vol. iii.)									in its extraction. Four stones had been removed from the urethra on the day following his admission.
Richard Stevens---	4	Feb. J6	April 23	June 7			Tyrr.		
(Lane, vol. iii.)									
	31	April 28,	May 21	July 15		G.			Stone, size of an almond with
(Ward Book—Lane		1823.							the shell on; soft and rough
vol. iii.)									at one point; a small por-> tion broken off in the ex-traction.
			May 28				Tyrr.		
(Lane, vol. iii.)									
William Padyham.. (Lane, vol. iv.)		Aug. 16	Aug. 27				Tyrr.		
		Oct. 7	Oct. 22	Nov. 28		G;			
(Ward Book.)									
			Dec.				Tyrr.		
(Lane, vol. v.)									
1825.									
	4	Feb. 10	Feb. 26	Mar. 25		G.			Operatedon in 1823. Oblong-
(Lane, vol. vi.)									stone, inch long, half inch
(see 1823.)									wide.
	7	Aug. 3	Aug. 9	Sept. 12		G.			Flattened round stone, three
(Green's Book.)									inches around, rough.
	45	Oct. 4	Oct. 14	Frb. 23,		G.			Had been cut in Oct., 1824;
(Green's Bonk.) (sie Id*.)				1826.					stone broke in present ope-
									ration; passed fragments,
									on second and third day.
	7	Nov. 3	Nov. 11	Dee. 15	Tr.				Stone large: had shivers on
(Lane, vol. ix.)									fifth day.
1826									
Anthony Willsmore. (Lane, vol. ix.)	12	Feb. 23	Mar. 3	April 24		G.			Oxalate of lime.
(o) The names of the remaining patients cannot be ascertained; but the total number is obtained from.
                         the Steward's report in Table I.

   Vol. hi.—32 
370
STATISTICAL  ACCOUNT  OF
1826—continued.
Charles Cruden..
  (Lane, vol. x.)
Heber  Humphrey.
  (Lane, vol. x.)
Age.






 17
John Palmer......
  (Lane, vol. x.)
John Newman...,
  (Green's Book.;
1827.
John Bone..........
Robert  Gosling or
  Gosden.
Henry Richardson..
  (Lane,  1827—28;
  vol.i.)
Edward Row......
John Gilby.---.....
James Sharp.......
  (Lane,  1827—28;
  vol. i.)
George Butler......
1828.
John Baker........
  (Lane, 1827—28;
  vol. ii.)
John Chaplin.,.....
  (Lane, 1827^--!8;
  vol. ii.)
John Gilby..........
  (Steward's book.)
James Gardner.....
  (Lane,  1.827—28;
  VOL ii.).
Frederick  Hinckley
  (Lane,  1827—28;
  vol. ii )
John Maybank.....
  (Lane, 1828—29;
  vol.i.)
Thomas Gash......
  (Steward's book.)
W'H'ar" Shaw.......
  (Steward's book.)
Admit'd




 June  1  June  2

 June 29  July  3
July  8

Nov, 25
S3
a*
July 21

Nov. 25
66   Feb. i5
     Mar.  8
June  8
Cured.
June 29

Aug.  9
Surgeon.
Aug. 25

Jan. 25
Feb  22 April 3
Mar. 16] May 17
June 22
Aug.  8
Aug. 25
Sept. 19


Nov. 29
Feb. 28


April 9
April 26

 Aug. 4
Aug. 14


Sept.  4


Oct.  1

Oct. 12-
Aug. 10
Aug. 25
Sept. 27
Dec.  7
Mar.  7


April 18
w
Tr.
Tr.
G,
Tyrr.
Sept. 11
Sept.  4
Nov. i5
Jan. 3.
 1828.
April 10


 June 14
May 8

Oct. 2
Aug. 1,9
Tr.
Tr.
Tr.
Oct.  2


Nov.  6


Nov. 20

Dec. 25
Tyrr,
Remarks.
Size of sparrow's egg.

Size of  walnut.  In  same
  evening patient  attacked
  with great pain  in  abdo-
  men, with high excitement;
  arising from accumulation
  of urine,  from closure of
  wound; a catheter passed
  through it, and symptoms
  ceased, but required to be
  passed next day; no further
  trouble.
Stone size of horse chestnut;
  flattened, and rough.
Stone as big as  top of  little
  finger, and grape-shaped, in
  bulb of urethra, causing re-
  tention  of urine;  removed
  by cut in perimeum. He had
  been  repeatedly  sounded,
  but the stone never felt.
Stone size of a pigeon's egg
  immediately,  after which,
  with much difficulty, a se-
  cond as large as a pullet's
  egg;  much venous bleeding
  at operation ;  on third day
  powers failed, and died on
  fourth.  Large   stone in
  right ureter, and same kid-
  ney wasted; bladder much
  thickened,  with spots of
  ulceration;   prostate  en-
  larged, and almost cartila-
  ginous.


Stone oval; flattened, size of
  a shilling,  rough; oxalate
  of lime.
Stone as large as  hazel-nut.
Stone size of a horse bean.


Stone size of a pullet's egg,
  rough; considerable bleed-
  ing some hours after; stop-
  ped  by pressure.   Much
  constitutional  excitement,
  and sickness  for first  five
  days.


First division of prostate not
  sufficient,  therefore a se-
  cond; stone small and ob-
  long;  seized with difficulty,
  as lodged behind a fold of
  bladder, and lying behind
  and below left  of prostate.

Stone large and^irregular.


Stone of large size.
Died, [oj June 25,1827, 
OPERATIONS FOR THE STONE.
371
	Age.	Admit'd	Cut.	Cured.	t Surgeon,				Remarks.
1828—continued.									
Edward Harrison...	9	Oct. 18	Oct. 24	Jan. 22,		G,			Stone large. Attacked with
(Lane, 1828—29;				1829.					peritonitis on second day.
vol. i.)									
	17	Nov. 27		Feb. 24,		G.			
(Steward's book.)				1829.					
		Dee 15		Feb. 7, 1829.			Tyrr.		
(Steward's book.)									
		Dec. 12,	Mar. 7	W:		G.		.	Third operation, against
(St. Thos. Med.		1827.							Green's advice; cut made
Soe Minute-Book )									on inner side of scar; great
(see 1824—25.)									difficulty in introducing gorget, on account of hard-ness of prostate; stone broken to pieces, and re-moved piecemeal, but nu-cleus remained, and neces-sary to enlarge wound with straight knife, then broke,
1829.									and extracted in two pieces; operation forty minutes.
	62	Jan. 9	Feb. 30	lb}		G.			Two stones; first of large size; second broke to
(Lane, 1828—29;									
vol. i.)									pieces, partially removed with scoop, and washed out by injecting warm water; patient much exhausted.
	i<r	Jan. 13	Feb. 20	Mar, 23			Tyrr.		Stone of large size.
(Lane, 1828—29;									
vol. i.)									
	62	Feb. 26	Mar. 6	April 30			Tyrr.		Stone large, oval,flat; weigh-
(Lane, 1828—29;									ed above ? ij.ss. Soon after
vol. i.)									operation bleedingto a pint;
	23	May 14	May 22	Aug. 6		G,			stopped by pressure. Stone circular and flattened ;
(Lane, 1828—29;									inch and half in diameter,
vol. ii.)									half-inch thick; having two processes similar to a pair of horns, each nearly half an inch long. Forceps at first passed over stone, on which they grated, but did not find it in bladder; was lodged in a cyst at the anterior part of prostate gland, communicating with
(Lane. 1828—29; vol. ii.)	10	June 16	June 26	June 24			Tyrr.		urethra. Large oblong stone, 1£ inch long.
(Lane, 1828—29;	12	June 25	July 16	Aug. G		G.		••	Stone shape of flat pebble.
vol. ii.)									
	73	Oct. 2$	Nov. 6	Dec. 17		G.			Has frequently voided small
(Green's book.)									as pin's-head stones. Stone size of a peach kernel, smooth, with soft surface, which crumbled.
	12	Oct. 22	Oct. 30	Jan. 7,		G.			Stone round, as large as a walnut, tuberculated; ox-
(Green's book.)				1830. '					
									alate of lime.
	60,	Dec. 3	Dec. 18	Jan. 14,	Tr.				Has occasionally passed small
(Clark's book.)				1830.					stones from childhood, and had a stone extracted from bladder hefore he was 15; then a stone removed from urethra by Cline; now a small fistulous orifice at junction of penis with scro-tum, and stone four inches down; removed by a cut;,
1830.									uric acid.
Robert Wheatler, or	G6	Jan. 13	Jan. 26	April 15			Tyrr.		
Whittesley.									
	4	Jan. 28	Feb. 5	Mar. 11			Tyrr,		
	55	Mar. 25	April 1	May J 3		G,			Nothing particular.
(Lane, 1829—30;									
vol. ii.)									
Died,  [a] March 11,1S98.
[6J March.2,1829, 
372                           STATISTICAL  ACCOUNT OF
1830—continued.
James Taylor......
  (Lane, 1829—30;
  vol. ii.)
Stephen Kensley...
  (Lane, 1829—30;
  vol. ii.)
William Saxbee....
  (Green's book)
 Stephen Saxbee....
 Thomas Dove......
  (Greek's book.)
 John Mason.......

       1831.
 Elizabeth Cook.....
 John Wilkinson...
"Thomas Hingeston
  (Green's book.)

 Thomas Goodsoul..
 Thomas Thorpe...,

       1832.
George Si in ton ..
Thomas Brunier .
 (Green's book.)
Charles Tighe.
Henry Baron..
Age.
14
Cured.
Mar. 25 April 5  Oct. 7
Surgeon.
G.
Remarks.
                                                       No difficulty in operation, but
                                                        siz"i of stone not mentioned.
Not more than four ounces of blood lost at operation; but an hour after he became pallid,
faint, and cold; in evening pulse very small and quick, and very restless; ammonia and
opium given, which were soon  rejected, but solid  opium retained.   During night he sunk
still  more,  and  on following morning the pulse  was scarcely perceptible;  countenance
cadaverous; thirst extreme; brandy then eiven, but thrown up, but ammonia with lemon
juice retained, and gin every four hours.  On thirdA&y was better, and sickness subsiding;
port wine given.  On fourth day re-action had taken place, and he had great tenderness
of the lower part of the belly; caster oil ordered, and repeated in  evening, and hot poul-
tices to the belly.   In the course of the night the bowels were freely opened, and be was
much belter  on the fifth day.  The wound was still pale, but the urine flowed freely
through it; on each side of  the raphe a dark purple spot; was allowed a chop and porter
and eggs. On sixth day had pain in perineum; and on same evening became suddenly
faint, the limbs  thrown forcibly out. and he appeared dying, but recovered by sprinkling
with cold water.  On ninth day quinine ordered; on twelfth day pus discharged from the
wound; and  on fifteenth a  considerable slough removed, after which half a pint of pus
discharged.  From this time he gradually improved.
  5   April 6 April 14| June 101   .     G.     .      •    IStone  size  of filbert;   uric
                                                        acid.
66
May 27| June  4   [o]
Moderate-sized stone; super-
  ficial perineal artery tied
             i        ■                                   nciai  peruiieai ariery iiea
at operation; wound attacked with erysipelas on tenth day, probably caught from patient
near him, which extended to thighs;  slough on  buttock; cellular tissue on one side of
scrotum sloughy;  no peritonaeal inflammation nor other internal mischief.
July 22
Aug. 24

Oct. 28
Jan. 25
Feb.  3
Feb. 15
Feb. 21
Nov.  8
Feb. 23
May 2
July 29
Aug. 31

Nov-  5
Feb.  1
Feb. 17
Feb. 25
Feb. 28
Nov. 12
Mar.  2
May 22
Sept.
Oct-.
Dec. 23
April 14
 Mar. 24
 Ma*. 14
Mar. 21
Dec. 18
April  12
 July
G.
G.
Tyrr
Tyrr,
Tyrr.
Tyrr.
Stone large.

Oxalate of lime.
Small flat stone,  uric acid;
  attacked with peritonitis on
  sixth day.
                                                      Stone large as crown piece,
                                                        weighed  ^xiv.;  aitery of
bulb divided, bled freely, and tied at once, but not efficient, and therefore pressure for four
hours, effectual.
 19   July  2 July 13 Aug.  18   .      .    Tyrr
 26   Aug.  2 Ock 26 Nov. 29   .      G.
      1S33.

Edward Verle.....
Josiah Wheeler...
Robert Willis.....
Thomas Hatinam.
William Henry Burt

      1834.
John Holden.....
WilliamBatt.
Frederick  Norman.
William Roderick..
William Thomas...
Feb. 28
June 13
Sept. 19
Oct.  2
Nov. 19
Mar. 14
Mar. 27

Aug. 22
Oct. 28

Oct. 30
April 12
 July  5
 Oct.  4
 Oct. II
April  4


April  4


Nov.  7

Nov.
Aug.  6
  M
Nov. 22
Jan. 24,
 1834.
  M


  [•]
Sept.  4
Dec. 18

Dec. 18
Weight, 7j. gr. xi  Nucleus,
  urate  of ammonia;   the
  remainder  uric  acid, with
  traces of lime.
Weight, ziv.  Uric acid, with
  a nucleus  of  oxalate  of
  lime.
Weight, giij. gr. xxii.; phos-
  phate of lime.

Stone broken to  pieces;  not
  analvzed.
Weight, gj.gijgr. viii. Nu-
  cleus uric aciri,covered witb
  a layer of uric aciil and ox-
  alate of lithe, and the crust
  urate of ammonia.
Died. [«] June 21, 1830.    [fc| April 13, !£33.    [c] Nov. 10.    [d\ April 7.    [«] April 14. 
OPERATIONS FOR THE STONE.
373
	Age.	Admit'd	Cut,	Cured.	Surgeon. Remarks.				
1835.									
	14	Jan. 1	Jan. 16	Feb. 19		G.	•		Weight, gij. Qij. gr. vii. Oxalate of lime.with traces
John Medden......	4	Feb. 17	Feb. 37	Aoril 13	G.				of uric acid on the exterior..
	*f	May 22	July 3 Aue. 9		Tr,				
	4	July 21	July 31	Sept. 4		G.			Weight, sjij. ^ ij. Nucleus of uric acid, with a mixed co-vering of uric acid and fusi-ble calculus, and a crust of phosphate of lime with-
	32	Nov. 25	Dec. 11 April 22, 1836.			•	Tyrr.	•	traces of uric acid.
1835.									
	5	Dec. 15 1835.	Jan. 23 Mar. 11			G.		•	
Thomas Popkins....	12	Sept. 17. 1835.	Feb. 12 Mar. 31			•	Tyrr.		
Joseph Anderson....	21	Mar. 24	April 2 May 11				Tyrr.	.	
William Garland....	4	July 2b	Aug. | gept. 17		.	G.			
	4	Aug. 25	Sept. 23 Oct. 25		Tr.				
	2i	Nov. 2	Dec. 9j Jan. 24, 1 1837.			G.	'		
Robert Taunton___	10	Nov. 7	Dec. 9 Jan.24,			G.		.	Weight, gv. gr. xxr. Nu-
				1837.					cleus and next two layers consisting of oxalate of lime; the remainder fusi-ble calculus.
	5	Nov. 24	Dec. 9	Mar. 11, 1837.		G.		•	Weight, gij. gr. viii. Cystic oxide.
      1837.

Felix Aug.Davenpon

WiHiam Stokes.....
George Lucas.......
Henry Peverill.

James Row....
William Perry.....
Henry Turner......
William Sheldrake.
John Hawes.
John Pratt.
1838.
Henry Wannan....
James Harding.....
Thomas Bull.......
William  Brockwell.
George Thornton...
John  Slinn........
Nov. 8
 1836.
Feb. 21
Jan. 19
Jan. 20
Feb. 25
Feb. 3
Feb. 22
Mar.
Tr.
Tyrr.
South.
                                                     Stone weighed 5iij.^ij.gr.vj.;
                                                       pure oxalate of lime,covered
with transparent crystals of oxalate of lime; bleeding from perineal artery soon after
operation, and three hours after, soon stopped by pressure.
 21
 2J
57
June  1 June 24
Nov. 22,
  1836.
June 26
Aug. 18
Aug. 22
June  2
Sept.
Sept.
Sept. 16
  M

July 2
Sept. 23
Sept. 25
Oct. 24
4J  Sept. 12 Sept. 30 Oct. 25
50
17
75
 4
10
23
Sept. 14
Jan.  2
Jan. 23
Mar. 14
July 31
July 26
Nov. 23
Sept. 30
Feb. 10
Feb. 10
Mar. 31
Aug.  4
Aug. 18
Nov. 30
Oct.  26
Mar. 13
April 10
May 29
Sept.
Sept. 25
  W
South
South
Tyrr.
Tyrr.
Tyrr.
Tyrr,
Tyrr
Tyrr
South
Stone  crushed.  Uric  acid
  stone of zvij. TSij. gr. vj.
Weight, ^ij.  Nucleus, urate
  of ammonia,  with a crust
  of uric acid having traces
  of lime on its exterior.

Stone broke in extraction;
  prostate very large;  free
  bleeding  for  short  time,
  stopped  by pressure;  had
  sloughy wound-

Weight, zij.  Nucleus, urate
  with traces of oxalate of
  lime ;  next layer, oxalate
  of lime;  crust,  urate  of
  lime.

Free bleeding from superficial
  perinseal, which was  tied,
  and from artery of bulb, or
  internal pudic; stopped by
  pressure seven hours.
32f
                                                      A great gin-drinker; bled in
                                                        course  of the  fimt  after-
 noon, but stanched by pressure.  Passed no water till four a. m. of second day when the
 finger passed through wound into the bladder, and the water then flowed freely. Passed
 clots several times daily till death.  Became excessively irritable, but always quieted bv
igin, which was given freely, but not to the amount it afterwards appeared he had bei»n
 accustomed to take.                                                           - *

                        Died,  [o] Feb. 26.      {»] July 1.      [c] Dec. 8. 
'  374                          STATISTICAL  ACCOUNT OF
1838—continued.

Henry Forster.....
      1889.

One case......
      1840.

Joseph Boston..
.lames Charman.
Robert Crofton..
Joseph Palmer..
William Fell....
Edward Phillips.
James Tanner...
      1841.

Alfred Strugnall.
John Borer.
John N. Petrie.
James Lailey.....
Richard Collier....
Henry Bowerman.
     1842.

Alfred Greaves.

John Wybrew.
George West..
Daniel Nisbit.
      1843.

Alfred Coventry,
Age.
13
Admit'd
Nov. 2:
13
59
Jan.  7
Jan. 31
April 2
June
July
June 23
Oct. 26
Mar. ]'
Cut.
Dec. 15
 Jan. 18
 Feb. 22
April 11
 July 29
 July 18
Nov.  7
Mar. 20
April 13 May  3 June 21
w
Mar. 10
April 24
June 2
Pept. 8
Aug. 26
Oct.
Dec.
May  1
Burgeon.
G.
Tyrr.

Tyrr.
Tyrr
Tyrr,
Remarks.
South. Oxalate of lime; pain in belly
        next day; on seventh day
        bleeding began, and repeat-
        ed  frequently afterwards.
        Case given at p. 335.
Name and date not known,
  but  is  recorded  iu  the
  Steward's book.
South
Uric acid, and very flat.

Large oblong stone.
Two stones, one ?vij., other

  3>v- 9-i- Sr- xv'  Botn ""*
  acid.
Stone crushed.
                                                      Weight, gij. gr. xv. Nucleus,
                                                        uric acid,  with traces of
                                                        oxalate of lime; the re-
                                                        mainder oxalate of lime.
                                                Mack. Had been  lithotritized  two
                                                        years since,  but no  frag-
ments passed at or after the operation, which was followed by a severe attack of irritative
fever, from which he did not recover for several weeks.  Though much urged, he would
not submit to a second lithotritie operation, on account of the severity of the pain he had
suffered.   In the present operation for lithotomy, the forceps were withdrawn with some
difficulty, containing four seemingly distinct and unequal-sized stones, weighing together
zxi. gr. xiv., of which the largest exceeded the united bulk of the other three.  On careful
examination, these were evidently the fragments of one single stone, which they readily
formed by properly placing, and bad been, doubtless, broken in the lithotritie operation;
the broken surfaces had become coated afresh.   The  stone is uric acid, coated with
phosphates.
                                                 Solly
14
66
12
Geo. Will. Langfoid

James Landon.....

Joseph Bishop......
Henry Tabernacle
 2£

 34

62
34
May 27

June 15
July 29
Sept. 21
Sept. 2,
 1841
June 14
July 28
Aug. 13
Jan. 14
Jan. 24

Jan. 31
Feb.  1
Aug. 23
July  1

June 22
Aug.  5
Oct.
Mar.  3

July  9
Oct.
Sept. 17
Feb.  4
Feb.  4

Mar. 11
Feb. 11
July 22

Aug.  3
Sept. 14
April 3

Aug. 13
Nov.  3
Oct. 29
Mar. 11


Mar. 4

April 15

April 27
Nov. 18
Jan. 9,
 1844
Tyrr.
Tyrr.
Tyrr.
Tyrr
G.
Mack.
Mack.
B.Tr,
B.Tr
Soil)
Stone small, and  consisting
  of triple phosphate.
Nucleus, oxalate nf lime eo.
  vered with uric acid, upon
  which a layer of phosphate
  and carbonate of lime mix-
  ed ;  crust of phosphate of
  lime.
Weight, ?iv. gr. x.; oxalate
  of lime'thickly coated with
  phosphates.

Uric acid.
Stone broken to  pieces, and
  not  analyzed.
Nucleus of  uric acid, next
  layer oxalate of lime; crust,
  uric acid.
Uric acid, with traces of fu-
  sible calculus.
Weight, gr. vj.  Impure oxa-
  late of lime.
Nucleus, oxalate of lime,  »ne
  remainder uric acid mixed
  with a little oxalate of lima.
This patient had been litbotri-
  tized ten times previouil^
                        1CJ1.                            --------       -         ,
and was passing large quantities of triple phosphate at the period of the operation oi
lithotomy, in which two triple phosphate stones were removed.
Died,  [a] Jan. 8,1839.            [J]Oet.5, 
OPERATIONS FOR THE STONE.
375
1843—-continued.

Joseph Burgess.....
     1844.

William Lapworth..

William Evenden...
smaller;  both consisting of uric acid.  Much venous bleeding, which was not checked for
two hours and a half.
William Sparkes..
George Sawyer.
John Snooks...


John Easton...

     1845.

Henry Smith...


Nathan Robins
Age.
Admit'd
Cut.
Cured.
Surgeon.
      Oct. 30 Nov. 14  Dee. 19   .     .     .   Solly Stone pyriform, 1J inches
                                                long, with four small no-
dules at extremities, and weighed gvii. ^'j-  Nucleus of each stone triple phosphate, and
the remainder composed of layers of oxalate of lime.
Remarks.
74
Dec. 5, Jan.
 1843.
Dec. 23,1 Jan.
 1841
6 Feb.  6

8 Mar. 26
Solly
Stone, size of kidney bean ;
  uric acid.
Two  stones, one size  of  a
  walnut,  the other a  third
  47   April 6   .     fo]     .     .     .   [Solly (Extensive ulceration of kid-
     I       |                        I     |     |  neys.  Large nucleus  of
animal matter, seemingly a clot of blood; the stone composed of uric acid and oxalate
of lime.
44
11
July 111 July 27, Nov. 10
Aug. 20 Sept. 161 Oct. 22
Aug. 20
May  6
Sept. 9
Oct.  5
May 30
Dec.  3
July 18
L*J
Mack
Mack.
Mack.
                                              Nucleus, uric acid; remainder
                                                oxalate of lime mixed with
                                                uric acid.
                                              Nucleus, oxalate of lime;
                                                next layer, uric acid, with
traces of fusible calculus covered with oxalate of lime; the orust, fusible calculus and uric
acid mixed. Scarlet fever appeared on the fifth day. After death it was found bis family
were infected when he left home.
South.
Clark.
Weight, gr. xlvii.; consisted
  of urate of ammonia, with
  a trace of urate of lime.
Oxalate of lime.
Died, [a] April 18.
[6J Oct. 20.
   [The analyses of the greater number of the above stones are by Dr. Leeson, and copied from St.
 Thomas's Museum Catalogue.  Those of Lucas, Borer, Wvbrkw, Landon and Snooks are by my friend
 Thomas Tavlor.  I should be much obliged by any St. Thomas's pupil communicating to ine notes of
 any cases of stone which he possesses, of which Ihavebeen unable to obtain particulars: more especially
 of those in the early part of this table, so as to render it more complete.—j. p. s.j

                              [OF  LITHECTASY.
   Lithectasy,  or  Cystectasy, which has been, within the  last few years,
 warmly advocated by Dr: Willis (a), has for its object the removal of
 stones from the  bladder, without division of its neck.   The  operation
 consists in opening the urethra, in the perineum, behind the bulb of  the
 penis, to  the  extent  of a  few lines,  and  then  slowly dilating the mem-
 branous and prostatic portions of  that canal, and the neck  of the bladder.
 How far  this  mode  of treatment will  succeed has yet to  be  tested by
 experience; but I am disposed, with Fergusson, to  believe, that  the
 neck of the bladder would  not be so surely  uninjured by the  dilatation
 as is presumed.

   The original proposer of this method appears to have been John Douglas (b), who
 6eem6 to have been led to it by having noticed the passage of small stones  through
 the fistulous canals, left after  the  operation with the great apparatus, as performed
 by Mariana, and  already mentioned, (p.  571,) and also  by the natural  escape of
 stones through the dilatation  of the short urethra of women.   He, therefore, pro-
posed  the establishment  of a perinseal fistula, so  that, as near as might be, the
opportunity for  the escape of  a  stone  from the male  bladder, should be similar to
that from the female bladder, in both cases requiring  little more than the dilatation
of the neck of the bladder.  He then put the question, " Whether  it be not possible
to dilate the artificial fistula in the perinaeum of males, and the urethra in females
with sponge  or gentian tents, gradually increased for some time  to such a width that

  (a)  On the  Treatment of Stone  in the     (b) Two Chirurgical Questions stated and
Bladder by medical and mechanical means,  answered; in Phil. Transactions vol xxxiv
London, 1842. 8vo.                       p. 318.  1726,27. 
376
LITHECTASY.
we may easily pass a pair of forceps into the bladder, with which the stone, when
small, may be extracted, and when large or of an irregular  figure, broke, and the
pieces extracted  gradually, and at different times, when they  cannot be extracted at
once, without fatiguing the patient too much," (p. 320,) and after discussing the
subject, he concludes:—"Therefore, artificial fistulas in males, and the urethra in
females, may be dilated so as to extract any stone, without cutting the body of the
bladder, or  lacerating any  of the parts." (p. 322.)  It does  not  appear, though
Douglas proposed, that he ever practised  this method, and like many other proposals,
it was lost sight of for many years; still, however, it is his  operation, though Dr.
N. Arnott (c) says, " that the means proposed by Douglas are inadequate " for its
performance; forgetting however to mention that Douglas had honestly  referred to
a case of Collet's (b), in which a perineal  fistula after lithotomy had been success-
fully dilated with  sponge tent, as in Douglas's proposed operation.
   In 1819, however, Collet's plan was suggested and practised by Dr. Arnott (c),
in a case under the care of Astley Cooper, for a recto-vesical  fistula of nine months'
standing, after an unsuccessful operation  for the stone, in which the rectum had been
wounded, and the stone left in the  bladder.   For the relief of this fistula, Astley
Cooper, made an opening into the urethra, from the perinaeum, and introducing a
female catheter, immediately struck a stone.  This not being expected to be large,
Astley Cooper yielded to Arnott's proposal of dilating the  passage from the peri-
naeum into the bladder with his fluid-dilator instead of sponge tent; after the em-
ployment of which,  for thirty hours, the passage from the perinaeum to the bladder
was enlarged to three-quarters of an inch in diameter, and Cooper then  introduced
a pair of stone-forceps, and extracted a stone as large as a moderate-sized walnut.
   Stimulated  by Willis's  enthusiastic  expectations, Elliott of Carlisle (d) per-
formed this  operation in  July, 1842, on a lad of  seventeen, with the variation of
making the wound larger than recommended by Willis.  " The different steps in
the operation were precisely the same as in lithotomy, until the prostate  and mem-
branous part of the urethra were exposed.  The latter was opened close to the pros-
tate, and  divided cautiously  towards the  bulb by  carrying the knife  along the
groove of the staff till an opening was made of sufficient size.   The staff was then
withdrawn, and the point of the forefinger of the left hand served  as a guide for the
introduction of the dilator, which, having been previously well greased, was passed
along without difficulty.  A little warm gum mucilage was next slowly injected
into the intrument, until the patient slightly complained of the feeling of distention.
On removing him from the table to the bed he complained of a strong inclination to
make water, which was found to arise from the dilating part of the instrument having
slipped into the bladder.   It was  emptied, partially withdrawn, and, when fairly
within ihe neck  of the bladder, again distended.  Another  opiate was  given, one
having been given before the operation.   In three hours' time a few teaspoonfuls of
the mucilage were again thrown into the dilator till the patient complained.  The
urine had passed  freely along that  part  of the tube which communiaated with the
bladder."   He went  on well; no further injection was made;  but in  the middle of
the following day he was a little  uneasy, and another  opiate was given.   At the end
of twenty-five hours  Elliott "emptied the dilator  and withdrew it, at the same
time passing his left forefinger along it into  the bladder.   He immediately felt the
stone, which  was of Bmall  size, and  in  shape resembled a coffee bean, but about
four times the size.   It was removed  with the scoop and finger,"  (p. 137,) and a
lithotomy-tube introduced.  In his  remarks on the case, Elliott advises the dilata-
tion " being done at intervals, for, say a  quarter of an hour at a time, as  less likely
to cause irritation than if continued for a period of thirty or forty hours, as has been
mentioned, (p.  139.)
   Dr. Wright, of Alalton, Yorkshire (e), performed the second lithectasy on a man
 of sixty, in the autumn of the same year, and made "an opening a few lines in ex-
 tent into the membranous  paTt of the urethra," but could not introduce the dilator,
 evidently for want of room; attempts were made to enlarge the passage  sufficiently
 with bougies for its admission, but it could be only imperfectly got in, and was left
 without distending it till  three days after, when the injection escaped, the bladder-
 part of the instrument having rotted."   Another instrument  was then passed with
   (a) Lancet, 1842.-43; vol. ii. p. 612.         (.d) Edinburgh Medical und Surgical Jour-
    (b) Traite de la Taille.                 nal, vol. lix. p. 135.
   (c) Essays on the different modes of ex.    (e) London .Medical Gazette, vol- xxxiv. p,
 trading Stone from the Bbddcr, by James  77.  1843-44.
Arnott.  London, 1821.  8vo. 
LITHECTASY.                          377
difficulty, but the patient could  not bear the distention, and during the following
weeks suffered much constitutional excitement.  Not till the eighth day after intro-
ducing the  second instrument could any progress be made with the distention, but
then it went on rapidly, and on the eleventh, "the urethra having been dilated to as
great an  extent as the instrument would allow, an effort was  made to extract the
stone.  It was seized with the lithotomy forceps, but it was discovered  to be too
large to  remove  entire without  using more violence than was thought prudent or
safe."  (p. 79.)  The stone was, therefore, broken up with Fergusson's  lithotrite,
and brought away piece-meal; it weighed a  little short of two ounces troy." (p.
78.)   The  patient did well.  Wright inquires, " Would it not be better to make
the incision in front of or anterior to the bulb, where the canal  is so superficial that
it could be opened by a mere scratch ?  It certainly requires no formidable incision
to reach the membranous portion:  still it must be of some depth, and it occurs to
me as just possible that on  introducing the dilator, its extremity might be carried
past the opening in the urethra into the surrounding cellular tissue.  I imagine the
bulbous portion would be dilated as  easily as the membranons part of the urethra"
(p. 79.)
  In June  1843, Fergusson (a) performed the third lithectasy in a man of sixty-four,
who had suffered very severely, and for five years had been continually passing stones
as large as peas.  The urethra was opened by "an incision along the raphe about
one inch and a half in length, terminating about half an inch  in front of the anus,
from which point two incisions, each about three-fourths of an inch in length, were
carried downwards and outwards.   The superficial cellular tissue  being divided to
a similar extent, the point of a knife (a common lithotomy bistoury) was thrust into
the groove of the staff a  little in front of the triangular ligament.   The edge of the
blade was  so applied as to divide  the triangular ligament to  a slight extent, first
downwards and outwards on one side, and then in a similar way on  the other; the
groove of the staff being then distinctly felt by the forefinger  of the left hand, the
metal  point of an Arnott's dilator was placed within it, and slid cautiously into the
bladder.  The staff was  next withdrawn, and the bag of the  dilator was partially
distended with a  solution of gum arabic, the distention having been continued until
the  patient complained of pain."   Additional quantities of fluid  were repeatedly
thrown in  for the first two hours;  again, at the third, and at the end  of the fourth,
the instrument being fully distended, was withdrawn, and another larger one having
a passage through it for the escape of the urine, was introduced.  At the ninth hour,
a larger instrument was passed, and directed to be distended as the patient could bear
it.   At the twentieth hour, this dilator, an inch and a quarter in diameter, having been
fully distended, was removed, and the stone attempted to be removed with the scoop
several times unsuccessfully, as it  brought away only fragments.  Forceps were
also used, but the stone was too large to pass, and was therefore broken by forcibly
closing the blades; the  pieces were readily removed.  Constitutional excitement,
however, came on, and he  died on the evening of the sixth day.  On examination,
the principal circumstance was that " the cellular tissue between the bladder and rec-
tum, and that lying on the outer surface of the gut was softened, and slightly infiltrated
with a sero-purulent fluid." (p. 576.)  It would seem from Fergusson's observa-
tions, that he thought the distention had been made too quickly; for he says:—
" Unless the dilating process were effected  in  a much slower manner than was
recommended for lithectasy, he feared that the mucous membrane and urethra would
not  only be dilated, but actually torn." (p. 577.)  And further, that " it was one of
the main objects in lithectasy to avoid any wound of the neck of the bladder; but
he doubted if this could  be avoided, and a certain amount of  inflammation might,
therefore, be calculated upon."  *  *  *  On any future occasion, he should suggest
that a longer period should  be expended in using the dilator, and also  that the event
of the stone proving too large for ready removal, the lithotrite should at once be used.
* *  * It was his opinion that in such an operation there would always  be greater
difficulty in extracting a  stone of any considerable size than in lithotomy; for in the
latter case the wound extended down alongside of the anus, and the forceps holding
the  stone could be more readily depressed, whilst in  the  former, (lithectasy,) the
manoeuvres were conducted near the angle of the pubes, and consequently in the nar-
rowest part of the space  between the bones, a space which  the experienced lithoto-
mist was always careful to avoid."  (p. 578.)
               (a)  London Medical Gazette, vol. xxxiv. p. 77.  1843-44. 
[   378   ]
FIFTH   DIVISION.
OF  DISEASES  WHICH  CONSIST  IN THE  DEGENERATION
  OF  ORGANIC PARTS, OR IN THE PRODUCTION OF  NEW
  STRUCTURES.
  Astruc, J., M. D.,  Traite des Tumeurs et Ulceres;  avec  deux Lettres, &c.
Paris, 1759.  2 vols.  12mo.
  Plenck, J. J., Novum Systema Tumorum, quo hi Morbi in sua genera et species
rediguntur.  Viennae, 1767.   12mo.
  Dumas, Sur les Transformations des Organes; in Sedillot's Journal de Medecine,
vol. xxiii.-xxv.
  Abernethy, John, An Attempt to form a Classification of Tumours according to
their Anatomical Structure;  in his Surgical Works, vol. ii. Second Edition.  Lon-
don, 1816.
  Laennec, Note sur 1'Anatomie Pathologique ;  in Corvisart, Leroux et Boyer's
Journal de Medecine, vol. ix. p. 360, an xm.  And Article Jinatomie Pathologique;
in Diet, des Sciences Medicales, vol. ii. p. 46.
  Cruvelhier, Essaies sur 1'Anatomie Pathologique en general et sur les Trans-
formations et Productions Organiques en particulier.  2 vols.  Paris, 1816.
  Meckel, Handbuch der Pathologischen Anatomie, vol. ii. part ii. p. 111.
  Baron, J., M. D., An Inquiry Illustrating the NatHre of Tuberculated Secretions
of Serous  Membranes, and  the origin of Tubercles  and Tumours in the different
textures of the body.   London, 1819.
  Caspar, Zur Lehre von den Afterorganisationen; in Horn's Archiv. fur Medicin-
ische Erfahrung, vol. ii. p. 385.  1821.
  Heusinger, C. F., System der Histologic, vol. i. part i. ii.   Eisenach. 1822-23.
4to.
  von \\Lalther, Ueber Verhartung, Scirrhus, harten und weichen Krebs, Medullar-
Sarcom, Blutschwamra, Teleangiektasie und Aneurysma per anastomosin; in Journal
fur Chirurgie und Augenheilkunde, vol. v. part iii.
  Lawrence, William, Observations on Tumours, with Cases; in Med.-Chir.
Trans., vol. xvii. p. 1.  1832.
  Warren, J. C, Surgical Observations on Tumours.  Boston, 1837.  8vo.
  Ritgen, Ueber Afterbildungen; in von Walther's Journal,  vol. xi.
  Muller, J., Ueber den feineren Bau und die Formen der krankhaften Geschwulste.
Berlin, 1836.  fol.
  Vogel, J-, Icones Histologiae Pathologicae.  Lips., 1843.
  —'■------; in R. Wtagner's HandwOrterbuch der Physiologie mit Rucksicht auf
physiologische Pathologie, Art. Gewebe (in pathologisoher Hinsicht.)

   2147.  The two classes of disease to be considered in the  present sec-
tion,,to wit, the degeneration of organic parts and the production of new
structures, agree together so far as a general character of the degeneration
of organic parts, is,  that the enlargement of the surrounding parts depends
not  merely on  the  increased deposits into them of the matters  forming
them in their natural state,  but that in the parenchyma of the part, more
or less, of such matter foreign to their natural structure, is produced and 
DISEASED CHANGES OF STRUCTURE.
379
deposited; hence is it often very difficult to determine, whether  a dis-
eased structure is to be attributed to the change of the organ, or to  a new
formation.
  [Lawrence has well  observed:—»" It is  not easy to draw a clear distinction
between new or accidental prpductions and changes of structure, or degenerations of
organs.  There is no definite boundary between them;  on the contrary, as in other
diseases, there is an insensible transition from one to the other.  In the  case of
Fungus haematodes, we find the same structure sometimes occurring as a new pro-
duction, an independent tumour; sometimes as a change of structure in  a part.
Indeed, we meet with this growth in three distinct forms; viz., as a deposit enclosed
in a cyst, as an unencysted formation, and as an infiltration in the substance of an
organ.  Again, we find a similar gradual transition between the structures composing
various kinds of tumour, so that We often hesitate  in deciding to which species a
particular swelling should be referred.  As the same gradual blending of one form
into another occurs throughout the whole field of disease, we cannot wonder  that the
several attempts at reducing its infinitely diversified  phenomena to an artificial
arrangement of classes, orders, genera, species and varieties should have failed.'7
(P- 4-)]
  2148. All degenerations of organic parts  appear to have their origin
in a local increased vascular activity, on which depends the deposit of a
substance more or less resembling the  elementary parts of the  organ, or
of a  peculiar substance, in  the interstices of the part, in which  by  the
shooting forth of  the Vessels, and their very  extensive ramifications,  the
unnatural formative disposition is sustained, and the growth of the tumour
increased.  We find, therefore, also in  most cases, that although there
be no characteristic signs of  inflammation, yet that increase of tempera-
ture, peculiar sensibility on  pressure, tension, and  the like  accompany
the beginning of degeneration.  In  most cases, the increase of vascular
activity  is not to be distinguished  by the  symptoms which characterize
it; for little as we can comprehend  the natural growth and development
of organs without increased activity of the vital processes, just so little
 can we  understand it in diseased  structures.   Development of vessels,
 diseased secretion, continued production of the secreted  matter, with
 growth  of vessels in it  are  the processes, in which the course of these
 diseased formations are constantly repealed.   The unnatural commixture
 and condition of the juices, and the large quantity of inorganizable matter
 may indeed effect the separation of peculiar substances, distend, increase,
 and change the tissue of different organs ; but special degeneration with
 self-active production, proceeds only with  increased development,  and
 multiplication of vessels.  Secreted inorganizable matter remains either
 in that state, or hardens, and then first  operates on the surrounding parts,
 but  always remains without vascular connexions, and is destroyed  in a
 purely chemical manner, as the history of the formation of tubercles shows,
 although even  they may be converted from the formless condition  into
 cells.
   2149.  In  the diseased changes of organic parts,  either the vessels,
 arteries, capillaries or veins, often the one more than the other, are  spe-
 cially developed, or the uninjected part of the cellular tissue is specially
 prevalent by the deposit of formless matter, or both exist at the same time
 in different proportions.  If these  conversions depend only on quantita-
 tively changed  nourishment, they can increase to  an enormous  extent,
 without otherwise  than mechanically  operating destructively; they sup-
 port themselves like the natural tissues, and participate in the  general 
380
PRODUCTION OF NEW STRUCTURES.
change of matter.  But if there be at the same time a qualitative change
of the nutritive matter, if they depend on general diathesis, and alteration
of the formative disposition, they have a specific  character, are  accom-
panied with reaction of  the whole organism, and  draw all the tissues
without distinction of their  organization, into the same diseased  change;
they cannot retain their development  unchanged  in the highest degree,
but  according to  their  nature are  destroyed and  pass  into softening.
Hence arises the division into benignant and malignant tumours.
   2150.  The after-products, which  must be considered as new forma-
tions, are either repetitions of natural  formations,  as  the adipose and
encysted tumours, and the like;  or they are formed from  substances
foreign to  the  natural composition  of  organic  parts,  as, for example,
medullary fungus.   They  are vegetative  formations, which simply by
their further  growth, compress  the  neighbouring  parts, do not  convert
them into the same mass, for  instance,  adipose tumours, cysts, polyps,
and  the like ;  they are  inconvenient, therefore, only by their  size.   But
others possess the above-described specific characters, consequently have
a fatal reaction  on the whole body,  and  draw the  neighbouring tissues
into the same diseased change.
  Diseased growths are subject to the same general laws as are  the origin and
development of the natural  tissues.  According to the results of microscopic ob-
servation,  two theories have been put forth on this subject, to wit, the cellular theory
and  the corpuscular theory.
  According to the cellular theory, there is every where at first a simple formative
matter, cyloblastema, in which are formed nuclear cells, cytoblasts, and in them cells
are produced;  or  the nuclear cell is formed  first, and the cell walls are formed
secondarily around it.  In many cells the pathologic tissue is perfected with  the
complete development of  the cell.  In general these  first-formed (primary) cells
undergo still further changes, and from them are produced elementary parts, which
exhibit no more of the original cellular form.  It is usually then the cell-walls which
pass into  the remaining parts of the organism, more rarely do the nuclear cells
undergo a still further development, and still more rarely do organic pathologic
tissues arise, the development of which can never be traced to a cellular formation.
It is highly probable that the nature of the subsequently produced tissue does not
depend on the nature of the cytoblast, but upon the subsequent accession of external
influences.
  According to the corpuscular theory, the  formative corpuscles are produced in the
plastic matter  by  clotting together.  In the  midst of this matter, consisting of
granules and formless matter, a  formative corpuscle arises, and a nucleus, composed
of a homogeneous tough matter, which continues increasing, so that at last there
remains only a thin peripheric layer, which also becomes changed.   In this nucleus
a great quantity of molecular corpuscles are formed.  The corpuscle then drops in
on either side, and the middle protrudes, so that it resembles a knife-like body, and
passes into the form of haematoids, or ring-shaped bodies, a nucleus with a ring.  Of
the formative  as well of the haematoid bodies, one part lies unconnected with  the
rest  and moveable; this is the blood corpuscle; the other part is connected by con-
tiguous linear  ranks, by layers  of plates  and heaps of corpuscles, and forms  the
tissue (a).
   2151.  The tumours produced by those  unnatural formations, which
are  not to be considered as repetitions of natural parts, belong to the most
difficult subjects of the healing art; they may be considered in reference
to their origin, their further  development, or to their manifold differences,


  (a) Vogel, above cited.—Baumgaertner Lehre von den Gegensatzen in den Kraften irn
leben den thierischcm Koper cin Grundriss zur Physiologie und allgem. Pathologie  und
Therapie.  p. 32. Stuttgardt, 1842. Second Edition.—Arnold holds the same views as
Baumgaertner. 
KINDS OF TUMOURS.
381
for the purpose of grounding thereon their classification.   In former times
the various  swellings  of  this kind were spoken of under the general
designations, scirrhus, carcinoma, sieatoma, and the rest.  More careful
inquiry has,  however, recently showed remarkable  differences in the
nature of the diseasedly-produced substances which form these tumours,
and upon these it has been attempted to class them.
  2152. Abernethy points  out five peculiar kinds of tumours, to wit,
the pancreatic, mammary, pulpy or medullary, tuberculated and carcino-
matous Sarcoma.   Laennec admits  a  fourfold variety of the tissue in
which these tumours are formed, namely, the tuberculous, scirrhous, cere-
briform, and melanosis.  Meckel considering Laennec's melanosis the
same as Abernethy's tuberculated  and medullary sarcoma, points out
six different tissues,  the  pancreatic, the mammilloid, the cerebriform ot
medullary, the scirrhous, and the tuberculous or scrofulous.
  2153. John MTiller (a)  has very recently endeavoured, from micro-
scopico-chemical observations, to found  a division of tumours, according
to their chemical nature, their  microscopic  structure, and  the  manner of
their  development.   In reference  to  their  chemical composition,  all
 tumours are, according to  the elementary parts of which they consist,
 either fatty  tumours,  jelly-yielding {b), or albuminous  tumours;  other
substances,  as osmazome, saliva,  caseine, and so forth,  may indeed be
present in them, but only in small quantity proportionally to the principal
 elementary parts.
   The more minute microscopic elements  of tumours are, besides capil-
 lary vessels, fibres, granules,  cells without  and with nuclei,  tailed or
 spindle-shaped corpuscles, vessels, and by far the most common element
 is cells.
   The principle of dividing tumours into groups can be obtained neither
 merely from  their minute structure nor their chemical nature; for tumours
 the most differing in reference to their physiological nature and curability,
 may equally possess the  most delicate  structure ;  in  similar  structures
 chemical differences may exist; With similar chemical nature, there may
 be  difference of structure, or difference  in respect of physiological pecu-
 liarities and  curability.  In the formation of groups these several points
 must be taken into consideration.
   2154.  These various opinions serve to prove how difficult it is to make
 an  accurate and sufficient division of tumours dependent on their un-
 natural structure.   The ground of this difficulty rests, without doubt, on
 the manifold  changes to which the diseased matter  is  subject  in the
 yarious periods of the development of the tumour; further, on the undis*
 tinguishable influence which the natural structure of an organ has upon
 the after-formation developed  in  it, and on the variety  of Causes  upon
 which it depends.   There are, therefore, tumours, in which are present,
 at the same time, several of these diseased products, either lying near to,
 or  intimately connected with each  other.  But if pathological  anatomy
be  of direct use and immediate application to practical medicine, it must
not rest on the mere examination df the changes of organic parts and of
                            (a) Above cited.
  (b) This is a well-chosen designation, as their soft and  solid parts contain the ma-
 it is shown by  Thknard' that "gelatin does torials proper to its production."  Traite de
 not exist in the  humdurs" df animals ; but all Chimie, vol; iv. p. 379.  1827.  Fifth Edition.
   Vol. hi.—33                ^ 
382             ENLARGEMENT OF THE  TONGUE.
the substances forming the tumour, and assume these alone as the ground
of division ; but it must at the same time consider the symptoms, course,
and effect upon the immediate neighbourhood, and the whole body, if it
would not be seduced, by incorrect particulars, into subdividing similar
diseased conditions.   Under this  supposition, the number of  tumours
founded on the above-mentioned variety of diseased tissue, may be con-
veniently  referred  to  three, namely, medullary fungus, scirrhus,  and
tubercle, in  which case the pancreatic and mammary tissues are  to be
considered merely as accidental modifications of the medullary (a).
   2155. These unnatural structures, completely foreign  to the natural
composition of the organism, may agree in general with each  other; they
consist, probably, or for the most part, of albumen, their  tissue  is more
or less distinctly cellular; they contain a fluid of various consistence, and
enclosed in differently-shaped cells ;  at first they are harder than in the
subsequent periods of their development, and then are for the most part
harder than the organs  in which they are  met with, in which case they
soften, and  are  converted into a fluid, or into a substance of looser tex-
ture.   Their form is for the most part more or less round; they strive to
destroy the  neighbouring parts, and the organism which  are  drawn into
the same diseased  structure,  or  displaced  by  pressure,  and further
propagate the diseased affection  by the lymphatic vessels, and  perhaps
also in other ways.
             L—OF ENLARGEMENT OF THE TONGUE.

(Prolapsus Linguae, Macroglossa, Lat.; Vorfall der Zunge, Germ.; Hypertrophic de
                            la Langue, Fr.)
  Clanny, W. R., M.D.; in Edinburgh Medical and Surgical Journal, vol. i. p.
317.   1805.
  von Siebold, C, Beobachtung iiber die Verkiirzung widematurlich zu grosser
Zunge; in Chiron, vol. i. p. 651.
  Klein, Beobachtung einer durch Abschneidung abgekiirzten verlangerten Zunge;
in Chiron, vol. i. p. 665.
  Percy, Article Langue (Pathologie Chirurgicale); in Diet,  des Sciences Medi-
cales, vol. xvii. p. 244.
  Mirault; in Memoires de la Societe de Medecine de Montpellier, 1816, partiv.
p. 517.
  van Doeveren, H. H., Dissert, de Macroglossa, seu Linguae enormitate.  Lugd.
Batav., 1824;  cum tabulis duobus.  8vo.
  2156.  If the tongue  increase very much in bulk it protrudes over the
jaw, and can only be brought back into ihe mouth with difficulty, or not
at all.  This evil is generally  congenital; but  the  enlargement of the
tongue is not at  first considerable.   Its fore part appears  only between
the lips, it projects in a mass'as it enlarges over the lower lip and jaw,
and  causes great deformity.  By the hanging down of the fore part of the
tongue the swelling becomes larger,  the tongue-bone and larynx are
drawn forwards; there is great difficulty in swallowing, the spittle flows
out, and from the constant dryness of the throat, swallowing becomes still
more  difficult.   The articulation of the voice is greatly hindered; and
when  the disease has long continued, the muscles of the tongue are in a
(a) WaI/Cher, above cited- 
TREATMENT OF ENLARGEMENT OF THE TONGUE.
383
palsied state.  By the continued position of the tongue between the jaws
the circulation is stopped in the protruded  part, the tongue swells more
considerably, and presses the teeth and the alveolar process of the lower
jaw outwards;  by the constant rubbing of the tongue indentations and
excoriations are produced; the constant exposure of the protruded part
to the air causes clefts and chinks, and often deep ulcerations; and the
papille become unnaturally thick and prominent.
   2157. The enlargement of the tongue takes places either a shorter  or
a longer time after birth, or after cutting the second set of teeth, and is fre-
quently preceded by convulsions, and its cause seems to be palsy of the
muscles of the tongue.   In such cases  the incisive and cuspid teeth are
not pushed forwards, bnt are rendered  useless, and fall out by the con-
stant rubbing of the tongue (a).
  The enlargement of the tongue above mentioned must be distinguished from that
protrusion which depends on inflammatory swelling, and from  tumours of various
kinds developed in the tongue.
   2158. The congenital lengthening o/the  tongue is of no great conse-
quence; it is easily relieved if recent,  and  not incurable  even when  it
have existed longer.   The above-described symptoms accompanying this
complaint  when severe, especially its ill effects on nutrition, partly  in
regard to the difficulty of swallowing, and partly on account of the con-
tinued loss of the saliva, render its early treatment necessary.
   2159. The treatment  varies according as the disease  is congenital,  or
as it has occurred after  birth ;  and in  the former  case, with reference  to
the length  of time it has existed.   Soon after birth it is generally sufficient
to prevent the complaint increasing, to irritate that part of  the tongue
protruded between the lips with acrid powders, as pepper and the like,  in
order to induce the child to draw it back.  If it be necessary to keep the
tongue in the mouth, a bandage must be applied to keep the lower against
the upper  jaw.   As  the enlargement of the tongue  is encouraged by
sucking, a wet-nurse must be chosen whose nipple is large and long, so
that the tongue  may require less  lengthening  as the  child sucks than
with  a short nipple, or the child must be fed with a pap-boat.  In the
interval, when the child  is not sucking, it must be endeavoured  to prevent
the protrusion of the  tongue by the means already directed.
   [Clanny (b) mentions the case of a boy five years old, on whom the tongue had
begun to protrude within the first year, and at the former age had  projected three
inches; but  was returned with difficulty, and the jaws kept together, as recom-
mended by  Lassus (c).  The tongue was  replaced  in  the mouth  with much
difficulty, and retained by keeping the jaws perfectly closed with a handkerchief
passed round them, and over the crown of the head, for the period of five weeks.]
  2160. If the enlargement of the tongue be so considerable that it can-
not at once be brought  back into the  mouth, its size  may often be gra-
dually diminished by repeated application of astringent irritating remedies.
Scarifications and leeches  may, with  this view,  be useful, as  well as
moderate and gradually increasing  pressure, by means of a roller  or  a
little bag of linen.   This compression of the tongue, in which the bandage

  (a) Boyer, Traite des Maladies Chirurgi-   (c) Mem. de l'lnstit. National, vol. i. n.  1
cales et des Operations qui leur conviennent, an vi.; and in Medical and Physical Journal
vol. vi. p. 385.                        vol. vup. 353.  1801.
  (b) Above cited, p. 3.17. 
384        TREATMENT OF ENLARGEMENT OF THE TONGUE.


must be frequently moistened with a  stringent, and the  patient  kept on
his back, is advantageous, if properly persevered in, oftentimes in very
far advanced cases.  When  the tongue has  been so  far  reduced that it
can be brought back into the mouth, the  jaws must be  kept constantly
closed by  means  of a bandage.   If the surface of the tongue be dry^it
must be moistened by frequent washing and  fomentation (c).
   2161. When the enlargement of the tongue is so considerable that no
benefit is  attained by the above  treatment, and  when by the long con-
tinuance of the disease its fore part is changed in structure, there  remains
nothing but shortening itc length with the  knife or with a ligature.
   2162. The patient, seated on a chair, must have  his head fixed by an
assistant  standing  behind him, and his mouth  kept open either with a
cork  inserted  between his  back teeth, or by means of a speculum  oris.
The patient then  protrudes  and retracts his  tongue, so that the operator
may decide how  much shall be removed.   The tongue being protruded,
is held by an  assistant obliquely upwards with a pair ofpolypus or curved
oesophagus forceps.   The.operator then grasps the front of the tongue with
his fingers, or fixes it with a  hook; and with a strong bistoury cuts off some
lines of the tongue in  a semilunar shape, at a stroke.  The forceps serve
as  a  tourniquet,  and the  bleeding is  stanched either  by ligature, by the
actual cautery, or by pressure and styptics.
  Where the state of  the tongue permits, it is best, according to Percy (b), to cut
out, by the  strokes  of the knife, a j\ shaped piece, with its point backwards, and
after  stanching the bleeding to bring the wound together with the  interrupted
suture.  If, after the operation, the lower incisive teeth project considerably, attempts
must be made, by continued  pressure, to put them back; and if this should be un-
successful, they must be drawn.  If the lower  lip  continue everted and much out-
spread, so that the spittle cannot be retained, a triangular piece must be cut out as
in the operation for cancer of the lip, and the wound healed  by the twisted suture
(Mirault.)   The application of a ligature for the removal of part of the tongue, in
which the ligature is at once  tied round it, or for the purpose of hastening its cutting
through, a double thread is passed with a needle into the tongue, and the ends tied
on each side, and gradually tightened, till the tied part dies, is attended with greater
pain, and is more tedious than cutting it off with the knife,  but is more safe against
bleeding.
   [Harris  (c) of Philadelphia  tried to remove a  portion  of enlarged tongue, by
introducing with a needle a double iron wire through the middle of the tongue, and
having separated the  two portions of wire, he brought them across the tongue,
passed the two ends of each through a corresponding double canula on each side,
and then twisted them ;  the  circulation ceased, but only for two hours.  He then
passed a strong silk ligature, and fastened  it in the same way; but in forty-eight
hours the circulation had returned.  He therefore amputated the tongue with a catlin,
through the track made by the ligature; the two principal arteries were tied at once,
and other three, which had been allowed to bleed,  to diminish the irritation caused
by the previous ligatures, were taken up afterwards.  The wound was dressed with
dry lint, and the patient recovered perfectly, with the  exception of a slight lisp in
her speech.   Harris, therefore, strongly recommends amputation, in preference to
the ligature.]
   2163. The protrusion of the  tongue  dependent on  paralysis of its
muscles, requires, besides the constant retraction of the tongue, blisters
behind the ears,  and on the neck, the application of irritants, of electri-
city,  galvanism, and the  like.


  (st) Bo.yeR;, above eitcd^ p., 387.,             (c)  American Journal of Medical Sciences,
  \h) AboxQ cUeoY                       vol. vii.. p. 1.  1830, and vol. xx. p. 17.  1837. 
BRONCHOCELE.
385-
                       II.—OF BRONCHOCELE.

            (Bronchocele, Struma, Lat.;  Kropf, Germ.; Goitre, Fr.)
  Haller, De Strumes; in Opusc. Pathol., p. 16.
  White, Thomas, A Treatise on Struma or  Scrofula.  London, 1784.  8vp.
  Ackermann, J. F., Ueber die Cretinen eine besondere Menschenabart  in den
Alpen.  Gotha, 1790.
  Fodere, Traite du Goitre et du Cretinisme, &c.   Paris, an vm.  8vo.
  Wichmann's Ideen zur Diagnostik, vol. i. p. 99.
  Gautieri, Tyroliensium, Corynthiorum Styriprumque Struma.  Viennae,  1794.
  Wenzel, J. and K., Ueber den Cretinismus.  Wien, 1800.
  Maas, Dissert, de Glandula Thyreoidea tam sana, quam morbosa, eademque im-
primis Strumosa.   Wirceb., 1810.
  Hausleutner, Ueber  Erkenntniss, Natur und Heilung des Kropfes; in Horn's
Archiv., vol. xiii.  1813.
  von Walther, P., Neue Heilart des Kropfes, u. s. w.  Sulzbach, 1817.
  Burns, Allan, Observations on the  Surgical Anatomy of the Head and Neck.
Glasgow, 1811.  8vo.
  Huhlibach, Der Kropf nach seiner Ursache, Verhiitung und  Heilung.  Wien,
1822.
  Hedenus,  Tractatus de Glandula Thyreoidea. tam  sana, quam morbosa, imprimis
de Struma, ejusque causis et medela.  Lipsiae, 1822.
  Prosser, Thomas, An Account and Method of Cure of the Bronchocele or Derby
Neck.  London, 1771.   8vo.
  Wilmer,  B., Cases and Observations in Surgery, with a Method of curing Bron-
chocele in Coventry.  London, 1779.  8vo.
  Barton, B. Smith, M.D., A Memoir concerning the Disease called Goitre,  as it
prevails in different parts'of North America.  Philadelphia, 1800.  8vo.
  Holbrook, James, Practical Observations on Hydrocele; also on Bronchocele,&c,
London, 1825.  8vo.
  M'Clellan, Inquiry into the Nature  and Causes  of Goitre, from a work on the
Geology of Kemaon, Calcutta, 1835; and republished in Dublin Journal of Medical
Science, vol. xi. p. 295.   1837.
  Inglis, James, M.D., A Treatise on English Bronchocele, with a few Remarks
on the Use of Iodine and its Compounds.   London,  1838.   8vo.
  Copland, James,  M.D., Article Bronchocele,- in his Dictionary of Practical Medi-
cine, vol. i. p. 269.
   [Gibson, W., Remarks on Bronchocele, in Philadelphia Journal  of the
Med. Sci., vol i.   1820.—g.w. n.]

   2164.  Bronchocele is a  chronic,  painless, more  quickly  or slowly
arising swelling on the fore  and under  part of the  neck, depending on
enlargement of the thyroid gland, and varying considerably in  reference
to its extent, form, and hardness.  The swelling begins  in one or other
lobe, or affects  the whole gland, and may attain an enormous  size; in
most cases  it has a pendulous shape.   At first the skin is unchanged; as
the growth increases, the veins in the neck and on the tumour swell  and
become varicose.  If continuing still longer, the swelling usually feels
elastic, soft, and regular;  but after a further time, becomes firmer,  and
in some parts quite hard  and uneven.   Sometimes the  swelling is so
firmly connected with the neighbouring  parts,  that it is little or  not at all
moveable.   If left alone, the bronchocele continues increasing; but in
rare cases runs on to inflammation or  suppuration, by which it diminishes,
or entirely disappears.
  By the above description of bronchocele, its distinction into  true and false, by
which latter term various swellings in other parts of the neck have been described,
is got rid of.
                                 33*
» 
386         KINDS  OF  BRONCHOCELE ;  TREATMENT.
  2165. So  long as the bronchocele is not large, it causes little or no
inconvenience; but with its increasing size, the voice gradually becomes
hoarser, the  swallowing and breathing difficult, and there are severe fits
of coughing.  These symptoms increase in correspondence with the
greater enlargement of the swelling, till there is danger of suffocation;
in consequence of the obstructed circulation in  the vessels of the neck,
the blood collects in the vessels of the head ; the face becomes puffy and
bluish, the patient complains of  headach, and apoplectic symptoms may
ensue.  Owing to the disturbed breathing, and thejess expansion of the
chest, the circulation through the  lungs is  interfered with, the obstacle
which the arteries  suffer  to  the impulse  of blood  given by  the heart
is increased, the  cavities of the heart expand, and their walls thin; and
hence arises the frequent enlargement  of the  heart observed in  bron-
chocele (a).
  2166. Various kinds of bronchocele must  be distinguished according
to the variety of degeneration of the thyroid gland, which  accompany
its enlargement,  namely, the  vascular^ the lymphatic, and the scirrhous
bronchocele.  The designation of  an  inflammatory swelling of the thy-
roid  gland,  {Cynanche thyreoidea,) as  inflammatory  bronchocele,  is im-
proper.
  Inflammation of the thyroid gland, which may be caused by cold external violence,
and the like, produces, on account of  its quickly-arising swelling, considerable dif-
ficulty in breathing and swallowing, determination to the head, rushing in the ears,
disposition to  bleeding from  the nose, and the  like, and is usually accompanied
with fever.  If it run on to suppuration, the abscess does not protrude much, and
the collection of pus, with increase of the above inconveniences, may become very
considerable.
  The treatment of  inflamed  thyroid gland requires blood-letting, leeches in great
number on the sides of the neck, calomel, and  the like.  If an abscess form, it must
be opened as soon as the presence of pus is ascertained.
  2167. In  Vascular  or Aneurysmatic  Bronchocele {Struma  vasculosa,
aneurysmatica)  the  vessels of the thyroid gland, arteries,  veins, and
capillary vessels, which, with cellular tissue,  make up the greater part of
its parenchyma, become considerably enlarged.  The kind of broncho-
cele  is characterized  by its  sudden  origin, its quick growth,  and large
size.   The swelling is warm, firm, and tense; the patient feels in it a
violent beating, sometimes a roaring.   If the hand be applied, the beating
of the arteries is  felt at some one part of its  external surface,  but espe-
cially in the  course  of the large arteries in the substance of the gland;
even  the superficial twigs and branches are  so much enlarged that they
are seen through the general coverings, and  their pulsation is  distinctly
perceptible.  The  superior thyroideal artery, before  it  enters the sub-
stance of  the gland, is felt beating violently, if  the gland be not so very
much enlarged that it cover this artery and spread over it with its upper
outer lobe.   Vascular bronchocele produces, earlier than any other, dif-
ficulty of  breathing and swallowing, frequent bleeding from  the  nose,
dizziness, and  determination to the head; it constantly increases.
  2168. Lymphatic Bronchocele (Struma lymphatica) is of  most frequent
occurrence, and  in many places endemic.  The cells in the parenchyma
of the thyroid gland become filled with a clammy transparent fluid, some-

   tfl) Lullier.—Winslow ; in Journal general'de Medecine, vol. Ivii. p. 414. 1816. 
VASCULAR AND LYMPHATIC  BRONCHOCELE.        387
times with a viscid, brown mucous substance, sometimes with a lardy or
cheesy mass,  and  sometimes with  concretions  and bony knob's.  The
walls of these cells  thicken, often exceedingly, even to a  cartilaginous
consistence, become united with  the masses collected  in  them,  so that
the cells are more  or less  completely destroyed, and the whole gland is
converted  into a shapeless mass.   The vessels may, indeed, here also
be enlarged, though not to the same degree as in  vascular  bronchocele.
Lymphatic bronchocele increases  more gradually, and feels more knobby.

  From this general sketch  lymphatic bronchocele exhibits itself under as many
forms, in reference to its external appearance, as it can present.  Sometimes it shows
a perfectly homogeneous, tolerable firm  substance, without any yielding  part,  and
resembles a sarcomatous degeneration.  Sometimes its surface  is irregular, several
large knots are produced, hard, in several parts  cartilaginous or bony.  Sometimes
particular cells enlarge, so that the greater part of the bronchocele consists of one or
several cysts, the walls of which are more or less thickened and filled with fluid of
different colour and consistence.
  This form of bronchocele was known to the  ancients, (Celsus,) was described
by Albucasis as Bronchocele aquosa, was variously noticed by Helwig, Heister,
and  Ploucquet, and has been fully described by Maunoir (a) as Hydrocele Colli.
Percy would have it named Hydro-Bronchocele, and Beck (b) has  described it as
Struma cystica.
  The  swelling developes itself  on the fore  part of the neck, on one or other side,
sometimes on both at once, in which  case there are often  two  lobes, with a consi-
derable depression in the mesial line.   It generally affords distinct fluctuation at
every part, is opaque, but sometimes so transparent that the cysts and fluid contained
in the deep-lying blood-vessels can be distinguished through the coverings (Pelle-
tan.)   Its  size is very various, and it may become so large that the breathing may
be rendered very difficult or completely stopped.  Its cavities are frequently divided
by a partition which  is open at some one  part, so that the two sides  of the swelling
communicate with each  other.  The  cysts,  which are almost always very thick,
resistant, and little contractile, usually contain a brownish-coloured fluid;  the other
parts are very different.
  Opinions vary as to the actual seat of the swelling.  Some say it  is developed at
the expense of the thyroid gland; others in  the tissue surrounding the  gland, in
which case  the gland, pressed back towards the  windpipe, becomes atrophic, and is
more or less surrounded with a false membrane, and the cyst is placed at its hinder
upper part.   If the swelling  be developed in the gland itself, there are very rarely
 found any  traces of  its parenchyma, the  vessels alone remain, and  are filled with
fluid which has usually the colour of  wine lees.  That the thyroid gland  usually
remains sound in this disease, as has  been also supposed,  appears without founda-
 tion; and according to the above-described, ordinary relations of the gland, its de-
 termination as a peculiar kind of lymphatic bronchocele is legitimate.  It is charac-
 terized by  its egg-shaped or globe-like form,  without  knobby elevations, by the
 elastic tension of the most  projecting part  of  the swelling, by the bulging of its
 contents in different  directions on the  application of pressure which is not painful,
 by its more or less  distinct  fluctuation, and its transparency when  present.   The
 beating of the arteries is less distinct, and if present, as  Dupuytren has noticed in
 one case, there is a motion and heaving of the swelling by the communicated pulsa-
 tion, and not depending on its expansion  and contraction  (Pigne.)
   [Under  the one term, lymphatic bronchocele, Chelius here includes two decidedly
different diseases; first, cysts in the substance of the gland, which he has described
in the principal clause of the paragraph, may fairly retain the name; and,  secondly,
 serous  cysts in the neck, which are called  by  Maunoir, Hydrocele du Cou, but in
reality  are  only cysts developed in the cellular  tissue, and  have nothing to do with
the  thyroid gland, except spreading over it as over the other parts in the neck; they
will be again noticed in treating of Encysted Tumours,  (p. 695.)—j. f. s.]

               (a) Memoires sur les Amputations, p. 93.  Geneve, 1825.
               (6) Ueber den Kropf.  Freiburg, 1833. 
388
SCIRRHOUS BRONCHOCELE.
  2169. In Scirrhous Bronchocele {Struma scirrhosa) the  thyroid  gland
is less enlarged, but unusually hard, knobby, and irregular; the neigh-
bouring cellular tissue wastes; from the very first the pain is violent and
gnawing, and spreads up the neck; breathing and  swallowing are very
difficult, the one more  than the  other however, according to the part of
the gland  diseased.   The scirrhous mass very soon adheres to the air-
tube and to the muscles of the neck, and in  the last stages the coverings
become wrinkled and  in  folds.  A sanious fluid often  collects in the
cells, immediately beneath the surface;  the mass of the swelling presses
backwards, by which the inconveniences  .are very much  increased.  At
last it is converted into a carcinoma  and a *rue  cancerous ulcer, with
which the  neighbouring glands of the neck become swollen.
   2170. Much uncertainty prevails as to the cause of bronchocele.  In
many districts, especially in low valleys, it is an endemic, unless its cause
can be decidedly referred to the state of the atmosphere, the use of water
containing salts of difficult solution, or of snow water (1).   Cretinism
and bronchocele do not stand in -any necessary causal relation; the intel-
lectual faculties  are weak from birth  in cretins, and in.many this blunt-
ness of intellect is complete, without swelling of the  thyroid  gland, at
least without any such  as can produce  obstruction to the circulation.
Experience, however, shows in most cases in cretins a peculiar misforma-
tion of the skull, by which the circulation in the carotids is more or less
disturbed, and  the enlargement of the thyroid gland produced by the
greater inflow  of blood (2).   Females are  more commonly subject to
bronchocele than males, and its commencement usually  begins with the
menstrual development (3).   Bronchocele frequently  makes its appear-
ance in scrofulous subjects (4).  I have twice noticed congenital  swell-
ing of the thyroid gland.   Violent exertion, labour pains,  carrying heavy
weights upon  the head, screaming, and the like, frequently produce  it,
and sometimes very quickly.   Walther supposes, that in aneurysmatic
bronchocele the arterial system is always in a somewhat  diseased condi-
tion, and  has a greater or less degree of aneurysmal diathesis.
   Of late the opinion advanced by Bordeu, of a  closure of the  tracheo-thyroideal
passage as  the cause of bronchocele, has been revived.
   [(1) That the cause of bronchocele depends on the mineral substances contained
 in the waters of the districts where it is common, appears  to be proved  beyond all
 doubt by M'Clellan's observations (a), and he seems to think probably also on the
 state of the atmosphere.  He refers to the observations of Saunders (b) on the fre-
 quency of goitre in Sumatra, in proof that snow water is not the cause of this dis-
 ease, and he shows that it really depends upon the changed condition of the water
 which has  circulated through the caverns of" the Alpine or compact limestone, and
 although not percolating the rock itself, has  acted upon the extraneous fossils and
 metallic substances with which  such rocks abound, and become  impregnated with
 them,.  He observes, that "Alpine limestone, does not occur to any great extent in
 the mountains of Ireland, nor in those of Scotland and Wales; and in these countries
 goitre is unknown.  In England  the disease is known by the name of Derbyshire
 Neck, and  is principally confined to Derbyshire, where the particular rock in ques-
 tion forms  the characteristic features of the county.  In the Alps of Switzerland and
 Tyrol, where goitre and cretinism both prevail, we have the authority of geologists
 that Alpine limestone and nagefiugh (usually composed of fragments of limestone
 more or less rounded, and of various magnitudes, cemented  together by a basis of
 calc-sinter, Jameson) compose the greatest portion of the mountains.  Now this
 nagelflugh  is of the same rock, or nearly so, as that on which the villages of Gose-
   (a) Above cited.    (b) Journey to Boutan ; in  Phil. Trans., vol. Ixxix. p. 89.  1789. 
CAUSES OF BRONCHOCELE.
389
 ragong, Batuda, and Deota, are erected, villages whose inhabitants are affected with
 goitre to the extent of half their population."  (p. 318.)  In regard to the condition
 of the atmosphere as exciting this disease, he says :—" As this volatile poison (car-
 bonic acid gas) exists in limestone to the extent of 44 parts in 100 of the solid rock,
 it is  possible to conceive, that a  sufficient quantity of it, to cause a more or less
 vitiated condition of the air may be extricated from limestone by atmospheric heat,
 assisted by such other causes as promote the decomposition of the rock.  * *  *  A
 reference to the mineral  topography  of all  the villages in Kemaon, which I have
 examined, but one, seems to  favour rather than negative these views.  *   *  *  If
 there be difficulties in the  way of  conceiving the possibility of the emission of car-
 bonic acid gas from limestone, its absorption by lime water may be suggested as a
 means by which it may be attracted by the moisture on the surface and at the base
 of calcareous mountains." (p. 321.)
   (2) M'Clellan observes on this point:—" From goitre as it appears in Kemaon,
 in its more distinct form, as well as in conjuction with cretinism, there are many
 reasons for believing that both complaints are intimately connected with each other;
 if not identically the same, they are mere modifications of different degrees of inten-
 sity of the same causes."  (p. 335.)
   (3) According to M'Clellan, "the disease begins at any period of life after the
 age of three years, and never as far  as he has seen, arrives at its full  size sooner
 than six  years from the time of its commencement,  btft is generally much slower,
 its progressive augmentation seldom however becoming perfectly suspended during
 a residence in an affected village.  *  *  *  The usual size of a full grown goitre is
 about one foot ten inches in circumference, including the neck; and about two feet
 from one angle of the lower jaw to the opposite side, measuring under the tumour."
 (p. 317.)
  Inglis (a) says as to the age at which bronchocele is most usual:—" We may
 infer that the first ten years of life are comparatively exempt from the disease, and
 that the second ten  are most subject to it; as out of one hundred and eleven, only
 eleven appear during the first ten, sixty-three during  the second, and twenty-four in
 the following;  the  fourth  ten years present four cases, the succeeding, four; and
 from the age of fifty to sixty-two only two cases are found." (p. 57.)   Dr.  Copland
 also observes that in a considerable number of cases which have come before him
 in females, he has never met  with  any before the period of commencing puberty."
 Inglis has also compared the proportion of cases in  this country, which have been
 collected by several writers, from  which it appears that, in a  hundred cases, those
 observed in men varied between two and five and a half per cent.  (p. 32.)
  (4) Dr. Robertson  indeed  says:—" There  are many  reasons to induce us  to
 regard goitre as a particular variety of scrofula; in this country (England) it is only
 seen in  highly scrofulous  constitutions."  As to  the differences between  sorofula
 and bronchocele stated by Postiglione (b), M'Clellan denies that the latter should
 be considered a merely local disease,  or that it begins at a later period than scrofula
 and does not spontaneously disappear; but he admits that scrofulous glands often sup-
 purate, whilst bronchocele rarely undergoes this change, which  he considers the only
real distinction between the two. From " the consideration of the predisposing cause,"
 however, he observes, we are led to the conclusion " that the same inherent diathesis,
 that under certain circumstances gives rise to scrofula, would, under exposure to the ex-
 citing cause of goitre, occasion that peculiar form of disease."  (pp. 339, 40.)]
  2171.  The size, duration, and  nature of the disease, must be taken into
 the account as  regards the prognosis in  bronchocele.   Small lymphatic
 bronchoceles  in  persons under twenty-four years of age are commonly
 soon cured.   But the cure is more tedious if  the swelling be larger and
 firmer and in  older  people.   In large  bronchoceles both internal and
 external employment of medicinal remedies are frequently useless, and
 a decidedly operative treatment must be employed to get rid of the swell-
ing entirely, or at least to diminish it to  such degree that the patient's
sufferings  may  be  bearable.   The carcinomatous  degeneration  of the

  (a) Above cited.
  (b) Memoria Patologico practica sulla Natura di Gozzo.  Firenze, 1811.  12mo. 
390
BRONCHOCELE, TREATMENT OF.
thyroid glandis incurable.   In rare cases, bronchocele, when consequent
on severe violence, cold and the like, may be attacked with more or less
violent inflammation  {Thyreophyma  acutum)  of Frank (a),  in which
case, with pain, increased heat, and sometimes with redness of the bron-
chocele, its tension  and size quickly and considerably increase; the arte-
ries of  the  neck pulsate strongly, the  veins swell, there is  difficulty in
breathing and swallowing, determination to the head,  redness  and puffi-
ness of the face, and  frequently considerable fever.   This inflammation
may run to suppuration; the bronchocele may be completely or  in great
part destroyed ; the collected pus, if the abscess be not opened in proper
time may produce,  by  burrowing, considerable destruction of the neigh-
bouring parts,  may eat away even  the air-tube itself and  empty into
it {b).
  2172. The treatment of bronchocele  must vary according to the nature
of the  swelling, as the remedies applicable  to one form of the complaint,
are of no use in another.
  2173. In vascular bronchocele, the  further growth  of the tumour can
alone  be prevented and  its  diminution effected,  at  the  very  first, by
general and local  blood-letting, by the  patient at  the same time keeping
perfectly quiet; by the continued employment of cold applications, and
the internal use of digitalis, and by carefully avoiding  every  exertion; at
least, I have in two cases followed  this practice with success.  If the
vascular bronchocele have already attained  considerable size, nothing is
of any service, and  the proper remedy for diminishing, if not of perfectly
getting rid of the swelling,  by which  the  inconveniences it causes are
also removed, consists in tying the superior thyroideal artery,  by which
the thyroid gland  is deprived of the greatest quantity of the blood which
flows into it.
  2174. This  Operation  was  first  proposed, in  way of question, by
Charles G. Lange (c), afterwards by Jones {d), especially applied by
Spangenberg to aneurysmal bronchocele,  and first undertaken by Wil-
liam Blizard (e), in whose cases great diminution of the size of the swell-
ing ensued, but the patient died of hospital-gangrene.  Walther (f)
performed the operation successfully ; also Coates (g), Wedemeyer (h),
Jameson {i), Earle  (j), Beck {k),  and  I,  myself,   in six  instances.
Fritze {1), Zang (m), and  Langenbeck (n) have met with fatal cases

  (a) De curandis  hominum morbis Epito-    (/) Above cited, in his  Journal fur Chi-
me, lib. vi. pais ii. p. lxxx.—Hupeden, Diss, rurgie und Augenheilkundc, vol. ii. p. 584.
sistens Animadversiones de affectionibus in-    ig) Med-Chir. Tr.ms., vol. x.p. 312. Ibl9.
flammatoriis  Glandulae Thyroidea).  Got-    (A) Langenbeck's  Neue Bibliothek, vol.
tings, 1824.                          iii. part. ii. p.  185.
  (6) Baillie, Matthew, M.D., a Series of    (i) American Medical Recorder, vol. v. p.
Engravings, with Explanations, intended to  116.  Ib22.
illustrate the Morbid Anatomy of some of    (j) London Medical and PhysicalJournal,
the  mosi  important  parts  of the  Human  vol. lvi. p. 201.  Sept. Ib26.
Body. SfCO"d Edition.  London, 1812. 4to.    (&) Above cited.
  (c) Dissertatio de Strumis et Scrophulis,    (l) Hedencs, above cited, p. 255.
p. 16.  Witernb., 1707.                     (m) VerunoliickterV. rswh, eine Kropfge-
  (d) A Treatise on  the Process employed  schwulst riurch TJnlerbindung  der Arteria
by Niturein suppressing the Haunorrhage  thyreoidea superior zn heilen,  Mitgttheilt
from divided and punctured Arteries, and on van Dr. Horen; in Rust's Magazin, vol. vii. p.
the use of ihe Ligature, &c.  London, 1805. 315.
8vo.                                   (n) Neue Bibliothek, vol. iv. part iii. p.
  (e) Allan Bukns, above cited, p. 203.     558. 
      OPERATION OF TYING  SUPERIOR THYROIDEAL ARTERY.  391


from  bleeding, and inflammatory symptoms.  Graefe (a) and myself (b)
have operated without any permanent result.
  2175.  Tying the superior thyroideal artery is performed in the following
manner.   The patient seated ou  a high  stool, opposite  the  light,  in-
clines his head to the contrary side on which the operator stands, and
rests it on  the breast of an assistant.   At  the point where the artery is
felt pulsating, the skin having been moderately stretched  to prevent any
fold, a cut is to be made through it, which beginning a little below the
angle of  the lower jaw and rather to its outside, is carried inwards  and
downwards along the inner edge of the m. sterno*mastoideus; and a second
cut divides the m.  platysma  myoides  in  the same direction, the blood
which flows into the wound being sopped up by an assistant with  a moist
sponge.   The tip of the left forefinger is passed into the wound to ascer-
tain most accurately the situation of the artery.  A director is then  pushed
into the cellular tissue, covering the artery and the tissue divided with the
bistoury; after which, it must be endeavoured to  isolate the vessel with
the blunt end of the director,  with the  handle of the scalpel or with the
finger; but the use of any cutting instrument is to be avoided.  The artery
having been  laid  bare is now  brought a little up, and a single round liga-
ture  carried with  Deschamps'  needle about it, and tied with two single
knots.  The ends of  the thread lying out of the wound are fixed with a
piece of  plaster,  and  the  edges  being brought together  with strips of
plaster, some wadding and  a  compress are applied, and  the whole kept
 in place  by a circular bandage.
   The laying bare of the artery is rendered easy by the upper edge of the bron-
 chocele raising it up considerably.   If the m. omohyoidtus, as it passes  above the
 artery, interfere with  the isolation of the vessel, it  may be advantageously cut
 through.   It is easier to tie the artery between this muscle and its entrance into the
 gland than above it.  I have, however, found, in one case in which I tied the artery
 above this muscle, that it was as  easy as tying it below.   A branch of the glosso-
 pharyngeal nerve, which lies close to the thyroid artery, must be taken care of, and
 drawn outwards.   This also applies to the thyroideal  veins, and the laryngeal
 branches  of the thyroideal artery;  the ligature is applied where this artery is already
 given off.   Every spouting vessel must be taken up as the operation goes on.
   Various propositions have been made as to the mode of finding the superior  thy-
 roideal artery, and the direction of the cut through the skin, and this step of the ope-
 ration has been subjected to as definite rules, as for finding arteries in other parts of
 the  body    According to Jameson and Zang, the cut through the skin should be be-
 gun  on the middle of the lobe of the  thyroid  gland, near the upper edge of the
 thyroid cartilage, and continued for the length of two inches, according to Jameson,
 of one, towards the clavicle,   von Walther and others fix for the beginning of the
 cut the space between the tongue-bone and the thyroid cartilage, from which it is to
 be continued three inches in length on the inner edge of the m. sterno-mastoideus,
 towards the breast-bone. According  to Langenbeck  and Bujalskv, it should be-
 gin immediately over the submaxillary gland, and be carried down in a straight line
 to the lower edge of the thyroid cartilage.  All these rules are, however, precarious;
 the  situation and course of the superior thyroideal  artery vary so considerably ac-
 cording to the size and extension  of the bronchocele in different directions, that any
 such determination of the beginning  and extent of the wound through the skin,

   (a) Hedunus, above cited, p. 255.         gen uber die Struma vascuIoSa, und die Un-
   (6) Weissflag, Dissert., Animadversiones  terbindung der pberen SchildrUsen-Schlaga-
 de Struma aneurysmatica. rt de  Arteriis  dern; in Heidelberg, klinisch. Annalen, vol/
 Glandule Thyroideoe Superioribus ligandfs.  i. p. 208.
 Heidelb:,  1823. 4to.—Chklius, Bemerkun- 
 392 BRONCHOCELE | TYING OF SUPERIOR THYROIDEAL ARTERY.

 cannot in general apply, and the above-mentioned rules  on this point can alone be
 held with.
   2176. The patient having been put to bed, with his head a little raised
 and laid on the side, must be kept quiet and treated precisely as when an
 artery is tied for aneurysm.  It seems in this case always advisable after
 the operation to have recourse to a not  inconsiderable blood-letting, for
 the purpose of checking a great flow of blood to the brain.  If inflamma-
 tory symptoms, difficulty of breathing and  swallowing, headach, and the
 like, should  occur, general and local blood-lettings are to be considered
 the most efficient remedies.  Violent  cough requires  extract of hyoscy-
 amus, together with antiphlogistic means.
   If both superior  thyroideal arteries  require tying, that of the other
 side must  be tied  after the wound of  the first operation have healed.
 After  tying, the  bronchocele  loses its elastic  feel, the pulsation di-
 minishes, the warmth  lessens,  and the swelling becomes smaller  and
 shrivelled.
   2177. If this operation be compared with those modes of treatment
 formerly recommended in  that  stage of  bronchocele which threatens
 danger, as extirpation of the thyroid gland, the introduction of a seton,
 or issues, it must undoubtedly be preferred, partly on account of its easy
 performance, and partly for its happy result, when the bronchocele  is of
 the vascular kind, that is, depending more on the enlargement of the ves-
 sels than on the thickening  of the uninjectable part of its tissue, or on the
 pouring out of lymph-clots and degenerations in its cells.   If the growth
 of the bronchocele cannot be in any way prevented, dangerous symptoms
 may be produced, and  the  superior thyroideal artery felt pulsating dis-
 tinctly.  A slight degree of still little developed general  affection of the
 vessels accompanying aneurysmal bronchocele must not contraindicate the
 operation ;  but in far advanced diseased alteration of the heart and arte-
 rial system, those ill consequences at least may accrue after the operation,
 which happen  after the operation for aneurysm, when there is an aneu-
 rysmal diathesis (1).   If these circumstances be carefully considered be-
 fore  the operation, and that performed with due  caution, the results, in
most cases, correspond  with our expectations.  To this  must be  added
 that aneurysmal struma, as above mentioned, {par. 2167,)  is not common;
that the symptoms maybe illusory, since the bronchocele characterized as
 aneurysmal, exhibits in its interior more or less thickening, cavities  and
cells rilled with serous or brownish fluid, and that such bronchocele may
 also  be efficiently treated with seton (a); hence the propriety of tying the
superior thyroideal artery is  not disparaged.
  von Walther doubts the possibility of the growth of the tumour after
tying the superior thyroideal artery, and  asserts the  adhesion of a very
large portion of the expanded and tied vessel.  I have, however, noticed
the contrary,  as the growth of the swelling  may be continued by the en-
largement of the inferior thyroideal artery and its communication with
the superior (2).  In general this does not happen, and perhaps can only,
when  the inferior as well  as the superior  artery is  at  the same time
enlarged {b.)   It must,  however, be always remembered, in  deciding

     (a) Rusts' Magazin, above cited.—Langenbeck, above cited.
     (i) Chelius, above cited, p. 233; and in Heidelb. klinish. Annalen, vol. i. part i. 
TREATMENT OF LYMPHATIC BRONCHOCELE.         393
on tying the superior thyroideal  artery, that if it  be much  enlarged  by
disease, the ligature  will  not effect its  obliteration, but bleeding must
ensue,  which  in many instances will have an unhappy result.
   (1) P. von Walther (a) has successfully practised tying the superior thyroideal
artery as above  directed  in a case of aneurysmal struma.
   [(2) In confirmation of Chelius's statement regarding the growth of the broncho-
cele, after tying the superior thyroideal artery, although the swelling had at first de-
creased even  considerably,  Crawford (b) states that Coates informed him as to
the final result of  his  operation above mentioned, "though the  case proceeded
extremely well  for some time  after the patient  was discharged and lost sight of,  yet
the tumour subsequently, he  understood, enlarged, and in the end  destroyed  the
woman  by suffocation."  Also, in a case  of Wickham's of Winchester, the largest
he ever  saw,  "  after the  ligature of the artery, the swelling gradually diminished for
about six weeks, after which it as  gradually regained its former size.   It seemed
that the decrease of the  tumour continued so long as the part  of the gland, which
had been supplied by the vessel, remained without nourishment; but as soon as the
supply was restored by the anastomosing branches from  the opposite superior and
the two inferior thyroideal arteries,  the swelling returned to its former dimensions.
 Such, I should  conceive, would be the  case  unless all the thyroideal arteries were
obliterated, which it would be a very difficult task to accomplish, if not altogether
 impracticable from the depth of the lower vessel." (p. 3--J1.)]
   The circumstances  above noticed  in regard to the enlargement  of  the inferior
thyroideal  artery has led  to  the proposal of tying it  also.  Velpeau  (c), Die-
trich (d), and  Laymann (e)  have given special directions for finding this artery.
   There may be cases in which after tying the superior thyroideal artery, the broncho-
cele does not properly decrease, on account of the existing enlargement of the inferior
 thyroideal artery.   But as  regards the  mode  of tying the latter vesel, that which
 has been already mentioned as to the direction of the cut for tying the  superior artery,
 applies to it also.   Only if the inferior thyroideal can be decidedly distinguished,
 by its pulsation and size at the lower part of the bronchocele, may it be decided to
 tie it, and the direction of the cut must then be decided by the situation of the vessel.
 In a case in which I had tied  the superior thyroideal artery and the bronchocele had
 diminished considerably, I felt the inferior artery pulsate distinctly,  and could have
 undertaken tying it with ease, if the diminution of the swelling and  the subsidence
 of the previous  symptoms had not rendered it unnecessary.
   2178. Lymphatic  bronchocele,  if not exceedingly large, and of very
 long duration may be  always  cured by the use  of internal and external
 remedies,  or  at least be so far controlled,  that the  disease produces  no
 serious inconvenience.
   2179. Of  all  the  remedies which have been employed  internally for
 bronchocele,  burnt sponge has  been most used.   It  has  been  given in
 different forms,  and with various  combinations;  but  according to  my
 experience most advantageously with red  foxglove.   Iodine, which is con-
 sidered the most important element in the burnt sponge, has, from Coin-
 det's. (f) experience and  recommendation acquired great repute.   Forty-
  fa) In his Journal fur Chirurgie und Au-
genheilkunde, vol. ii. p. 584.
  <b) Cyclopaedia of Practical  Medicine*,
vol. i.
  (c) Traite d'Anatomie Chirurgicale, vol.
ii.  Paris,  1825.  8vo.
  (d) Das  Aufsuchen der Schlagadern, p.
95.  Niirnberg, 1831.
  (e) Dissert,  de  ligaridis  Arteriis thy.
reoideis, praesertim inferioribus  ad sanan-
dam Strumam. Bonnae, 1833.
  (/')  Docouverte  d'lin  nouveau  remade
contre  le Goitre; Bibllolheque Universale
   Vol. hi.—34
de Gen&vc,  vol. xiv. p. 190.  1820.—Nou
velles Recherches sur les effets de l'lodine
el sur les precautions a suivre dans le traite-
ment du Goitre par ce nouveau remede;  in
Bibl. Univers., Vol. xvi.  p. 140.  1821.__
Formev, Bemerkungen uber den Kropf und
Nachricht uber ein dagegen neu entdecktes
Mittel.  1820.—Graefe, Ueber die Indica-
tionen,  nach welchen die Iodine gegen
KrOpfe  anzuwenden  ist;  in  Journal fur
Chirurgie und Augenheilkunde, vol. ii.  d
616.                                V' 
394
TREATMENT OF
eight grains of iodine are to be dissolved in an ounce of spirits of wine,
and  of this ten drops are to be taken thrice  a day, in  a glass of water
sweetened with sugar.   After eight  days the  dose is to be  increased to
fifteen drops, and some days after to twenty drops.  It is observed in
this  treatment, that within the first eight days, the skin over the broncho-
cele is less tense, the  substance of the swelling softer, the several parts of
the gland more  distinct, and its removal gradual.   Small bronchoceles
usually disappear in  eight  or ten weeks, and very large  ones diminish.
In this employment of iodine it is noticed, that besides the softening and
removal of the bronchocele, usually the  pulse becomes quickened, and
that  there  are other variations from the natural  condition.  On the
setting in  of these symptoms the iodine must be at once  left off, and only
again employed eight or ten days after, when they have subsided (1).
   Very large  doses of iodine, or its too long continued use cause palpita-
tions of the heart, dry, frequent cough, loss of sleep, quick wasting, loss
of power,  dwellings  of  the bones, tremors, a painful  hardness of the
bronchocele,  sometimes wasting of the  breasts, considerable and con-
tinued loss of appetite (2).   These symptoms may be always removed by
warm bathing,  valerian, quinine, volatile alkalies,  and other antispas-
modics;  and  the  painful hardness  of the bronchocele  by leeches and
softening  fomentations.   In consequence of  these effects of iodine, it
must always be given with caution, and with due reference to the con-
stitution  of the patient,  and the  condition of  the  bronchocele.  Very
tense, painful bronchocele  make no  difference;  however, if there be in
addition spasms  or bilious symptoms, leeches,  softening fomentations,
antispasmodic, and antigastric remedies must be employed.   The use of
iodine is  contraindicated in pregnancy, in the disposition to flooding, in
incipient  diseases of the breast, in  wasting fevers, and in irritable and
nervous constitutions.  Iodine  acts-  especially on men, who  have no
other ailment than bronchocele, if it occur  in  later life, or the patient
have reached manhood.   When the symptoms endanger life, or become
fatal from the use of iodine, their cause depends on inattention to the
points above  noticed ; or  in the mode in which the iodine  is employed
(par. 776.)  As  in using tincture of iodine by  mixing it with sugared
water, the iodine is  thrown down, and  so  gets  into the  stomach in an
undissolved state, it seems  preferable to  use it in the mode  prescribed
by Lugol, half a  grain to a whole grain of iodine dissolved in a pint of
distilled water, to be taken during  the day {par. 776); or a  solution of
hydriodate of potash  {par. 856) may he given, from which I have never
noticed the symptoms just  stated.
   The other remedies which have been also employed in bronchocele, as calcined
egg  shells, baryles, carbonate of soda, of potash, soap, vinegar of squills, oxysul-
phuret of antimony, digitalis belladonna, and many others, are some of them little
longer in use, and some given  in combination with burnt sponge.
   Graefe considers the following as Very efficacious :—
         9* Potass, tart.                Rad. imperator.
           Spong. ust.                Cinnam. acut. aa ^ij.
           Sacch. alba, aa Jjss.         Sulph. antim. aurat.  J)j.
           Ammonia,  hydrochl.-        Piper, long. 3i.
                                      Misce ut fiat pulvis subtilissimus.
   Persons who are little irritable, pasty,  and have large  lymphatic  bronchocele,
should take daily, morning and evening, a: small beaped-up teaspoonful. Irritable
wasted persons, whose  bronchoeele is small, shou-ld take the same dose only once. 
LYMPHATIC BRONCHOCELE.
395
The remedy  is very efficacious, though most nauseous  when swallowed dry, and
must be continued longer if the patient take it in water.
  [(1) Inglis objects to Coindet's mode of employing  iodine, that " were it used
in any quantity, the result would be a disposition of pure iodine upon the mucous
membrane of the stomach on account of the affinity which exists between alcohol
and water.   Nor would the evil stop here.  Iodine has a great affinity for hydrogen;
so that  whenever it comes in contact with  other vegetable or animal  matter, it
decomposes it, taking its  hydrogen  to form hydriodic  acid; the mucous  membrane
of the stomach would therefore suffer, Which dissection  after death proves really to
take place, by poisoning with iodine; there being always found,  as Orfila  has
shown,  ulceration of the mucous  membrane of the stomach and  intestines.   On
which account he prefers, even to  the weakest tincture,  an aqueous solution either
of the hydriodate of potassa, the hydriodate of iron, or of iodine  rendered  more
soluble  by the presence of a salt, as the nitrate of ammonia, the hydriodate of soda,
or the hydriodate of potassa." (p. 65.)  But  of these several preparations he gives
preference to the ioduret of iron, in the following form:—tyferri iodur. sjss., potass.
hydriod. £)j. aq. destill.% jss. Solve. Cap. gutt. xx. ter die ex aqua;  and for the fol-
lowing reason:—"That in his goitrous patients he generally found some catamenial
irregularity, more particularly amenorrhaea.   Now  he found  that when the tincture
of cantharides, and of the muriate  of iron failed to induce the natural Secretion, the
ioduret of iron often succeeded; its use, therefore, is peculiarly indicated in hroncho-
cele." (p. 67.)
  (2) Still more serious symptoms than those mentioned result from the improper
use of iodine (a).  " The patient becomes affected with a sense of faintness, tremor,
and sinking, dimness of vision, palpitation, and other symptoms of a nervous kind.
The degree of tremor,  Dr. Gairdner informs  us, is  sometimes  so great  as to
present  some resemblance to chorea, though the limbs can always be kept steady.
More violent effects than these occur at times; symptoms apparently proceeding from
the direct and acrid effects of iodine on the alimentary canal, and strongly resembling
the Indian cholera;  violent and incessant vomiting, strong spasms of the back and
legs; extremely frequent, small and oppressed pulse, urgent thirst, and excruciating
pain of  the stomach  and bowels;  the latter  being  sometimes violently purged, at
other times obstinately confined."  (p. 329.)  These severe symptoms I have never
witnessed, perhaps because I have been accustomed to use iodide of potass, which
the stomach will bear, in doses up to five grains, and even more, though  continued
for  many weeks.   Occasionally, however, the iodide  of potass  will cause nausea
and loss of appetite, so that its discontinuance for a time will be necessary.  I have
seen it also several times produce ptyalism  in persons of irritable constitution.   On
these accounts, it is necessary to watch its effects carefully.
  The best modes of giving iodide of potass, is, in doses of from three to five grains,
according to the age  and  condition of the patient, twice a-day, either in compound
decoction of sarsaparilla, or in compound infusion of gentian, or pennyroyal water,
with  some  warm tincture.—j. f. s.]
   2180. Of the  very great number of external remedies which have been
advised to be used alone, or at the  same time with  internal medicines,
the following may be  mentioned as the  most effectual and most useful;
frequently rubbing the swelling with flannel, rubbing with  camphorated
liniment, with diluted caustic liquor  of ammonia,  soap liniment  with
liquor of ammonia, with ung. digital, purpur., with  mercurial  ointment
and  tincture of  cantharides, with naphtha,  with foetid  oil  of tartar  and
opium, nightly application of discutient plasters of soap, of mercury mixed
with  volatile salts  and camphor, empl. cicut. ammoniaco c,  and  the like.
As the internal use of iodine, even when employed with the greatest care
frequently  produces  injurious  effects,  Coindet (b) advises  its  external

  (a) Diet, of Pract. Med., vol. i.            xvi. p. 326.—Biehler, Beobachtung iiber die
  {b) Notice sur l'administration de 1'Iode aussere  Anwendung des  hydriodinsauren
par  frictions; et sur I'application  de ce  Natrum; in von Graefe und von Walther's
medicament au traitement des scrofules et  Journal, vol. iii. p. 277.—Baup, Observations
des quelques maladies de systeme lympha-  sur les Effcts de 1'Iode contre le Goitre; in
tique; in Biblioth. Univers. de Geneve, vol.  Bibl. Univers. de Geneve, vol. xviii. p. 304. 
396         TREATMENT OF BRONCHOCELE BY SETON |

application, and frequent  experience has proved its  great influence  in
bronchocele, as  well  as in  other  glandular  swellings. • Ha4f a dram of
iodide of potash is to be  made into an ointment with half  an ounce of
lard, and a piece as big as  a nut rubbed into the  bronchocele morning
and evening.  The cure is  mostly completed in from four  to five weeks;
in some instances it  must be combined with the internal  use of iodine.
If the bronchocele become painful  and  harder, this ointment must be
withheld for  a time,  and leeches and warm applications made use of.
Caution must also be recommended in the external use of iodine.

  [In using iodide of potash as an ointment, it is better not to rub it in, as almost
invariably, sooner  or later, and  in irritable persons after two or three rubbings, it
irritates the skin so much, that the cuticle  separates and a sore is produced, which
compels the suspension of its employment.  All the wished for advantages will be
gained by simply smearing the ointment thickly over the affected part, and covering
it with a piece of lint once or twice a-day; and very rarely is the skin in this way
irritated..  Some practitioners paint the swelling over with the tincture of  iodine;
but this not infrequently blisters the skin, and therefore its use cannot be persisted
in.—j. f. s.]

  2181. Of all  the remedies, both  internal and  external,  recommended
in the treatment of  lymphatic bronchocele,  I prefer  the internal use of
burnt sponge with ginger, sometimes wilh the addition of digitalis, and
frequent smart rubbing with camphor liniment.   From the results of my
own experience, I have not done more by the internal and external use
of iodine, than  by the plan just  mentioned;  and  where  that has been
inefficient, so has also iodine.
  2182,. When  considerable alteration and  cartilaginous  hardening has
taken place in lymphatic bronchocele, and when by the cautious employ-
ment of internal and external  remedies, no  diminution of the swelling
has been produced, and symptoms threatening life  arise, the lessening of
the tumour may be effected by tying the superior thyroideal artery, if it
be much enlarged, and pulsate violently.   But in  these cases the intro-
duction of a  seton is most advantageous, by  which the destruction of the
swelling, by  suppuration,  and the obliteration of the vessels by the in-
flammation excited, is effected.
  2183. The seton  should  be passed either  from above downwards, or
from one side to the other,  through the substance of  the swollen gland;
in doing which the superficial veins must be  cautiously avoided, and the
needle not passed too deeply.  In general a reddish-brown thickish fluid
escapes; and some days after, the seton must be drawn fuither; the in
flammation  thereby excited is of little  inconvenience to the patient.   If
the seton be not sufficiently active, a due degree of irritation may be ex-
cited by smearing it with some acrid ointment; or pieces of hellebore root
may be introduced with it.   The seton must remain  in for a long time in
order to keep up suppuration till the  cure is complete, and to prevent the
burrowing of the pus.   Suppuration rarely extends  throughout the whole
gland, but generally destroys only that part of it which is in the neigh-
bourhood of the seton.  If luxuriant granulations appear at the openings,
they must be snipped off.   When suppuration ceases, and the wound has
perfectly healed, the lessening of the bronchocele  continues till  it has
completely disappeared.  For some time  the skin has a wrinkled ap-
pearance, but soon, afterwards becomes natural,.  At the scars the skin at 
BY EXTIRPATION.
397
first seems adherent to the  thyroid gland, but this also disappears in a
little time. # Quadri's successful cases show that a seton  may be passed
repeatedly, even as often  as sixteen times, in various directions through
the bronchocele, without any particular symptoms appearing.  In the re-
introduction  of  a  seton-needle  through  the still remaining part  of a
bronchocele,  Qtjadri found  considerable resistance at the part  where  it
had been previously employed; on which account he concluded that the
recurrence  of bronchocele,  after using a  seton, was very improbable.
Although the  use of a seton is  not so dangerous a  remedy as  by many
supposed, I have known, from  my own  experience, as  well as that of
others, fatal results, which seemed'to me todepend on. the unhealthy and
copious suppuration which  ensued when  the  seton had' been drawn
through the larger cavities of the bronchocele, the  firm and  cartilaginous
walls of which  did  not fall together, and foul  ichor,  collected from one
dressing to another, caused  fatal reaction (a).
   2184.  Of similar operation to;the seton is  the  emptying a bronchocele
with a  sufficiently large cut, and exciting inflammation and suppuration
by introducing lint  into it.   The front of the gland  is laid bare, with a
longitudinal cut, the bleeding  vessels tied,  the swelling cut  into and
emptied of its contents,  by pressure made  upon it,  lint  introduced and
suppuration endeavoured to be excited, by digestive  remedies.   This
treatment appears specially applicable in that kind of lymphatic  broncho-
cele which contains fluid in several small or large  cavities, and with-
stands  the use of the-internal and external remedies above mentioned, as
well also as when by the introduction of the seton dangerous symptoms
are feared from  the  collection of foul ichor {b).
   The  mere puncturingand  emptying the fluid in Struma cystica is only-palliative,
and  the fluid soon re-collects,  and  frequently soon exceeds what  it was before.
Maunoir has, after puncturing  the swelling, thrown in  irritating injections; but
experience does not speak in favour of this mode  of treatment, as the fluid, if not
very irritating, is of no use, and  if it be, may produce very violent symptoms.  The
objections already made to the use of the seton apply also here, although it is used
by many in this form of bronchocele;  As notwithstanding the inlying of the seton
the fluid oftentimes will not  escape  properly, the introduction of an elastic tube into
the lower opening has been advised, through which at the same time, soothing-and
irritating injections may be made (Pigne after Sanson.)  The copious suppuration
gradually diminishes,  the cavities  shrink, and, by degrees, are  converted into a
single canal (c).  Serious symptoms may, however, occur after this mode of pro-
ceeding, and the cure is in general only completed in from five to six months.
   Chelius has  not correctly, stated'Maunoir's practice.  It is perfectly true that at
first he used injections, having previously emptied the eyst with a trocar and canula;

   (a) L. Heister, Dissert, de Tumore cystico  Nouveau. Journal de Medecine, vol. x. p. 25.
singular!. IJelmstad, 1744.—Stergman, Dis-  1821.—Beck,  above  cited.—Rognetta, in
sert. de Struma.  Jenae, 17115.—Klein, Beo-  Revue  Medicale.  1834, vol. i.  p. 379.—■
bachtungen  iiber die Heilung des Kropfes  HEiDE.\-REiCB,-in  von Graf.fe und von Wat
durch Vereiterung  vermittelst  eines durch  ther's  Journal,  vol-  xxiii.  p. 680.  1835,
gezogenen  Haarseiles;  in  von. Siebold's  and iu AUjEremeine Zeitung fur  Chirurgie,
Sammlung chirurgischen  Beobachtungen,  innere  Heilkunde  und ihre Ilulfswissen-
vol. i. p. 11.—Quadri, Memoir on a  New  schaften,  1643, No.  4, 5, has communicated
Mode of treating Bronchocele; in Med.-Chir.  the largest experience on this mode of opera-
Trans., vol. x. p. 16.—CopelandHutchinson,  tive treatment  of bronchocele, together with
Cases of Bronchocele, or Goitre, treated by  careful anatomical observations..
seton, with  Observations;  in Med.-Chir.   (c) O'Beirne; in Dublin Journal of Medi-
Trans., vol. xi. p. 235.—Chelius,above cited,  cal Science, vol. vi.  p. 1.  1834.—Bransby.
p. 238.                                 Cooper; in Guy's Hospital Reports, vol. i.
  (b) Fodere,  above cited.—Lemaire,  in p. 1*05.  1836.
                                  34* 
398       TREATMENT OF BRONCHOCELE  BY  SETON, &C.

but he found their consequences so serious that he speedily gave them up, and em-
ployed setons with success in the five cases which he relates.   The useaof setons has
also been followed  successfully by O'Beirne and  Bransby  Cooper, without any
additional irritant.—j. f. s.]
   2185. The  favourable  results  to  which experience points from the
above-mentioned various modes of operation, in the most severe cases of
struma, which have resisted all the internal and external remedies, and
endangered life, must  decidedly reject  the  extirpation of the bronchocele
as very dangerous, and almost entirely to be  forbidden.  Single cases in
which this operation has been successfully performed do not oppose this
opinion, as on the other hand just as many have been  adduced in which
the patient  has died either under the hands of the operator, or a short time
after the operation, in which, on account of the bleeding, the completion of
the operation  was  prevented, or  the patient was only  saved with the
greatest difficulty.
  fti those cases only, where there is a  partial, defined swelling of the thyroid gland,
which is moveable or has  a neck, and which is unconnected with the deep important
organs of the neck, is extirpation to be held indicated.  The skin is to be divided on
the tumour and< separated from it on each side, the swelling drawn well forwards
with a hook, and its cellular connexions carefully separated with some strokes of the
knife, in doing which the blood  must  be cautiously sopped up with a sponge, the
spouting vessels tied directly, and if possible before they are cut  through.   If the
neck of the swelling be connected with any important organ, if there be reason to
fear any vessel running through it,  the rest must  be tied.  The treatment of the
wound is to be conducted according to  the general rules (a).
   [Green operated in 1829 on a bronchocele of this kind  in a woman twenty-nine
years old.  The swelling was as big as the fist, growing from a small base on the
right side;  its  surface presented many enlarged veins, and an artery of equal size
with the radial ran across its base; it was very  firm  and  irregularly lobulated.
Two semicircular cuts, meeting above  and below, and including the skin covering
the swelling, were made, and the divided veins bled freely.   The artery was found
and tied; but in doing so was wounded, and there  was  much bleeding.  The base
ef the tumour was then cleared, and bleeding from the jugular vein was stopped by
pressure upon it.   The windpipe and the sheath of the carotid artery were exposed
as the base of the swelling was  isolated, and a strong ligature having been passed
Bound it, the tumour  was removed at a stroke, and  the  bleeding ceased;  but it
recurred half-an-hour after, was evidently venous, and stopped by pressure.   In the
eourse of a few days suppuration ensued, and the ligature  was removed, but low
fever ensued, and she died on the tenth day after the operation.]
   2186. In cases in whieh, on  account of its situation and condition, the
extirpation of the bronchocele has seemed to be indicated, tying it at its
base  has been performed successfully by Mayor in three, and by Bach (b)
in two, instances.  The skin is  divided by a crucial cut upon the swell-
ing, the flaps dissected back to their base, and the neck of the tumour
isolated as far as possible  with  the finger.   A  strong ligature  is  then
applied around it, and tied with a loop-tier.   According to Mayor, the
ligature should be tied as tight as possible;  but according to Bach only
lightly for  the  first two or three days,  for the  purpose of preventing the
violent pain, symptoms of choking, bleeding by cutting through a vessel,
and  inflammation  of  the veins,  but afterwards  it  is to  be  tightened.


   (a)  Hedenus;  in  von Graefe und von  iii. p. 337.—Zartmann,  Dissert, de  Struma
Walt-hick's Journal, vol. ii. p. 240.—Gratfe,  extirpatione.  Bonnte, lb29.
see Hedenus, De Glandula Thyreoidea turn    (b) Hirtz; in Gazette Medicale de Paris,
sana quam morbosa, p. 267.  Lips., 1822.—  vol. ix. p. 9.  1841.
Mandt ; in Rust's Magazin, vol. xxxvii. part 
ENLARGEMENT OF THE CLITORIS, &C.           399
When the tumour has mortified, it should be cut off* in front of the liga-
ture, which must then be tightened, so as to hasten throwing off'the stem.
This tying, after previously laying bare the neck, is indeed less dangerous
than extirpation ; it  is, however, very hazardous.  The whole  swelling
must become gangrenous, so that a mass of filth remains till it is entirely
thrown off, and there is still a horrible  wound,  which always leaves an
ugly scar; besides which  the inflammation and  symptoms of suffocation
may be very severe.   Regal de Gaillac (a) has made use of  the  sub-
cutaneous ligature  for removing bronchocele.
III.—OF ENLARGEMENT  OF THE CLITORIS AND OF THE  LABIA.

(Hypertrophia  Clitoridis et  Labrorum, Lat.;  Vergrosserung- der Klitoris und der
                         Schaamlippen, Germ.)

  2187. The clitoris may, either as a congenital vice, or, as consequent
on early masturbation, enlarge to such size as more or less to destroy the
functions of the female generative organs, and even be capable of leading
to vicious practices.  The  condition of the clitoris may be, excepting
its size, either natural, or it may deviate more or less from its. natural
state, its vessels may become varicose, and the like.
  Syphilitic affections not unfrequently give rise to considerable enlargement of the
clitoris.  I have seen an instance in which it was about two inches long; it became
hard, and its natural structure was completely destroyed;  and the same happens in
scirrhous degeneration of the organ.
  2188. When the clitoris  is of very great length, nothing is left but to
cut it short;  and if otherwise degenerated-, to remove it  down  to the
healthy part.  The patient being held by  assistants in a  proper posture,
and the labia  separated, the clitoris  should be  taken with the fingers or
forceps, drawn forwards, and the excess, or the degenerated part, cut off
with a bistoury, or scissors, at one or more strokes.   The  bleeding, which
if the vessels  be  large is very great, must, as far as possible, be stanched
by tying, by  cold water, by styptics, and by pressure against the arch of
the pubes.  If there be  no bleeding, the surface of the wound must be
dressed with dry lint, covered with a compress, and this fastened  with a
T bandage.   Some moistened linen should  also be placed  between  the
nymphe, and some wads oflint in the vagina, to prevent  it growing toge-
ther and narrowing.  The  after-treatment is conducted  on  the  ordinary
rules.
  The case of an idiot, cured by the removal of the clitoris, is related1 by a physician
of Berlin (b).
  2189.  The labia may, like the clitoris, either from original formation,
or as consequence of continued  inflammation,  syphilitic sores, and  the
like,  attain such  size as  to cause difficulty in walking, and interruption to
coition  ; and, by their continued irritation, excoriations, and even deep
ulceration, may be produced.   With enlargement of the labia the vessels

  (a) Bulletin jreneral de Therapeutique.  Thyreoide et le leur Traitement.  These de
1841, Oct.—Liston ; in Lancet.  1841, vol.  Concours.  Paris, 1841.
i. p. 691.—A.Sanson, Des Tumeurs du Corps   (b)  von Graefk und von Walther's
                                    Journal, vol. vii. p. 1.  182&. 
400
WARTS;CAUSES AND
commonly become varicose, the labia themselves quite hard, and the
discharge of the urine may be more or less completely prevented.
  For enlargement of the labia from elephantiasis see Birrel (a); also Monod (b).
  [Enlargement of the labia to such size as to need removal with the knife, is not,
so far as I am aware, at all common.   But great increase in the bulk of the nymphae,
in which also the prepuce of the clitoris  participates, is of very frequent occurrence
in women of the town.  In St. Thomas's Museum there is an instance of one
nympha removed by Astley Cooper, which is as big as two fists, and has a very
whimsical history attached to it.  The disease merely consists of a large develop-
ment of tough cellular tissue within the double skin; and  in general is not very
vascular.—j. f. s.]
  2190. It is rarely possible, except when the enlargement of  the labia
results from  continued irritation, or venereal affection, and has  not  yet
attained  any considerable size, by proper  treatment for the removal of
the irritating cause, or of the syphilis, to be of  any use.   If the enlarge-
ment be consequence of the congenital  formation, or if accidental,  but
have  long  continued, and  the  structure  of the  labia be considerably
altered, their removal with the knife or scissors is the only remedy.  The
patient is to  be placed in  the same posture as for shortening the clitoris,
the enlarged or degenerated  labium  is to  be  taken hold of with  the
fingers of  the  left hand,  drawn  a little  forwards, and  with a  convex
bistoury, or with  curved  scissors,  at one  or more strokes, the  degene-
rated or  enlarged  labium is to be removed.  The wounded surface must
be, carefully examined,  and if any  degeneration  remain,  it must be
seized with the forceps  and cut off.  The bleeding is to be stanched by
tying the vessels, or if this be not possible, with cold water or pressure.
The same dressing is to be employed as for the clitoris.   If the enlarge-
ment be very great, two moderately large  semilunar  cuts must be made,
to include  the degenerated part; which, havingbeen removed, the edges
of the wound are to be  brought together lenghthways, throughout their
whole extent, with suture.
  [The removal of the enlarged nymphae is usually best performed with a pair of
small  shears, of sufficient size to take off the whole at a stroke.  If the prepuce of
the clitoris be  also enlarged, it is rarely necessary to meddle with it, as  after the
removal of the nymphae, it in general shrinks to a moderate size.   I have not found
it needful, in any case in which I have operated, to employ sutures;  or to do more,
than at first to apply a cold wet rag to stanch the bleeding, and afterwards a poultice;
as the wound, skins,  the scar contracts, and the edges soon draw together.—j. f. s.]
                           IV.—OF  WARTS.

                (Verrucx, Lat.;  Worzen, Germ.; Verrues, Fr.)

  2191. Warts are variously-shaped growths  of the skin which appear
Under two  different  forms.   They  ace  either superficial, with a broad
base, or most commonly attached by a thin neck, do  not project much
above the  surface of the skin, are soft,  compressible,  covered with the
ordinary epidermis, and have  the same  sensibility as  the skin.   Warts
commonly arise at those parts where the skin is delicate and sensitive;
specially, therefore, on the face, neck, and back of the hand, and more
  (a) Edinburgh Medicaland Surgical Jour-    (6> Bulletin de la Societe Anatomique,
nal, vol. xxiii. p. 257.   1825.             Sept'. 1835, p. 12. 
y
                             TREATMENT.                         401


frequently in women than in men.   Or warts are thick, have a broad base,
and situated more deeply in the skin; their form  is conical or cylindrical;
they are immoveable and  hard, outspreading on their top ; and the skin
about their base seems burst through, as by the eruption of the wart, and
its colour is completely changed ; the top of the  wart is almost insensible,
but frequently it is very  painful within.

  [Besides the warts here mentioned, the generative organs are frequently attacked
with two kinds, one of which has much the appearance of the " seedy wart," as it
is commonly called, on other parts of the body, and is  a very common attendant on
gonorrhceal discharge, which has been allowed to remain on the skin and irritate it.
At first this kind of wart has a little pedicle, with, in comparison to its size, a broad
head, consisting of little flat prolongations, like the tips of leaves closely set toge-
ther; from this there is an acrid secretion which is contagious, and wherever it rests,
produces in the same individual, or in another having commerce with her or him,
the same growth.  The neighbouring parts soon become contaminated ; and it is not
unfrequent to see the whole  of the external female organs thickly covered with them,
as also the glans penis of the male;  and should there chance  to be  in the  latter,
phimosis, the warty growths rapidly increase, and distend the prepuce, till at last it
bursts, and their protrusion gives the glans a cauliflower-like appearance.  The other
kind of venereal wart has not the narrow neck nor the  leaf-like  head,  but is broad-
based, not unfrequently sore, and sometimes even having somewhat the character of
a shallow badly-skinned  ulcer; this  form  more  commonly is noticed when there
are—or have been—sores, having a very chancrous character; and are often observed
to exist when decided syphilitic eruptions cover the body.
   Warts sometimes take on a malignant character, and affect the neighbouring glands,
and occasionally they seem to have a malignant character from the very first.  I have
seen them upon the back of the hand and on  other parts of the body;  they gene-
ally have a broad base and a sort of cauliflower surface, and spread by enlargement
of their base; sometimes they are tender and painful, at other times, not so; their
head breaks off easily and bleeds freely, and sometimes, ulcerates, still, however,
retaining the same warty character.—j.  f. s.]

   2192. The  causes of wartis are, for the most  part, unknown: local in-
fluences, as pressure, blows, chafing, and the  like,  frequently seem to
produce them; their foundation, however, is, in general, constitutional
as they are produced in  great numbers in certain persons, and especially
on different parts, without any local influence being discovered ; and they
recur after having been  removed by local remedies.   The blood may be
in such state that where it touches the skin  it may produce warts.
   2193. In treating warts  it must  first be considered whether they de-
pend on any  decided  internal cause or  not, in  order to employ the pro-
per opposite  remedies.   Besides attention  to diet, mercurial  remedies,
soap, fluid extracts, and  resins, are  recommended.  In using these means,
the warts often of themselves, or by the application of external remedies
at the same time, waste  away.  Frequently also, at the period of puberty,
they drop off" without  any assistance.
   2194. The  external  remedies  advised  for  treating warts are very
numerous;  but they  are  all alike, in  that  they may  be destroyed by
caustic, or removed by  tying, or the knife.   To the caustics belong  the
juice of euphorbium, hemlock, sedum acre, strong acetic acid, tincture of
cantharides,  caustic  ammonia, sulphuric acid, hydrochloric acid, butyr
of antimony,  lunar caustic, and tlie like, with which  the  wart is well to
be touched;  and this  must be repeated as often as  the crust falls off till
the wart is completely destroyed.   These remedies are especially appli-
cable,  if the  wart have  a broad base.   If it have a neck, it may be tied 
402
CALLOSITIES AND CORNS.
with a thread, which must be tightened daily ; or it may be cut off with
a knife.   If the wart  be thick, it is  best to remove part with the knife,
and destroy the remainder with caustic.   It must not be forgotten, how-
ever, that in thus treating warts, unhealthy sores are often produced, and
that the scars, after using caustic, are more disfiguring than the previous
warts.  Warts which  are very hard,  irregular on their surface, and very
painful, disallow the above modes of treatment; and if any thing be done,
their complete removal, without leaving any of the degeneration, together
with  the  proper remedies for any general disease connected with them,
must be employed.
  [Common warts, when occurring,  as they frequently do,  in children, in  large
numbers upon the fingers and hands, often disappear with as little apparent cause as
they have  originated, and frequently, in a very short time.   I do  not  think  much
advantage is gained by teasing them with any application; for they are rarely cured
more quickly than if left alone.  When, however, there be a single one or two upon
the  neck, or on the edge of the eyelid, or on the lid itself, it may be as well either to
snip it off  with scissors, or to tie it with a thin thread; and this more especially in
adults.  If a common wart have, as it has occasionally, a very broad base, attempts
to remove  it, by destroying with strong acids, will now and then set up inflammation
of the absorbents; and when this has been checked, and the destroyed wart sloughed
out, the scar takes on again the same disposition, and  the wart is reproduced; it
may become of larger size than before, of which I have had personal experience.
  Gonorrhceal warts, if few and distinct, may be snipped off^ and the wound touched
with caustic potash; but if very numerous and close set, so that this cannot be done,
they must be thoroughly destroyed piecemeal, either with  caustic  potash or nitric
acid ;  but before leaving the patient, it will be proper to neutralize the application
with acid  or alkali, as  the case  may be, or a troublesome, sloughy, and often un-
manageable sore, will be the consequence.  Whilst these warts are small and short
they may very frequently be removed, by strewing daily upon them equal parts of
savine and sulphate of copper, powdered and well mixed together, the parts having
been previously well cleaned and dried, and the collection of the gonorrhceal matter
upon the skin prevented by strict attention to cleanliness.  Fumigation with cinna-
bar  is often also very efficacious.  The broad' warts, which seem to be truly syphi-
litic, almost invariably disappear under a mercurial course.
  Malignant warts must  be removed with  the subjacent cellular tissue down to the
muscle on which  they are  seated.  The application of caustic only irritates, and
quickens their growth.—j. f. s.]
                         *
                 V.—OF  CALLOSITIES AND  CORNS.

   (Indurationes et Clavi, Lat.; Schwielen undHuhneraugen, Germ.;  Cars, Fr.)

   2195.  Callosities are more  or  less  circumscribed  thickenings  of the
epidermis, produced  by continued  pressure.   They are most commonly
seen on the backs of the  toes, on their joints, especially on the last, and
between the toes (corns.)   They are generally flat, as if pressed into the
skin, are produced slowly, and only when they have become large cause
darting pain, una"er which circumstances the  neighbouring parts are in-
flamed  by the pressure of the callous mass.   Sometimes they commence
with violent pain,  especially in persons whose  skin is tender.   They are
more troublesome in  warm than in cold weather.   The skin is indented
in the middle  of a corn, and on examination,  the  corion is  often found
perforated.

  These projections of the epidermis consist of two substances; the upper is dry, in
shape like the head of a nail, and formed of layers of epidermis, one upon the other, 
HORNS.
403
which often readily separate from each other, especially if softened by bathing the
feet.  This substance shows no organization.  The other part deeper and semi-trans-
parent forms the base of the former, penetrates through the thickness of the  skin
down to the tendon, to the ligament, and  even to the  bone, upon which  it is in a
manner rooted, which  shows it to have a certain degree of organization.  Bresohet
observed it to be penetrated in  different directions by numerous vessels.  It is this
which especially causes the pain in changes of the weather, although  that is also
produced by the pressure of the horny substance upon the surrounding parts, in con-
sequence of which inflammation of its whole  extent ensues, and may even spread
(Pigne.)  The corn is, according to Brodie, in the beginning, a thickening of the
epidermis as a consequence of greater secretion from the cutis from pressure; subse-
quently a bursa forms; by degrees inflammation  of this bursa takes place beneath
the horny epidermis, in consequence of  which it becomes  very painful and runs on
to abscess.  Rosenbaum (a) explains the origin of this bursa as consequence of the
closure of the glands of the skin.
   2196. The cure of callosities and corns requires, above all things, the
removal of pressure from tight shoes, and even from tight stockings ; after
which they gradually subside of themselves.   If the corn be  upon the
sole of the foot, a felt sole must be worn, with  a  hole in it, to receive the
corn.   As palliatives may be used, softening plasters, frequently bathing
the feet, shaving off in slices, or scratching away with  the knife, or with
wetted  pumice-stone,  the  application  of a plaster, with  a hole  in its
middle, into which  the corn may be received.   The complete removal of
the corn, by dividing the skin around it with two cuts, lifting it  up with
forceps, and extirpating it with the knife or with  scissors, which is always
attended with  considerable pain;  also its destruction with caustic;  and
strewing it with different remedies, after previously  removing some layers
of the callous mass, are mere palliatives, if the  cause, that  is, pressure,
be not removed.  Some persons are more subject to  corns than others.
   The numerous remedies recommended for corns are either softening plasters and
salves, or irritating and caustic applications, which produce either inflammation,
suppuration, and throwing out of the corn, .or its  destruction.  The latter  remedies
are objectionable, as they often produce violent inflammation, extensive suppuration,
and danger of gangrene.   Also in removing them by slices, care must be taken that
neither pain nor bleeding arise; and the same also applies  to the subsequent touch-
ing with lunar caustic, (Wardrop,) with bals. vit.se Hoffm., with Unci, iodin. 3iv.,
ferri iodur. gr.  xii., antim. mur. 3iv., (Henderson,) and the like, as thereby dan-
gerous symptoms, especially in old and gouty persons, may be produced, and the
radical cure thereby as little effected as by extirpation, if the pressure be not re-
moved.   I  have witnessed dangerous consequences after such treatment, and agree
with P. Franks' warning de clavis pedum caule secandis.
                             VI.—OF  HORNS.

(Cornua, Excrescentiae Cutis, Corneae, Rhinodysmorphia corniculatai Lat.; Hornartige
                       Jluswiichse, Germ., Comes, Fr.)

  Journal de Medecine, Chirurgie et Pharmacie de "VanderMonde, vol. xiv.  1761.
  Rudolphi, Ueber  Hornbildungen;  in  Abhandlungen  der Berliner Akademie^
1814-15.
  Ernst. Dissert, de Corneis humani corporis Excrescentiis.  Berol., 1819.
  Westrumb ; in Horn's Archiv., 1828, p. 316.
  Froriep; in Casper's Wochenschrift, 1833, p. 412.
  Bulletin de la Societe Anatomique de Paris, 1835, pp. 98, 114, 13K

                 (a) Allgemein Medic. Zeitung.  1838.  No< 60, 
404
HORNS.
  Landouzi, Memoire sur une Come humaine.   Paris, 1836.
  Ainsworth, Dissert, de Corneis humani corporis Excrescentiis.  Berol., 1836;
cum tab. aeneis, iv.
  Wustefield ; in Casper's Wochenschrift, 1836, p. 635.
  Ebers ;------------------------------1837, p.  567.
  Steinhaeusen ;  in  von  Graefe  und von Walther's  Journal,  vol. xxiv.
p. 141.
  Cruvelhier, Anatomie pathologique, livr. 20.
  2197.  Horny growths of the skin, and mucous membrane, often rise
several inches above the surface of the skin, and have perfect resemblance
to the horns of beasts.  Usually there is only one, but  sometimes several
at once, or near together; many even are spread over the whole surface
of the body, under which  circumstances  the  disease seems to form the
transition to elephantiasis, where a  horny substance, in shape of scales or
spines, coversthe whole lower partof the body.  These horny growths occur
upon the hairy parts of  the head, upon  the forehead, nose, and  cheeks;
upon the breast,  back, shoulders, arms, and hands;  at the  beginning of
the mucous membranes, and on other parts.
  Horns have been observed on the hairy part of the head by Fabricius ab Aqua-
pendente, Bartholin, Gastellier, Lex, Home, Parkinson, Ansiaux, Piccinelli,
Caldani, Astley  Cooper, Testa, and by myself thrice ; on the nose by myself; on
the hands and feet by Borelli, Lachmund, Dolceus, Dennis, Marc, Otto, Lages;
on the thighs by Dumarceau and  Carradois;  on the face  by Borelli, Riverius,
Fournier, Vicq d'Azyr, Breschet, Wagner, Lorinser, A.Froriep; on the eyelids
hy Voisin ; on the back  and  breast-bone, by Rig-al ; on the loins and buttocks by
Cruvelhier and Rigal;  on the lachrymal caruncle by Chavane; on the conjunctive
coat, and on the tongue, by Breschet; on the red edge of the lip by Jaeger; on the
inside^of the prepuce, on a scar, after the operation for phimosis, by Dieffenbach;
on  the glans penis  by  Reghellini, Bonioli,  Caldani, Ebers, Richard-Destru,
Breschet, and Meckel.  For an account of the most  important early obervations
on such horny growth see Samuel Cooper (a).
  [Erasmus Wilson (b) has given an interesting statistical account of horns which
have grown on the  human body, having " succeeded in obtaining ninety cases; of
which forty-four were females, and thirty-nine males;  of the remainder the sex is
not mentioned.  Of this number forty-eight were seated on the head, four on the
face, four on the nose, eleven on the thigh, three on the leg  and foot, six  on the
back,  five  on the glans penis, and nine on the trunk of the body.  The greater fre-
quency of this disorder among females  than males is admitted by all authors; but
this fact is most conspicuously shown in the instance of the thigh and of the head;
for  example, of the  eleven cases of horny growth from the thigh, two  only were
males; and of the forty-eight affecting the head, twenty-seven occurred in females,
and nineteen in males; in the remaining two the sex being unmentioned.  That old
age is a predisposing cause of this affection, is proved by  the greater frequency of
its occurrence in elderly persons; thus, of forty-eight.cases in which the scalp was the
seat of the growth,  thirty-eight were above the mid period of life; several were over
seventy, and one was ninety-seven; three were young  persons, and three infants."
(pp. 64, 65.)
  In the Museum at St. Thomas's Hospital there are three examples of horns from
the human body, two of  which are those referred to by Astley Cooper; the larger
one, which is about  ten inches long, with a base an inch in diameter, and tapering
towards the tip; it grew on the upper part of a man's  head, and is twisted towards
its extremity somewhat like a ram's horn; it was removed, together with its root, by
Dr. Roots, of Kingston-on-Thames, after a growth of seven years, and had been pre-
ceded by one of three inches long, which had sprung up from the scar of a tumour,
of what kind is not mentioned, which  had been removed, and after growing four
iyears, fell off, or probably was pushed off,  as the  patient was lifting his hat

               (a) First lines of surgery, p. 346. Edition of 1840.
               (b) Med-Chir. Trans., vol. xxvii. 1844. 
HORNS J THEIR CAUSE.
405
 from his  head; leaving "the  surface from  which it dropped," says Roots, "per-
 fectly smooth, and free from any discharge whatever.  In a few months a new horn
 began to appear," &c. (p. 234) ; the horn is now in our Museum.  The other horn,
 which Astley Cooper speaks of, was from the pubes, about an inch in length,
 conical, and three quarters broad at its base and of an oval shape.  The  third case
 was a patient of  my own, who had two of these  horns growing from the left side
 of the scrotum; one rather  larger than the other, about the size of the little finger,
 and  two-thirds of its length; one dropped off whilst  he was  in the  house,
 leaving a  sore surface;  and I intended  removing the  other, but  he took fright
 when it was proposed  to him, and went away.   The Museum of the  Pathological
 Society of Dublin possesses  two  horns of  considerable size, which grew for  six
 years on the upper lip of a man about sixty years of age, and were  removed  by
 Pierce (a).
   In the Museum of the Royal College of Surgeons of England there  are two very
 remarkable horns, which  were purchased at the sale of Sir Ashton Lever's  collect
 tion, and marked, "supposed  to be excrescences from the human head," which is
 unfortunately all the history of them. That they are, however, human there can be no
 doubt, as on the larger one  a few short hairs remain, which, on examination with
 the microscope, presented  all the characters of  human  hair.  They are  conical
 and slightly contracted at their base, as if they had been girt somewhat by the aper-
 ture through which they protruded ;  or as if  a groove had  been formed round them
 preparatory to falling off,  as in the shedding of stags' horns.  The larger is three
 and a half inches long, and the smaller only one and three quarters; but the greatest
 diameter of both is an inch and a quarter.   The smaller one has been sawn through
 vertically and  presents a solid bony core, surrounded by a brownish horny sub-
 stance, varying from one and a half  to three  lines in thickness, and so completely
 covering it, that all connexion between the core and any other bony part must have
 been impossible.   The characters  of the core, in all  respects, even with the aid  of
 the microscope, prove its semblance to healthy compact bone.]
   2198. These  horny  growths are partial luxuriances of the epidermis,  or
 of the mucous lining of an encysted tumour, when the horny substance is
 deposited in a sebaceous bag  {tumor sebaceus).   In the first case, they
 sometimes begin without any pain or  decided cause, or after  some sort of
 irritation, as a little elevation in  the skin, with branny surface, with itch-
 ing,  burning,  or shooting.   After the  branny surface is  thrown off, there
 appears a small, hard, more or less convex swelling, of a white or gray
 colour, which grows more  or less quickly;  in exact relation  with its en-
 largement, it becomes harder, conical, shrivelled, twisted in a spiral shape
 exactly like a brute's horn, from one  to twelve inches long, and several
 inches round, is hardest at the  tip, grayish or dusky on the surface, rough,
 and sometimes covered with hairs.  In the second case, a nail or horn-like
 substance  is  secreted  in an encysted  tumour, (tumor sebaceus,)  which
 bursts the skin, hardens, and protrudes  in proportion as more of the sub-
 stance  is  secreted by  the tumour.   When  these growths have  attained
 great size, or  are periodical, at a certain time of year they are thrown off",
 and for the most part recur, or  leave ulcers behind them.
   [Of the mode in which these horns are formed from a previously obstructed fol-
 licle, Erasmus Wilson (b) has given a very good description, showing  how the se-
 baceous accumulations may become  converted into horn.  He says:—"From the
 torpid action of the skin, or from the nature of the contents of the cells, or from both
 causes together, the sebaceous  substance collects within the follicle, becomes im-
pacted, and acquires an abnormal degree of  density.  In this situation the impacted
mass exerts so great an amount of pressure on the vascular walls of the follicle as to
abrogate its special function, and the peculiar elements of the sebaceous secretion,
cease to be produced.   The formation of epithelium, however, still continues, and

  (a) Dublin Journal of Medical Science, vol. xvi. p. 329)  1839,        (6) Above cited*
  Vol.  111.-^35 
406
HORNS ; THEIR CAUSE.
layer after layer of epithelial scales are developed, until the mass acquires consider-
able size.   Tumours of  this kind, from the nature of the position of the sebaceous
follicle, namely, within  the corium, rarely acquire a large size as  compared with
tumours in other situations.  They are prevented from pressing inwards by the deep
stratum of the corium ; the same structure opposes their increase outwardly or later-
ally.   Nevertheless, I have seen a tumour of this kind, which measured three quar-
ters of an inch in diameter, but  not more than a quarter of an inch in  thickness.
The aperture of the follicle remains open, and is more or less distended in proportion
to the extent of the tumour; but from the nature of the  collection, there is no ten-
dency  to its escape.  I have called such tumours sebaceous accumulations.  Certain
minute tumours, commonly met with in clusters,  around and  upon the eyelids,
sebaceous miliary tubercles, are of the  same pathological nature with the  sebaceous
accumulations, but in these  the excretory follicle is closed.  The peculiar patholo-
gical character  of the tumours  just described, is their  laminated texture, and the
identity of structure of their contents with epidermis, most, if not all, of the peculiar
constituents of sebaceous substance being absent. * * * If now, in the cases above
recited, we imagine the upper wall of the laminated tumour to be removed, and the
accumulated substance exposed to the influence of the atmosphere, any moisture
retained by the epithelial laminae would soon become dissipated, and the wholemass
would  acquire the consistence and hardness of epidermis of equal thickness; in other
words, it would be converted into horn.  Such a case as I am now supposing,  does
sometimes in reality occur.  The  aperture of the follicle  acquires an unusual de-
gree of dilatation, and  some of the hardened contents of the tumour are pressed
through the opening.  By the addition of fresh layers from below, (the formative
power  having increased by the removal of superficial pressure,) the indurated mass
is still further forced outwards, dilating the  aperture as with a wedge, and finally
increasing its size to that of the entire base of the hypertrophied follicle.   The pro-
cess of formation of new  epithelial layers by the walls of the follicle (now become
the base of the mass) will go on, unless interrupted by surgical means, for years, and
in this manner those singular bodies, of which so many examples  are  on record,
horns,  are produced." (p. 57-59.)]

   2199.  The  proximate cause of these  growths is a perverse  and in-
creased secretion  of the vascular  net of the  skin, of the mucous mem-
branes, or of  the internal surface of encysted  tumours.   They  are most
usually produced in persons of advanced age, and their immediate cause
is continued irritation of the skin,  or of the mucous membrane by kicks,
blows, chafing,  wounds, scars, eruptions on  the skin, and  the like; or
they are  in causal relation  with suppressed  menstruation, rheumatism,
and gout,  or rickets.   Most cases, however,  show that persons affected
with these growths are in otherwise sound health;  and even when they
are thrown off, there is usually no disturbance of the constitution.

   Mercier (a)  distinctly observed in a growth  of this kind, which was an  inch
high and an inch and a half round its base, hard and dusky, from its base to its tip,
that it was formed of  fibres converging from the base to the  tip, and which at
bottom were separated by fat, so as to have the appearance of ordinary fibrous tissue.
The fat diminished, and the fibres becoming closer towards the tip, were mostly
grayish black,  and  extremely  hard ; they were also less  soft  and white as  they
approached  the  surface.   They were easily separated  at the root, and  were con-
tinuous with the fibres of the skin, which from the fact of vessels being also present,
led him to believe that they Were  not true hairs, but merely a degeneration of the
fibrous tissue.  Mercier supposed it connected with the skin, and that its  hardness
depended on the evaporation of the fat and  intermediate  fluid.  According to his
notion, some horns are not the result of diseased secretion, but of actual transforma-
 tidn of the  skin.  Hairs may however exist  in such  horns, just  as  in  encysted
ewellings, \>ut the horn  must not therefore  be considered to be formed of conglo-
meration of hair, as supposed by some  persons*
(a) Bullet, de la SocieW AnalomiqUe de Parh?.  1735, p. 114-131. 
BONY GROWTHS.
407
  2200. Examination of these horny growths proves  that their base is
formed of a soft tumour, and  their root usually, in mucous membranes
more particularly,  consists of  a  lardy, vascular tissue, similar  to the
matrix of a nail (Jaeger) ; upon this is a substance composed  of parallel
fibres, which increases in hardness and density near the surface and tip;
the fibres are fewer  towards the centre,  and separated by a soft fatty
mass, which is in greatest quantity  at the root.   The density  and hard-
ness of the growth  are in direct relation with  its dark colour; both are
least in the middle and  towards  the base.  These growths are held to
be  identical with the substance of nail, and the spurs of gallinaceous
birds, which is  confirmed  by chemical examination, being composed of
the  same  substances as the  horns of beasts, excepting the  antlers of
deer, which contain more  than a  fourth of their weight of gelatine, and
have oxygenated  albumen as their principal element.  Their colour,
hardness, and  transparency depend on the carbon, phosphate of  lime,
and glue-like substance  which  they contain (Jaeger.)
   2201. In  their treatment,  their cause  must be  removed   by proper
remedies, preparations of antimony and quicksilver, by baths,  decoctions
of woods,  Zittmann's decoction, and the like.  It has been noticed that
they drop off,  under the use  of purgatives.   If this  do not however
happen, the sound skin  must be divided by two semilunar cuts, and the
horn with  its root extirpated, in doing which every thing in and beneath
the skin, which has degenerated,  and is discoloured, or suspicious must
be carefully removed.   With this  object it may be  advisable  even to
cauterize the wound, so as to produce an issue, and  to  employ propey
after-treatment.  The merely cutting short these growths, by  sawing or
filing, in general causes their  increased growth; and also tearing them
 out, when the connexion of their root is not very great, is objectionable
 on account of the pain and the uncertain results.
                    VII.—OF BONY GROWTHS.

    (Tumores Ossium, Lat.; Knochenauswuchse, Germ.; Tumeurs des 6s, Fr.)
  Matani, Observationes de Ossium Tumoribus.   Colon. 1765.
  Herrmann, Dissert, de Osteosteatomate.  Lipsiee, 1767.
  Houstel, Sur les Exostoses des Os Cylindriques ; in Memoires de l'Academie-
de Chirurgie,!/vol. iii. p. 130.
  Bonn, Tabula* Ossium  Morbosorum, praecipue Thesauri Hoviani. Lugd. Batav.,
1788.
  von Heekeren, De Osteagenesi praeternaturali.  Lugd. Bat., 1797.
  Vollmar, Beobachtungen iiber die Knochenspechgesohwulst; in Loder's Journal5
fur die Chirurgie, u. s. w., vol. iii. p. 46.
  Boyer, Traite des Maladies Chirurgicales, vol. iii. p. 543.
  Otto,  Seltene Beobachtungen zur Anatomie*. Physiologie  und  Pathologie
zehorig.  Breslau, 1816.
  Cooper, Astley, On Exostosis; in his and Travers's Surgical Essays, part k
London, 1818.  Third Edition.
  Pech, Osteosarcoma, ejusque speciei insignis descriptio, etc.  Wirceb., 1819;
  Dietel, Comment. Anatom. Pathol, de Osteosteatomate.  Lips., 1822.
  Miescher, De Inflammalione Ossium.   Berol., 1836.  4to.
  Richter, A. L., Die Organischen Knochenkrankheiten.  Berlin,  i#39.

  [Gibson, W., The History and Treatment of Bony Tumours, in the
Philadelphia Journal of the Med.  Sci., vols, iii andUiu   1821.—a. w. n.] 
408
KINDS OF BONY GROWTHS.
   Also the general observations on Diseases of Bone, by Petit, Duverney, Pallas,
 Boettcher, Bertrandi and Closius.
   2202. Bony growths form swellings of greater or less extent, which
 arise from the surface or interior of the bone, and in which the texture of
 the  bone either remains  natural, or the enlarged bone  becomes unusually
 firm, hard, ivory like, or loosened up, spongy, and partially converted into
 a fleshy or  lardy mass.   According to these various  conditions are dis-
 tinguished true bony growths, (exostosis,) bone-flesh or bone-lard growths,
 {osteosarcoma, osteosteatoma,) and spina ventosa.
   2203. These diseased changes of bone may originate in the periosteum,
 in the bony  tissue itself, or in the medullary membrane.  Their general
 origin is an inflammatory condition of the periosteum, of the medullary
 membrane, or of the membrane lining the bone-cells, which swell  by the
 larger deposition  of the juices, and secrete a plastic matter, which  by the
 laws of  the  natural  growth of bone,  is converted into bony substance.
 Or there is  an unnatural growth of the bony tissue, or there is produced
 in the cells, a fleshy, lard-like  or  gelatinous  substance, which  absorbs
 the mass of the bone, and converts  it wholly or in great part into a lardy
 or fleshy substance.   The causes exciting this inflammatory condition,
 are  either external  violence  or dyscrasic  diseases,  especially syphilis,
 scrofula  and gout.   According to the chronic or acute character of this
 inflammation, and the variety of the  causes on which it depends, does
 the course and issue of this  diseased change of bone vary.
   2204.  True  Exostosis (Exostosis proprie  sic  dicta, Lat.;  eigentliche
 Knochenauswuchs, Germ.) is a more  or less circumscribed tumour arising
 from a bone, and depending on an  unnatural increase of the bony sub-
 stance.   This tumour is sometimes confined to one  part merely of  the
 bone, and attached  to  it by a thin  neck or by a broad  base; at  other
 times, it springs up without any  definite boundary;  and  sometimes
 occupies the whole  extent  of the  bone, under  which  circumstance  in
 tubular bones, the medullary cavity  is in general lessened, or completely
 destroyed.   Some exostoses consist  of a great development of the bony
 tissue itself, arise from  he  medullary membrane, or from the cellular
 structure of the bone; some form over its whole extent, between the bone
 itself and the periosteum.
  According to Jaeger  (a), exostosis never arises from the interior substance of the
 bone, but. is attached firmly  to its external surface;  between it and the exostosis, a
 fine line of the shell of  the bone forms the boundary; this is gradually absorbed, so
 that the cells of the  exostosis are  partially, or completely connected with those of the
 bone.  But the exostosis which is developed between the periosteum and the bone,
 is oftentimes  the consequence of a natural  secretion of the bony tissue itself, and
 spreads from the interior towards the exterior of the bone. In this case the perios-
 teum is only secondarily changed, and the tumour seems like a wedge sunk into the
 substance  of the bone,  is co,mmonly hard,  and like  ivory. The substance  of the
 mother bone is compact, hard and ivory-like  to a greater or less depth.  In other
 instances  the tumour springs from the periosteum itself, in consequence  of inflamma-
 tion of its substance; sometimes a plastic  exudation takes place on its inner surface,
 which becomes bony at the same time, and in the same manner as in the natural
formation of bone.  Sometimes  these deposits are separated by the internal plate of
the periosteum, and are then more or less  moveable upon  the bone itself;  at other
times they are firmly attached to the bone, which itself exhibits no change.   These
axosioses. are generally cellular,  and  rarely  ivory-like.  They are not unfrequently
(a) HandwOrterbucb, vol. ii. p. 507. 
EXOSTOSIS.
409
noticed at the seat of encysted tumours, which  by their pressure have given rise to
them.  (Pigne.)
   2205.  The internal  condition  of exostosis varies;  sometimes  if  the
swelling be  not large, and lie on  the  surface of the bone, a net-work of
body fibres is observed, in the interspaces of which a new mass of bone
is deposited; sometimes  the interior of  the swelling presents  rather a
laminated structure, sometimes  the hardness of the exostosis  is- greater
than that  of the healthy bone ; it  presents in its interior a regular compact
mass like ivory,  and  is either smooth  upon its surface-or has  distinct
studdings.
  To these must be certainly considered to belong those bonytumours whieh Astley
Cooper  has described as Cartilaginous Exostosis of the Medullary Membrane;
Scarpa (a) as Exostosis maligna; Otto (b) and von Walther (c) as- Osteosteatoma;
John Muller (d) has described  it most minutely in all its relations- as Enchondron
(Sarcoma cartilagineum, Tumor cartilaginous.),  He speaks of a good kind of swell-
ing of the bone, or even of the soft parts; for  instance,.of the glands, which form a
spheroidal  tumour, not lobulated, and acquiring  the size of a fist, or larger.  When
in the soft  parts it has a thin covering- of ceHulartissue, but in bone, where it occurs
most frequently, it appears like a soft ex-panskm of the bone overspread with perios-
teum, the expansion being either developed fromv within, with a bladder-like  expani
sion of the thinned shell of the bone; or more rarely it appears to be produced from
the exterior of  the bone, and then is  not necessarily enveloped in a bony shell.  In
the former  case the  bladder-like  expansion  of the. periosteum forms a sort of shell,
enclosing the  soft mass; sometimes  there are merely single, isolated, insular, thin
patches of  bone.  The joint-suriaces  of the btone are generally in this disease either
not at all or but little ehanged;  even-whea>a phalanx-of the finger enlarges  to a:
tumour of the size of a. lemon and round, the joint-surfaces  usually continue natural.
The parts  over the  swelling  in  general remain  unaltered^ although they be mucft
expanded.   Now and then the slow painless development of the tumour, as well as
the constitution- continuing healthy for ten or twenty-years, lead to the notion that
the swelling is not malignant.   The contents of the tumour  are soft, in. and upon
the bone in general, with interwoven projections of spongy substance, which, how-
ever, may be entirely deficient.   The parenchyma, of the  tumour usually presents,
on  being cut-into,  two elementary parts, distinguishable with the naked eye, of
fibro-membrannus, and a gray slightly transparent substance, similar to cartilage or
lough jelly.-  The fibro-membranous  part, whieh is rarely, wanting, forms  small or
large cells, of the  size of peas, or larger; and in the larger, smaller cells  are often
developed.  In their cavities is a grayish, rather transparent substance, distinguished
from cartilage  by its  softness, and rather resembling the soft hyaline, or glass-like
cartilage, existing in some fishes, and sometimes-even like tough jelly.  This sub-
stance may be easily shelled out of the cavities, and can be readily  broken  up*
When put in spirit of wine it still retains its slightly transparent character.  The
more transparent cartilaginous substance is massed  together by partitions of mem?
branous  structure, and such conglomeration is peculiar to the enchondrorn, and does
not occur in other swellings of bone.   If the mass seem  free on the surface little1
elevations  are  noticed, which-show-the  conglomeration  externally.  Microscopic
examination shows that the fibro-membranous part consists of transparent net-like
fibres;  the glassy mass completely resembles cartilage, and exhibits oval,  round,
semi-transparent cartilaginous corpuscles spread about in it. After boiling from ten
to twelve hours, the enchondrorn  of hone gives out a considerable quantity of gluten,
which, on  cooling,  becomes well gelatinized, but in its chemical properties is  en-
tirely different  from common gluten colla, but on the contrary, agrees with the pecu-
liar  gluten of  cartilaginous fishes, the cartilage gluten, or chondrin, described by
Muller.   The chemical examination of the enchondrorn of.soft parts presents a dif-

  («r) De Expansione Ossium,  &c.; in his  tomie, Physiologie,. und Pathologie gehorig,
De AnatomectPiithologiaOssiumCbmrnen-  p. 22.  Berlin, 1824.
tarii. Ticini, 1827.  4to...                  (c) Journal fur Chirurgie und Augenheife
  (b) Neue Scltcne Beobaelitungen zur Ana-  kunde, vol. xiii. part iii. .
                             (d) Above  cited, p. 31.
                                     35* 
410          exostosis; its causes,  symptoms,
 ference, as on boiling the common chondrin, but then even no chondrin contains, on
 the contrary, a considerable quantity of jellying gluten.  Usually the existence of
 enchondrorn proceeds from external causes, as bruises and the like, and this happens
 most commonly in childhood.  I have, however, seen it in the metacarpal bone of
 the thumb of an aged man, in whom it first arose at  a  late period, and whose cure
 was permanent after its extirpation.  A general cause  of the  disease is ordinarily
 not to be found, although tumours of this kind often occurring in different parts
 may lead to  such conclusion, but the cure is usually permanent after amputation.
 I have noticed this also after the removal of an enchondrorn of the testicle, and in
 the upper third of the upper arm.  The development of enchondrorn is in general
 without pain, and may so arise and continue  increasing for a long while.  If from
 any cause inflammation be set up in  the swelling, it proceeds to suppuration, the
 swelling bursts, and  the bone becomes necrotic.
  An interesting case of extirpation of the finger with  its metacarpal bone, at  the
 carpus, is given by Walther (a).  Muller (b) has also collected the various ob-
 servations on enchondrorn, and it has also been written on by J. Herz (c).
   2206. Exostoses may arise in all bones, but they most frequently appear
 ©n the compact parts of tubular bones, and on flat bones, in the middle of
 the thigh, of the shin bone, the upper-arm-bone, the radius and ulna, and
 on the bones of the skull, but rarely  in the neighbourhood of the spongy
joint-ends of bones.  The proximate cause  of exostosis is a  change of
 the nutritive process of the bone from  inflammation, in  consequence of
 which a large quantity of phosphate of lime is. deposited in the bony
 tissue, and  upon this its enlargement depends.  The time required  for
 its development seems correspondent with that for the  natural formation
 of bone and callus, as its subtratum is at first soft, and only at a later  pe-
 riod hardens.  The  occasional causes which bring about this inflamma-
 tion are, as already generally noticed, either  external violence or internal
 disease, especially syphilis,  gout,  and  scrofula.  There may be  so  re-
 markable predisposition to exostosis, or an increasing deposit of bony sub-
 stance,.that very inconsiderable external violence may  favour  its  forma-
 tion (d).  Syphilis in general produces, especially as consequence of in-
 flammatory  affection of the periosteum, superficial exostoses or nodes {Gum-
 mata,  Modi, Tophi Venerei,) and  most readily in bones little covered with
 soft parts.   Scrofula more commonly gives rise to the exostoses which are
 seated deeply in the bony tissue.
  I have observed a similar predisposition to exostosis in. an otherwise healthy and
 Strong young man.
  2207. The symptoms which accompany the origin and further develop-
 ment of exostoses vary according to their  cause and  nature.   Sometimes
 they occur with more or less distinct symptoms of inflammation;  some-
 times, however, without any pain.   If the exostosis depend  on syphilis,
 it is  nearly always  preceded by severe boring, or gnawing pain, setting in
 especially towards night, which at first spreads over the whole bone, but
 afterwards fixes on the point where  the exostosis forms.  In scrofulous
 exostosis the pain  is duller and less severe:  this is, however, in general
 the case, if the exostosis arise after external injury, when the pain usually
 soon subsides, and the swelling is so imperceptibly developed that it is
 commonly only first  noticed when it has acquired some size.   Exostosis
 principally forms either slowly or quickly; in the former, case  the struc-

  (a) Ak>ve cited.                                   (fc) Above cited;
  fci Dissert, de Enchondromate. Erlangen, 1843.
  dd), Abernethy, quoted in Samuel Cooper's Surgical Dictionary, p. 515.  Edit, of 1"838. 
DIAGNOSIS, PROGNOSIS AND TREATMENT.         411
ture of the growth is usually very firm and the pain slight, in the latter
the pain is very severe, the swelling grows quickly, and is often accom-
panied with violent  fever.  Sometimes the pain, which had existed at
first, subsides during the progress of the disease.  Not unfrequently the
swelling remains at a certain size, without further increasing, and without
causing other symptoms than those produced by its seat and pressure upon
the neighbouring parts, to wjt, a displacement of the muscles, disturbance
or loss of motion of the  part, wasting, paralysis, and the like:  such is
especially the case in  firm idiopathic  exostosis, which has been slowly
developed.   Less firm exostoses may run on to ulceration and ill-condi-
tioned ulcers. A rare termination of exostosis, especially of the firm kind,
is its complete separation  by necrosis.
  2208.  The diagnosis of exostosis, in  inference to its original causes, to
the substance forming it, and  the part of the bone where it has been
originally developed, is founded on the following circumstances.  Idiopa-
thic is distinguished from syphilitic, and scrofulous exostosis by the pre-
vious violence, and by the absence of  the symptoms which syphilitic or
scrofulous disease manifests.   Syphilitic exostosis is always accompanied
by the symptoms of general and inveterate syphilis, with nightly  pains of
the bones, is mostly  situated in bones  covered with little  soft parts, and
usually arises on the  surface of the bone.  Scrofulous  exostosis is accom-
panied with the general symptoms of  scrofulous  disease, and is mostly
situated in the deeper  bony tissue and the spongy joint-ends of bones.
Slow  development of the  exostosis; leads to  the  expectation of a firm,
ivory-like nature; whilst  a quicker, progress, accompanied with  much
pain,  points to a less firm  structure.  These symptoms are not, however,
certain.   When ulceration has taken  place, it may be ascertained with
the probe, or with the finger, from the  condition of the parts.
  2209.  The prognosis of exostosis is in general unfavourable;  it is most
favourable, however, in the idiopathic kind, if it  acquire  a certain size,
remain stationary, and is only inconvenient by its size and wTeight.   Sy-
philitic and  scrofulous exostoses are always accompanied with a high  de-
gree of  constitutional ailment; they may pass into malignant ulceration,
which wastes the powers.
  2210.  The treatmeat is  guided by the various causes and condition of
the swelling.  If syphilis or scrofula be at its root, the remedies opposed
to these must be employed.  If the pain be  considerable, leeches, rub-
bing with mercurial ointment and opuam, softening poultices with opium,
and the like..  The dispersion of a true exostosis is never to be expected
from the various dispersing remedies which have  been recommended.for
external use,ashemlock, mercurial, and ammoniacal plaster, Schmucker's
plaster,  rubbing in volatile salves, long-continued  blistering; they may
rather by their  irritation, set  up  inflammation in the  skin, increase  the
pain, and even encourage the enlargement of the swelling.   In  general
the progress of the disease is not arrested either by general or local treat-
ment.   When  these remedies have actually  dispersed bony swellings,
they were doubtless  only inflammatory swellings of the periosteum.
  2211.  In idiopathic  exostosis, the further increase of the swelling may,
perhaps,  at the onset, be prevented, by blood-letting,  and the continued
use of cold  applications, and afterwards by dispersing remedies; its size
may also, perhaps, be diminished. 
412           OSTEOSTEATOMA AND OSTEOSARCOMA.
   2212.  If the exostosis be void  of pain, if it do not enlarge, nor incon-
venience  the  patient,  or  if situated on any part  where  mechanical
treatment is  improper, it is advisable to let it alone.   But if the swelling
be very inconvenient to the patient,  and  if its situation admit  of me-
chanical  treatment, the only remedy is its  removal.  This  requires the
exposure of  the swelling by a crucial cut, or by twro semilunar cuts at its
base, and its separation with a fine  saw, or with a chisel and hammer.  If
the exostosis  be firm and large, it must be removed piecemeal;  a horizontal
cut with  a saw  being met by a vertical one.  The treatment of the wound
consists  either in bringing together its  edges, if the-part whence the
swelling  has been removed be  sound, or in  the application of a mild
dressing, as  has been described in wounds of bone with loss of substance.
If the size of the swelling permit  not its removal, amputation of the limb
must be performed.
   In most cases the removal of exostosis is best effected by Hey's, Machell's (a),
or Graefe's (b) saw, and Heine's bone-knife.
   When the position of the exostosis will not permit its removal in the above man-
ner, instead of proceeding  to amputation, its absorption should be encouraged by
removing the periosteum from the swelling, in consequence of which its vessels are
pulled out. This plan of treatment is at least recommended by Astley Cooper (c).
   On the side of the nail, especially, of the great toe, tumours not unfrequently arise
which are hard and  immoveable, covered with a glossy skin, their interior as hard as
the bone from  which they arise, and.they are mostly seated on a broad base. They
cause considerable inconvenience in walking; after extirpation they soon recur, and
the only remedy is the removal of the whole phalanx  (d).
   2213.  Osteosteatoma and  Osteosarcoma  {Knochenspeck und Knochen-
fleisch-Geschwulst, Germ.)  and Spina ventosa  (Winddorn,,Germ.) must
be considered as  allied:diseased conditions, inasmuch as in both there is
an enlargement of the  bone deviating from its  natural condition, with
which  its nature  is  completely changed  and converted, into a fungous,
fleshy, jelly-  cartilage- fibre- medulla- fat-  or lard-like substance, in which
are found larger or smaller, pieces of bone of various shape.
   2214.  The causes of osteosteatoma and osteosarcoma  are partly external,
partly internal; to the former belong violence  of all kinds; to the latter,
an ill condition of the juices, venerea], scrofulous, rheumatic, and gouty-
diseases.  Boyer and  others suppose that osteosarcoma  is  of  similar
nature  to carcinomatous  degeneration' of soft parts, and support  this
opinion especially by cases; in which, after the removal of the disease, or
after amputation of the limb affected with it, the same disease has taken
place  in  other  parts.   According to my view  such cases must be con-
sidered as uxeduWavy fungus of bone.
   The formation  of osteosteatoma and of osteosarcoma is always preceded
by an  inflammatory  condition,,the  cancellous  membrane  swells  up  and
thickens, the cells of the bone expand, the membrane  lining them pro-
duces fungous growths, the nourishment of the bone is so changed,  that
there is no longer any deposit of phosphate of lime,, but a flesh- or lard-
like, or other kind of substance, is produced.   If such bone be subjected

   (a) Astley Cooper, above cited, pi. xv. figs.   (d) R. Liston,. On the Cure of Exostosis
7, 8.                                of the last Phalanges of the Toes by excision
   (6) Schwalb, Dissert, de Serra orbiculari. of the Diseased Bone; in- Edinburgh Med.
Berol., 1819.                          and Surg. Journal, vol. xxvi. p. 27.   1826.
   (c) Above cited. 
OSTEOSTEATOMA AND OSTEOSARCOMA.           413
to maceration, nothing remains but the partially-expanded cells of the
bone, the walls of which  are  exceedingly fragile.   The formation of
osteosteatoma and  osteosarcoma proceeds, although, most frequently, yet1
not alone, from  the periosteum, as supposed by many, but also from the
whole bone.   Its firm connexion  with the periosteum does not contradict
this, as close connexion with the periosteum occurs in all irregular forma-
tions of bone.
   2215.  The substance of which osteosteatoma and osteosarcoma consists,
is various;  sometimes  homogeneous,  lard-like, similar to a  scirrhous
gland ; the cells of the bone are much expanded, and filled with fungous
growths,  sometimes pap-like, gelatinous, and brain-like at certain parts;
sometimes the tumour forms a hollow ball with firm walls, and its interior
is filled with painless, sponge-like granulations.
   2216.  The Symptoms accompanying osteosarcoma or osteosteatoma, are
not distinguished from those of exostosis.  In  most cases the disease is
preceded by  a deep-seated pain, which at first is slight and remitting, but
subsequently fixed to  the  spot  at which the swelling appears.  As the
substance grows, the pain in  it usually becomes severe and lancinating;
the skin  is tense, sometimes  inflames, at last bursts, hectic fever  is set
up, and the patient's powers are  broken up.  The ulceration may run
into a canCer-like ulcer.  Many differences, however, present themselves
in the progress of osteosarcoma  and osteosteatoma; the pain is sometimes
very severe  at the  onset, and diminishes or entirely subsides afterwards;
sometimes the disease remains in  one definite state, and the pain ceases;
sometimes  the pain prevails with equal severity from  the beginning to
the end of the disease.  It is self-evident that from the situation of the
disease, from its spreading, and from the neighbourhood of important
organs, symptoms  may be produced.
   2217.  The external condition  of the tumour varies; sometimes it is
confined  by well-marked bounds  to  one part of the bone, sometimes it
involves  the whole bone.  In  general, osteosteatoma and osteosarcoma
have no precisely defined limits, but  are gradually lost in the neighbour-
ing parts  ; the swelling does not entirely resist the pressure of the'finger,
but shows rather some elasticity,  and at several parts a seeming fluctua-
tion, by which it is distinguished from exostosis.
   2218.  The treatment of osteosteatoma and osteosarcoma precisely agrees
with that of exostosis.  At  first,  if  merely pain be present,  remedies
opposed  to  the  cause of the  disease must be  employed, in connexion
with blood-letting, cold applications  and the like upon the affected part,
for its somewhat  possible prevention.  These  are  the  only  remedies
which  can be employed for its control, when  the  swelling has already
made some progress;  howTever, usually, no advantage is thereby gained,
and time is  merely lost in  the progressive increase of the swelling.   The
alone remedy, if the  seat  and condition  of the disease permit,  is the
removal of the swelling with the saw, or with the chisel and hammer, or
the amputation of  the limb if tumour have attained considerable size, or
the whole bone be affected.   Where possible,  the amputation should be
performed above the next joint.
   The prognosis always remains  in other respects doubtful, because in
most cases the disease again  shows itself on the scar, or on some other
part. 
414
SPINA VENTOSA,
  2219. Spina ventosa or Pedarthrocace {Winddorn, Germ.) is a swelling
partially or entirely occupying the whole extent  of the bone, tolerably
equal and  regular, in which  the nature of the bony tissue is in various
ways conditioned.   Sometimes a regular, firm bony crust, which is per-
forated at different parts, forms the exterior of the swelling, in the cavities
of  which  a  cartilaginous  mass is found  with  irregular,  isolated  or
attached bony growths.   Sometimes the external wall of this  swelling
is formed merely of very much  expanded periosteum, and the substance
within, as  in the former case.   Sometimes  the interior contains one or
several cavities, filled with variously coloured ichorous fluid, a reddish
gelatinous  substance, or  with decomposed  and clotted blood.  In the
walls of these  cavities is found sometimes a cartilaginous, sometimes a
lard-like substance, sometimes necrosed or carious pieces of bone, which
must be considered partly as the remains of  the destroyed original bone,
and partly as a new production  {a).
   2220.  This disease always declares itself a longer or shorter time before
the swelling appears, by dull deep pain  in the bone, which is set  up either
of its own accord, or after some  external violence.   The swelling appears
either as a conical or spherical  knob, or as a regular swelling, including
the whole circumference  of the bone.   The  pain  is of varying severity,
and often  increases to a very considerable  degree as  the swelling in-
creases.   The soft parts surrounding the bone swell lip, the skin becomes
painful, red, thins at the most  elevated parts, bursts and discharges  an
ichorous fluid.  The  edges of  the  ulcerated aperture  thin and drop in-
wards, whilst the rest of the swelling retains. its. size and consistence.  A
probe  passed through this opening can with  ease be  carried deeply in
 every direction,  penetrating the cartilaginous  substance, and  but  little
 arrested by the fragile pieces of bone.   From the  discharge of the juices,
 and the absorption of the ichorous fluid hectic symptoms arise at  an earlier
 or later period;  fungous excrescences spring out of the apertures, are
 exceedingly sensitive, bleed easily, and increase the exceedingly severe
 pain.
    [Our celebrated countrymen, Richard Wiseman, has  given (b) a very excellent
 description of Spina ventosa, of which he says:—" It hath been taken notice of by very
 few authors, and I myself succeeded happily in the curing those in the lesser Bones,
 many years before I knew what name to call the Disease.  And in truth I do not now
 greatly approve of the name, but shall acquiesce in it and represent it to you, as I
 have frequently seen it in my Practice in the King's-Evill, it being a certain species
 of that Disease, and of no other that I ever saw. It taketh it's beginning from a thin
 acid serum in the medullary juice, which corroding the Fibres  maketh a solution of
 continuity  there, and at length corrupteth the interior part of the Bone, and at last
 (if not prevented) corrodes the Shell, and passeth it's subtill Humour through some
 porosity it  had  made.  This  Disease of the interior part, by degrees usually so
 affecteth the exteraall Shell of the Bone, as to raise it to a preternatural] Tumour,
 which, at the same time, overstretching the  Periosteum causeth an uneasiness;  and
 this Pain if it grow so acute as  to produce Inflammation, an Abscess consequently
 followeth.  If the Bone be spungy and soft, it is wonderfull to see how quickly the
 Fibres of it will be mollified by the influence of the serum of the Blood, and made
 apt for a sudden Distention, as if the part were rather musculare than Bone.  So in
  childrens  Fingers, I have seen a Bone swelled in  a night, and the like Tumour
 raised in the spongy Bones of elder persons in few days, without much difficulty to
 yield again to exsiccant Remedies.   Yet it sometimes  happeneth, that  the interior

    (a) Delpech, Precis Etementaire, vol. iii.    (b) Several Chirurgical Treatises.  Lon.
  p. 583.                               don, 1676.  fol. 
      richard Wiseman's description of spina ventosa.  415

part of the Bone is totally corrupted without any externall Tumefaction or Pains,
till the acid Humour maketh its way through the cortex, and eroding the Periosteum,
causeth a solution of continuity there; which by access of pain swelleth and in-
flameth the externall Parts, and produceth Maturation in few days.  Those in the pro-
tuberant Bones do also frequently raise Abscesses after the same manner, and some-
times whilst the exteriour Parts  suffer under another  Ulcer different from this.
Somewhat of their Differences I have showed you in the preceding lines, others
may be taken from the Quality of  the serum.  In some there is  a sudden  Tumour
raised in  a night, in others it  swelleth  gradually, and never corrupteth externally.
In others the Humour pierceth through the cortex, and Taiseth suddenly an Abscess.
And these Differences may be said lo arise somewhat from the Place or Bone they
affect: for, accordingly as the interiour part of it is softer or harder, or the externall
cortex is solid orporous, so itsuffers Solution sooner or later.  Those of the cranium for
the most part pass their way through the interiour lamina and affect the dura mater,
<$rc, producing great Pains, Convulsions, Spasmus, Epilepsies, and they die before the
Disease is discovered.  In the great Bones of the  Knees, Ancles, Elbows, &c, they
pass their Matter slowly, and  are more generally  diseased with Apostemations, ex-
ternally arising from the protuberance of them.  In the Os tali or Heelbone, which
is spongy within,  and full of externall pores, they make their way through more
suddenly, and so accordingly they do in the Jaws, Fingers and Toes.  The cause  of
the Spina ventosa I have already delivered you in short to be the Acid quality of the
scrum sanguinis in the Bone.  The most visible Signs of it are a protuberance of the
Bones without discolouring of the Skin, and often Without Tumour or Pain.  The
Apostemations proceeding from the Spina ventosa do most certainly shew them, they
rising always between the Membranes and Tendons, and somewhat of Fluctuation
may be felt there before the external Skin be considerably inflamed : also if upon
 Opening it you make search with  a Probe, you Will find it penetrate deep into the
 Bone, yet is the cortex of it white; whereas the other Abscesses do always begin
externally, and if the Bone be bare, yet is it only  superficially carious or stained by
 the Matter.  The Cure of the Spina ventosa in the lesser Bones, as  the  Cranium,
 Jaws, Fingers, and Toes is  feasable; but those in the bigger Bones are for the
 most part deplorable.   Infants and Children  are generally the subject of this Dis-
 ease." (pp. 262, 63.)]

   2221. The ground of Spina ventosa lies in an inflammation and ulcera-
 tion of the medullary membrane of the bone, upon which depends the
 destruction of the bone from within outwards.   The most common cause
 of thiscbmplaint is scrofula, although also syphilis, gout, rachitis, scurvy,
 smallpox, and the like, as well as external violence, particularly bruises,
 and concussions may  give rise to it.  The tubular bones, especially the
 metacarpal, metatarsal, and finger bortes, are most frequently attacked by
 this disease; but very rarely are the short and spongy bones, as the car-
 pal and  tarsal affected with it.  The degeneration of the spongy ends  of
 bones, which has  been considered with the  different  affections  of the
joints, (par. 221,) may indeed be placed, together With  Spina ventosa,  in
 the compact structure of tubular bones.  In most cases, especially in the
 finger and metacarpal bones of scrofulous persons. Spina ventosa  consists
 in  tubercular formation in the bone^  and according  to the degree  of
 softening in the tubufcular mass, does  the nature of the contents of the
 swelling vary.   Hence the death of the  bone is Caused to a  definite
 extent, and on its throwing off does the cure first commence.  In this disj
 ease, ordinarily, no new bone is produced, probably because the peri*
 osteum  and the  medullary membrane of the bone' are destroyed.   Hence
 also the bone, after the cure of the disease, is Considerably shorter, and
 the corresponding finger drawn backwards.
    2222. From  the symptoms  which accompariy the  development atod
 further progress of Spina ventosa j the distinction between it and exostosis, 
416       CAUSE AND TREATMENT OF SPINA VENTOSA.

osteosteatoma or  osteosarcoma, must,  in  many cases, he very difficult,
Spina ventosa may indeed  be distinguished from exostosis, inasmuch as
it involves the whole  circumference,  whilst  exostosis is  more  circum-
scribed and confined to one definite part  of the bone; the irregularities,
however, which Spina ventosa at first exhibits, and the thickness of the
soft parts covering it, render the certain knowledge of the  difference be-
tween them very difficult.   In  regard to the external form, Spina ventosa,
for the most part, agrees with  osteosteatoma and osteosarcoma ; its deve-
lopment, however, is in most cases-more  tedious than in both  those dis-
eases, and  the pain is more severe  and constant.
   2223.  Spina ventosa is  a disease of importance, slow and difficult to
cure, and proportionally more  so when attacking adults.   In general its
treatment corresponds at  the  commencement  of the disease  with  that
already directed for exostosis,  osteosteatoma, and osteosarcoma.   Suitable
remedies must be  employed to  counteract the internal  causes,  and the
great hope in  young persons, when the disease has originated in scrofula,
rests on  the use  of antiscrofulous  remedies;  and  by the  often occur-
ring total change  of  the constitution, at the  period of puberty, the cure
may be brought about, under  which  circumstances the necrosed pieces
are thrown off" from the  diseased  bone,  and  fistulous  openings close.
Poultices of aromatic herbs, of decoction of savine,  balhs of camomile,
of hemlock, and  the like, serve for  local applications.   If the  tumour
have burst, aromatic baths and poultices must  be employed, and a  free
outflow given to the  pus.    For assuaging the very severe pain, frequent
poulticing With  hemlock, sometimes with  the addition of opium, must be
employed ;  but if the disease have  reached such degree that the  powers
of the patient are  failing under hectic symptoms, amputation is the only
hope.   Laying  bare, boring holes in the  bony tumour, is also the appli-
cation of acrid remedies, or even of the actual cautery, for the destruction
of the diseased  bone, are  improper.
  The formation of tubercles in bone which has been referred to in various places, as
in spondylarthrocace and Spina ventosa, and indeed pointed out by the older writers.
(Galen, Severinus, Gerber, HancRe,) has been more carefully described  by Del-
pech and Neibert, but especially by the attention which the Anatomical Society of
Paris have given to the subject (a), and by Nelaton's clever treatise (b) it has been
carefully set forth.  Of this treatise  Pigne has given an abstract in his French Trans-
lation of this work, which I the more readily here repeat, as it confirms many of my
own earlier statements.
  The  causes of tubercular formations in bone are  those of tubercle in  general.
Most commonly it appears  in childhood, although  it is often enough  noticed in
adults.  All  the bones may be attacked with it, though the several bones may be
arranged in the following way, according to the frequency of its occurrence in them;
the vertebrae,  the shin-thigh-and upper-arm-bones, (in children,) the fingers, meta-
carpal and metatarsal bones, the breast-bone, ribs, iliac bones, the petrous portion of
the temporal bone, and the short carpal  and tarsal bones.   The disease  appears
under two forms; the tubercular mass is collected in one or several cavities, in the
middle of the bony substance (tubercula cystica, Lat.;  tubercules enkystes, Fr.); it
may be infiltrated into the cells of the bone (Infiltralio tuberculosa Lat.; infiltration
tuberculeuse, Fr.)          ^
   A. The encysted tubercles appear during their progress in five stages  (c):—
  (a) Bulletin de la Societe Anatomique de
Paris.  August and November, 1837; May
and July, 1838.
  (6) Rechercbes sur 1'Affection Tubercu-
leuse des Os.  Paris, 1837.
  (c) I have translated this abstract from
Pigne.—j. f. s. 
FORMATION OF  TUBERCLE IN BONE.             417
  1. Gray Granulations (Granulations grises.)—At  the  top  of the affected part of
the bone from which the periosteum  has been removed, some vascular points are
observed, forming  violaceous marblings, and  sometimes slight elevations which
deprive the bone of its regularity.  If layer after layer  of the compact part of the
bone be first removed, and afterwards its cellular tissue, a substance is reached of
many lines in  extent, formed by the union of little pearly granulations, half aline in
diameter, of a  white opaline colour.   Many of these  granulations, specially such as
are at the periphery, are encircled by a little bony shell  of very great  tenuity and
transparence.  It is not uncommon to  find some of these granulations, which present
in their centre a yellow opaque  spot, indicative of commencing transformation ; in
the interstices separating them some exceedingly  delicate  vessels  creep, which
inosculate with  those of the surrounding  bony tissue, upon which a very distinct
injection is perceived.  The surface of the bone, at  the nearest  point of this tuber-
culous  deposit,  is  often  doubled by a bony layer of  recent  formation.  These
granulations exhibit complete identity with those generally regarded as rudiments
of pulmonary tubercles;  they are pretty frequently  met  with on  bones, which on
other parts of  their extent exhibit well-developed tubercles;  and the lungs of  per-
sons in whom they are  met with generally contain tubercles.  The bony partitions
which  separate each of these granulations are not slow to be absorbed and disappear
entirely, and then occurs the second period.
  2. Crude encysted Tubercles (Tubercules crus enkystes.)—These granulations being
united into one single mass, lose their primitive colour and appearance; the vessels
and partitions which separated them have disappeared: there  is  soon merely an
opaque-white  mass, inclining to yellow, like that of putty, without any elasticity,
and retaining  the impress of the finger; it is  homogenous,  contains no bone, and
presents sometimes slight marblings, more white, or slightly gray.  This matter is
contained in a cyst, which lines all the  anfractuosities which  the tubercular cavity
presents.  This cyst, which has but little thickness, is at first gelatinous, transparent,
but ends in acquiring considerable resistance, and contains vessels more and  more
numerous as  the tubercle increases   in softness.   The bony cavity is more or less
regularly rounded, sometimes angular, and  forming  many adjacent cavities, which
open into the central cavity.   Its  surface, though  generally smoothed,  presents
sometimes a heap of  little bony needles  of exceeding  delicacy, almost  all  parallel,
and directed towards the centre of the cavity.  At  other times, instead of being
entirely bony, these  walls are formed  of  bony, fibrous  and  cartilaginous  tissue;
when,  in consequence of its development,  the  tubercle has reached the surface of
the bone, when  it is immediately beneath the periosteum, the latter becomes hyper-
trophied and  adheres strongly to the cyst.  For the rest, the  bony tissue which
bounds the excavation  has preserved its natural  density and texture; all the  parts
invaded by the tubercle, instead of being crowded together by it, are destroyed as it
were by a punch.  These tubercular collections have an extent varying  from two to
three  lines in  diameter, up to fifteen  and twenty; they are generally not  very
numerous, and  it is very common to find  only one  pretty large one, and many of
small   dimensions.   When  a  tubercle  is developed in a  bone,  its  periosteum
becomes  more vascular, as also the  bone at the point nearest  the accidental pro-
duction.  This  vascularity is soon followed by the  deposition of layers of newly
formed bone;  besides, tubercles developed near the extremity of a bone, open more
easily  into the cavity of the joint than on the surface of the bone;  and this may be
imagined, inasmuch as having traversed the entire primitive bony tissue, the  tubercle
has still to traverse the bony layers of new formation, Whilst towards the  joint no
such analogous  obstacle is met  with.
   3. Softened  tubercles (Tubercules ramollis.)—The more slowly the  matter contained
in the  cyst softens, and so soon as the softening operates regularly  from the centre
to the  circumference, so soon does it proceed from one part of the periphery to pro-
pagate itself to the  whole mass.
  4. Eliminary process (Travail d''elimination.)—The collection of tubercular matter
proceeds  then like a true abscess, which having reached the skin,  inflames and
perforates it, and gives  vent to a grumous liquid, consisting of white, cheesy flakes,
suspended in a turbid serosity.  When all the matter is voided, a  fistula remains,
which daily furnishes a varying quantity of serous pus,
  5. Reparatory  process (Travail reparaieur.)—At  the  end  of a period of very
variable length,  if  the patient can  stand against  the  abundant  suppurations, a
   Vol. hi.—36 
418
FORMATION  OF TUBERCLE IN BONE.
 tendency to cure is manifested; the cyst acquires considerable increase, thickens,
 hypertrophies to the extent of entirely  filling up the cavity which  it lines, and ends
 in presenting completely the appearance of fibro-meduUary tissue.   The termination
 of this affection is not always so fortunate; it may, however, be stated in a general
 way, that the disease tends much  more towards a cure  according as its primitive
 seat is nearer the skin.
   B.  Tubercular Infiltration embraces  three different states of the bone:
   1.  Gray infiltration (Infiltration grise.)—The  bony  parts  which are  affected
 present, in all the points which contain this tuberculous matter, spots of a  grayish,
 opaline, slightly rosy tint, and semitransparent, formed by the deposit  in the cells
 of the bony tissue, of a substance analogous in appearance to encephaloid substance;
 the circumference, instead of being lost insensibly, is suddenly bounded by a change
 of colour.   By the aid of a lens these spots are  seen traversed with blood-vessels of
 very great delicacy, and sometimes  by  a very well-marked circle of injection.  The
 density of the bony tissue is neither increased nor diminished.
   2. Purulent infiltration (Infiltration purulente.)—The infiltrated matter assumes,
 after a  longer or shorter  time, a pale yellow tint, and becomes completely opaque;
 it is at first pretty firm, but is not delayed in gradually softening;  soon is it entirely
 fluid and puriform ;  these collections are always very precisely bounded, as are the
 spots already mentioned.  When the infiltration has reached this period the blood-
 vessels disappear;  the bony tissue  undergoes an interstitial hypertrophy,  without
 the bulk of the bone being increased;  the little  cells are narrowed, and almost com-
 pletely obliterated, and the cellular tissue of the bone is then  as it were like ivory.
   3. Sequestration of ihe affected part  (Sequestration de la partie  affectee.)—When
 the bone has undergone the modifications just mentioned, it exhibits all the characters
 of a true sequester; there is neither vessel nor any indication of remaining life;
 besides, a circle of elimination is formed around  the  infiltrated portions, and the
 sequestration runs through the whole series  of  phenomena characterizing necrosis;
 abscesses,  fistulas,  abundant suppuration, and so on, are the  inevitable  result.  In
 some instances necrosis evidently exists, but its separation is long delayed.  It some-
 times happens  that the necrosed part is detached by little fragments, and in the
cyst which forms around the abscess a  quantity  more or less  considerable of bone,
like sand, is observed.   On the other hand, this purulent infiltration is often propa-
gated to neighbouring parts, and attacks a large extent of bony tissue; these cysts
are rarely so limited as in encysted  tubercle, and it is notvery uncommon  to see
a consecutive  and  accidental caries developed not in the part primarily infiltrated,
but in the bony tissue which surrounds  it.
   Purulent tubercular infiltration has been often confounded with  caries; but it is
 easy to perceive that these two  affections differ essentially  from each other; in fact,
 caries always proceeds from the periphery to the centre, and infiltration on the con-
 trary,  from the centre to  the  periphery.  In infiltration,* there is  an  interstitial
 hypertrophy, augmentation of density,  absence of vascularity ; in caries, there is  a
 rarefaction, softening and increased  vascularity of the bony  tissue.  Finally, the
 interstitial  hypertrophy is sufficient to distinguish this affection, and that of necrosis,
 and of inflammation with suppuration of the medullary membrane of the bone.
   As to the treatment little remains to be said.  The tuberculous affection is beyond
 all the resources of art; when it affects  an important organ, the patient is generally
 devoted to death; when it affeets the bony tissue, it is rare that it has not been de-
 veloped in the lungs  or in some other organ.  However, when it only affects the
 bones, it may be hoped,  that nature will effect the cure; especially if her efforts be
 seconded by a wholesome diet,a residence exposed to the sun; in a word, by atten-
 tion to the treatment of scrofula.  This happy result is much more frequent at the
 period of puberty than at any other time of life." (p. 491-93.)
   [A translation of Nelaton's excellent paper by Dr. King will be found
 in the N. Y.  Journ. of Med. & Surg., vol. i. 1839.—g. w.  n.] 
FUNGUS OF DURA MATER, AND OF SKULL-BONES.       419
     VIII—OF FUNGUS OF THE DURA MATER,  AND OF THE
                           SKULL-BONES.

{Fungus Burat Matris, Lat,; Schwammige Auswuchs auf der harten Himhaut, Germ.;
                       Fongus de la Dure-Mere, Fr.)
  Kautfmann, Dissert, de Tumore capitis  fungoso post  cariem  cranii exorto.
Helmst.; in Haller, Disput. Chirurg. Select., vol. i. p. 49.
  Locis, Memoires sur les Tumeurs fongueuses de la Dure-Mere; in Memoires de
PAcad. de Chirurgie, vol. v. p. 1.
  Sandifort, Exereitationes Anatomicae, cap. iii. Lugd. Batav., 1785.
  ■----, Museum Anatomicum Acad. Lugd. Batav., p. 142.   L. B.,  1793.
  vox Siebold, C; in Arnemann's Magazin fur die Wundarzneiwissenschaft, vol. i.
part. iv. p. 142.
  Wenzel,  J. and C, Ueber die  schwammigen Auswuchse  auf der aussere Him-
haut.  Mainz, 1811.  fol.; with six copper plates.
  von Walther, P., Ueber die schwammigen Auswuchse auf der harten Himhaut,
nach eigenen Beobachtungen; in  his Journal, fur Chirurgie und Augenheilkunde,
vol. i. p. 55.
  Schwarzschild, H., Dissert, de Fungis Capitis.  Heidelb., 1825.  4to.;  with
four lithographed plates.
  Seerig, A. G. H., Nonnulla de Fungi Durae Matris origine et diagnosi. Uratis-
laviae, 4to.;  with three lithographed plates.
  Ebermaier, Ueber den Schwamm der Schadelknochen und die schwammartigen
Auswuchse  der harten Himhaut.  Diisseldorf, 1829.  4to.
  Chelius, Zur Lehre von den schwammigen Auswiichsen der harten Himhaut und
der Schadelknochen.  Heidelb., 1831.  fol.;  with eleven plates.
  Unger, Beitrage zur Klinik der Chirurgie, vol. i. p. 264.
  Kosch, Beitrag zur der Lehre von den Schwammgewachsen am  Kopfe; in von
Graefe und von Walther's Journal, vol. xxiv. p. 542.
  Osius; in Heidelb. Med. Annalen, vol. iv. part iii.
   2224. Fungus of the dura mater is an unnatural growth, arising from
the surface of that membrane, which in  its  further development, by the
destruction of the bone, thrusts  up  beneath the external  coverings  and
raises them into a tumour.                    ,
   2225. The symptoms at first occurring in this  disease, are extremely
uncertain  and  indefinite, as  headach,  sometimes slight,  at other times
very severe, often periodical, sometimes spreading over the whole head,
and sometimes fixed  to one spot;  afterwards dizziness, a sensation of
concussion and confusion in the head; vomiting, pallid countenance, and
wasting; loss of sensation  in some  one part and  the like.   Sometimes,
however, in the early  stage, the  disease presents  no symptoms.  As the
fungus enlarges upon the  surface  of the dura mater, that membrane is
separated  to a  greater extent  from  the skull, and partly in consequence of
this, and in part by the pressure of the swelling, the bone is  destroyed by
absorption.  Before the tumour bursts  through the outer table of the
skull, that part of the bone crackles under pressure of the finger.
   2226. When the bone is destroyed and the fungus has arrived under
the coverings, of  the skull, it presents a regular, circumscribed more or
less  elastic soft swelling, over which the colour of the skin is unchanged.
This swelling in general enlarges but slowly, and presents as characteristic
signs; first, the sensation of pulsation, as observed, though more actively,
in aneurysm; second,  the edge of the hole in the bone, through which the
tumour protrudes, is  distinguishable around the whole circumference of
the swelling, more or less rounded or sharp, and having numerous pointed 
420
PROGNOSIS AND  DIAGNOSIS
projections; third, on the condition of this bony edge depends the greater
or less painfulness of the swelling; fourth, the possibility of returning the
swelling into the cavity of the skull with sudden cessation of its painful-
ness, under which circumstance, the fungus is no longer exposed to the
influence of the edge of the  hole in the bone.   With the external  pro-
trusion  of  the tumour, is  often  connected danger of  very urgent symp-
toms, as small pulse, vomiting, continual gulpings, cold hands and  feet,
frequent faintings, and cold  sweats over the whole body.   These symp-
toms, together with loss of sensation, palsy, and loss of intellect, may be
consequence  of keeping back the fungus by art, or by change of position
to the other side.
  2227. The pulsation often  diminishes as the swelling increases, and is
scarcely perceptible; the edge of the hole  in the bone may also be con-
cealed  as  the  outer part of the swelling spreads over it.   The  skin
becoming still  more tense, reddens, thins, at last bursts, and a fungus
protrudes through the opening, which bleeds frequently, and secretes an
ichorous fluid mixed with blood.   Hectic fever arises in consequence of
this loss of the juices, of the restlessness, and of the violence of the pain;
and under the colliquative symptoms death ensues, preceded for a longer
or shorter time by a  sleepy state, frequent faintings, loss of some of the
senses or of the powers of the mind.
  2228. Examination after death exhibits a swelling of a brownish colour,
sometimes  more or less grayish  white, at some  parts often a medullary
substance, of which some lobes are enveloped in their cellular tissue, and
to a certain extent held together.   This substance is penetrated by more
or less vessels, in  general connected not very firmly with the dura mater,
and not at all organically with the edge of the hole in  the bone, but only
retained by the pointed projections and dentations of the edge of the bone.
Upon the external surface of the  bone, the edge of the hole is sharply
defined, but  on the  inner table it runs off obliquely, so that the inner
plate is always further  destroyed than the external;  a  decided proof that
the fungus  has burst through the skull from within outwards.  This is
also  shown by preparations, in which the fungus not having yet com-
pletely destroyed the bone, the external table is undisturbed, and neither
the bone nor the  pericranium in any way diseased.  Not  unfrequently
such swellings appear on several parts of the skull in  various degrees of
development, just like swellings situated on other bones of the body.
  2229. Fungus  of the dura mater is  distinguished  by the  above de-
scribed symptoms from other diseases of the skull, from encysted, meli-
cerous, and atheromatous swellings, and from hernia cerebri, and specially
as the  latter either exists from birth or is produced  after some injury of
the skull, accompanied with loss of substance.  Schnieber {a) has indeed
mentioned  a  congenital fungus of the dura mater; I have, however, with
Seerig (6), doubts of the correctness of the diagnosis in this case.
  2230. The views  already stated in reference to the origin and course
of fungus of the  dura mater, which have been specially laid down by
Louis, Wenzel, and others, and which I have found confirmed by my
own observation on  the living and by examination of the dead, are op-
posed to those  advanced by  Sandifort, Siebold, and Walther.   Ac-

  (a) von Graefe und von Walther's Journal, vol. ii, p. 64.1*   (6) Above cited,. p.,24. 
OF  FUNGUS  OF  THE DURA  MATER.           421
 cording to the latter writers, fungus of the dura mater is a simultaneous
 degeneration of the dura mater, of the  skull-bones, and of the  external
 periosteum, but especially of the blood-vessels which pass from the latter
 to the diploe, and from it to the dura mater; a luxuriant vegetation of
 the net-like tissue between the  two tables of the skull-bones, with which
 the bone-earth is sucked up and a carnation of the bone at the same time
 arises.  This opinion, which had already  been advanced  by Louis in
 some cases,  Wenzel (a) admits  only  so  far as he supposes  that the
 original seat of the disease is restricted merely to that part of the bone on
 which the diseased cause so operates, that the natural functions are in
 some way disturbed  and interrupted; and this  may be sometimes the
 outer, sometimes the inner  table of the bone, sometimes both together,
 and sometimes the fungous tissue which lies between them.
   2231. Directly opposed to the symptoms on which Wenzel founded
 his diagnosis of  this disease, are those which Walther has advanced,
 supported by his own views and  careful observation.  He did not, indeed,
 notice any motion of the swelling ; the patient experienced only a certain
 roaring and rushing, best comparable with that which sometimes is per-
 ceived in the external ear-passages in violent beating of the carotid artery
 and its  branches.  A certain obscure  movement was felt in the swelling,
 but however only when the hand, or still better the tips of the fingers, are
 applied and pressed strongly upon  it for a long while; the movements
 are in this  way, after some time, distinctly felt.  In one case an alternate
 rising and sinking of the tumour was observed, similar to that concussion
 which the beating  of the arteries produces in all parts of the body.   Its
 degree  corresponds with the number and extension of the arteries in the
 swelling; the movements are similar to  the beats of the pulse, and cor-
 respond with them.  Walther could not feel any bony edge around the
 circumference of the  swelling,  and  considered this proved, because  the
 hole  in the bone was firmly, and throughout its whole extent filled with
 the swelling.  When ihe fungus attains considerable size, no symptoms
 of compression of the brain are  observed ; but in very rapid  growth they
 possibly may be.   The  external part of the tumour can be  returned.
 through the hole in the bone never,  or but very rarely, and only whilst it
 is still small and recent, in which case symptoms of compression of the
 brain must at once ensue.  Walther found, in general, that the swelling
 was completely free from pain, and that it was in no way sensible of
 touching, or of moderate pressure.   The connexion of the fungus with
 the skull-bones was  always firm.  The periosteum began to thicken  at a
 considerable distance from the swelling; and the thickening increased as
 it approached the tumour, and there the periosteum seemed reddened; it
 was firmly  connected, with the fungus.
  2232. Both these opinions are true, and founded upon careful observa-
 tion ;  but it is improper to attempt setting aside the one by the other, as
 both are obtained  from different states of the disease.  The opinion of
 Louis and  Wenzel  is applicable only to the true fungus of the dura
mater;  that which Siebold, Sandifort, Walther and others have
noticed, is not entitled to  the name offungus of the dura mater, but is to
be distinguished as a fungus  of the skull, {Fungus cranii,) as the degene-

                         (a) Above cited, p. 95.
                               36* 
422
KINDS AND CAUSES OF
ration in it begins  either from the diploe, or from the dicra mater and
pericranium at the same time, and the bone is converted into a fungous
substance of greater or less  firmness.  This distinction between fungus
dure matris and fungus cranii equally applies to similar degenerations in
other bones, where fungus growths are developed between the periosteum
and bone, and the bone is destroyed merely by these  increasing masses;
whilst other fungous groioths proceed from the bone itself and from the
medullary substance, and the bone is converted into a fungous, sarcomatous,
steatomatous, or other kind of substance.
  Those growths which are formed on the external surface of the dura mater in con-
sequence of ulceration of the skull-bones, must be distinguished from true fungus of
the dura mater.

   2233. If the several origins of fungus be reviewed, five different forms,
must, according to the observations of myself and others, be distinguished.
   First. The dura mater alone is capable of fungous degeneration, which
appears  either on its  internal or external surface^ or on  both  at once.
The fungous parts of the external surface of the dura mater are connected
firmly with the more or less completely destroyed internal surface of the
skull, so that the organically connected excrescence of the dura mater is
converted gradually into  the  same  fungous, steatomatous, or fibrous
substance.   When this  degeneration  gradually affects  the skull-bones
throughout their whole  thickness, and by its  external protrusion forms
a swelling, it becomes firmly connected with the bone, and imperceptibly
involves it, so that perhaps only at certain parts can its bounds be  per-
ceived through the firm edge of bone.  Such tumour admits of no return,
nor is any pulsation  felt; at least the pulsations of the brain can  alone be
communicated to it  when a large extent of the skull is included;  they
can, however, only be very slight, and distinguished  always  by their
regularity,  from  the pulsation of  single vessels, with  their numerous
ramifications in the swelling.
   In the other kind  of isolated fungous degeneration of the dura mater,
the degeneration is restricted entirely to it, and ordinarily to to its external
surface alone.  The fungus arising from the external surface of  the dura
mater  is especially  characterized by the enlargement of its substance,
without destroying the  surrounding parts otherwise than by pressure, on
which account the fungus is only organically connected  with the seat of
its original development, and never with  the bones of the skull, which it
destroys.  The destruction of the bones,  already noticed as occurring in
the progressive increase of the fungus, always corresponds to the extent
of the tumour, extends from within outwards,  and at last bursts through
the external table of the skull, so that the  swelling is perceived externally
beneath the coverings of the skull.   Hence on examination, according to
the various degrees of development of the fungus, more or less deep  hol-
lows are noticed on the inner table of the skull; and when the skull is
completely burst through, the destruction of its inner table is always  to a
far greater extent than  the opening in the outer table, its edge sharply
defined,  and  without exhibiting any other change.   When  the  swelling
appears externally, the  edge of  the bone throughout its whole  circum-
ference is distinctly perceptible ;  the  swelling pulsates actively and  syn-
chronously with the beat of the arteries, and so long as it has not acquired 
FUNGUS OF THE DURA MATER.              423
considerable size, may be wholly or  in part returned into the cavity of
the skull, and then more or less severe symptoms of  compression of the
brain occur.   The pericranium surrounding this swelling is either sac-
like or more or less united to it, which merely results from the continued
pressure  and inflammatory irritation,  as noticed in all tumours in relation
to their coverings and envelopes.
   2234.  Second. The dura mater  and pericranium may degenerate at the
same time, so that if a fungous mass is formed  between  the two and the
corresponding surfaces  of the skull-bones, with which  it is organically
connected, the destruction of the bone results  only from its conversion
into this substance, and proceeds from its two surfaces towards the middle,
so that the diploe is at last destroyed.  So long as the fungous mass has
not completely destroyed the bone, it forms a more or less large and
elevated  swelling, which is either imperceptibly lost in the  bone,  or an
edge  of  bone can be felt  here and there on its  circumference.   The
swelling  is more or less firm, shows no trace of communicated pulsation
from the  brain, so long as the skull still remains not completely destroyed;
and only when there is great vascular development in it, can the isolated
pulsation of the several vessels be distinguished by examination with the
fingers, but which, in reference to its strength, cannot be compared with
that in true fungus of the dura mater.
   2235.  Third.  The fungous mass  may be developed between the skull
and the pericranium, as fungus  pericranii.  Here,  at  least  according
to the observations hitherto made, the substance is  always firmly con-
nected with the bone ; indeed, for the  most  part, is formed by the diseased
change of the  bone.   The substance may form considerable growths, and
may also spread more towards the surface.   When the fungous mass has
changed  the skull through its entire thickness, it is always so closely and
firmly connected at its edge with  the bone, that those symptoms which
exist in  true  fungus of  the  dura  mater cannot be present, and the
swelling  is specially  under the same circumstances, as a  swelling of like
kind on  other bones.
   2236.  Fourth. The  degeneration begins in  the net-like tissue of the
diploe, and extends gradually inwards and  outwards, or more towards the
one than the other.   The swelling is here  equally firmly and organically
connected with the bone; when it has completely destroyed the bone at
the seat  of the degeneration, it presents  a similar connexion with the
dura  mater and pericranium; and there is neither pulsation  nor  possi-
bility of replacement; at the very most the edge of the bone can only be
perceived at one or other place.
   2237.  Fifth. There may be, finally, several  of the above-mentioned
diseased, and in regard to their origin, different changes present  at the
same time, according to which the  symptoms  variously present  them-
selves (a).
   2238.  The  causes of fungous  growths  of the dura mater and  skull-
bones are either internal  or  external.  To the former  belong syphilis,
rheumatic affections, scrofula, and other  diseases which are  connected
with an altered condition of the juices.   To the external causes belong
blows upon the head, bruises,  concussion of the skull without external
(a) Chelius, above cited, p. 69. 
 424        OPERATION FOR FUNGUS OF THE DURA  MATER.

 injury or fracture of the bone.   The distinction of the causes is frequently
 attended with great difficulty, as the external injury has  often so long
 preceded the  origin of  the  complaint,  that  its  causal  relation to it is
 doubtful.   When the  disease  arises  without  external violence,  the
 presence of internal disease is not always clear; but the progress  of  the
 complaint, and the existence of similar degeneration in other parts,  points
 to a peculiar diathesis, often characterized by no other  symptoms than
 the tumour: and in this  respect, indeed, it must  be distinguished  as the
 diathesis fungosa.   I do  not imagine, that without this internal condition,
 external causes can of themselves produce such  fungous degenerations.
 As the result of  these causes, an inflammatory condition  is always to  be
 considered  as the peculiar commencement of the  disease, by  which
 plastic exudation, irregular  vascular development, and the like,  are
 produced.  According as  these processes  occur, at the  same time, on
 the surface  of  the dura mater, in the bone  itself, under the pericranium
 and upon  the dura mater, the proper fungus dure matris and fungus
 cranii are produced.
   2239. Fungus of the dura mater, and  of the skull-bones, is a very im-
 portant disease,  which left to itself causes death, and the cure of which,
 or even its  mitigation,  is usually impossible.   In those cases where the
 complaint  is, from the symptoms mentioned,  {par. 2225,) supposed  to
 have arisen from external injury,  its  development may perhaps  be
 arrested by the early and continual use of cold  applications, by taking
 away blood, active purging, low diet, and the like.  But if the swelling
 have already become  apparent  externally, there is  no  remedy but its
 removal, by the  ligature or the knife after previously laying  bare, and
 enlarging the  hole  in  the  bone; cutting into the tumour, the constant
 application  of pressure, and the  use  of escharotics, can only promote an
 unfavourable result.
  Walther  supposes that the operation is contraindicated  in fungus of the dura
 mater, and that only the peculiar kind and special condition of the case, may here
 and there form an exception.   He is confirmed in this opinion by the view he takes
 of the origin  of the fungus, and by an operation he performed, in which, after the
 first cut, so severe  bleeding ensued, that he was obliged  to abstain from finishing
 the operation.  In  reference to fungus cranii, I must, from my  own observation,
 assent to this opinion.  But the operation for true fungus  of the dura mater must be
 considered permissible, if the disease have not advanced too far; if there be  only a
 swelling, and no degeneration of the  other parts.  The prognosis, however, in this
 operation, is always extremely doubtful; independent of its danger, it has scarcely
 ever a permanent result, as, at least according to my experience, the fungus  of the
 dura mater is always characterized  as medullary fungus (Fungus  medullaris,)
 which, on account of the general diathesis is always incurable.
   2240. In performing this operation, the  general coverings  are  to be
 divided  upon  the swelling with  a crucial  cut, extending beyond  it on
 either  side  to the extent  of an inch ;  the  flaps are then separated and
 turned back.   The galea  aponeurotica and periosteum are found uncon-
nected with the tumour, and to be divided like the skin, for the purpose
of laying bare the fungus; or this may be done by two cuts on the base
of the swelling.  The edge of the hole in the bone having been exposed,
it  must be  endeavoured by  repeated  applications of the crown of the
trephine, and by removing the intermediate pieces with  Hey's saw, to
obtain a space large enough for the examination of the  base of the 
        OPERATION FOR FUNGUS OF THE DURA MATER.         425


swelling.   If its connexion with the dura mater be then found not very
firm, it may be separated with the finger, or with the knife-handle; or if
its connexion be firmer,  it may be carefully cut away with the knife ; of
that part of the dura mater to which it is attached  may be cut off; or a
ligature may be applied with  a loop-tier, which, however,  on account of
the readiness  with which  serious symptoms are set up, should be tied
with  very great  caution  (a).  The  after-treatment  is to be  guided
according to the rules laid down for the operation of trepanning.
  Only under the above-mentioned restrictions, is the removal of the fungus permis-
sible ; in every other case the operation merely hastens death. Thus, in Berard's (b)
case, who by means of sixteen applications of the trephine, made an opening in  the
skull five inches long and four and a half wide, which laid bare the  dura mater with
the longitudinal sinus and the upper edge of the falx, after the removal  of the outer
part of the swelling, pulsation was observed in the  rest of it; fainting and convul-
sions immediately ensued, and the patient died in twenty-four hours. The swelling
arose  from the outer surface of the dura mater, and after  destroying the bone, had
protruded through an oblong aperture, whilst its base spread beneath the skull.  Its
structure resembled that of brain.   The inner surface of the dura mater was healthy.
  Orioli (c)  removed a fungus of the dura  mater successfully. A little swelling
projected beneath the right ear, accompanied with  loss of  sight, and had gradually
reached the size of a small nut.   The whole swelling pulsated, but was  compres-
sible, and the pulsation then ceased ; it also  for the most part ceased when the tem-
poral artery of that side was  compressed.   Neither bony  edge nor crepitation was
felt beneath, or on the side of the swelling.  The disease was thought to be a tem-
poral aneurysm.   In three weeks  the tumour had increased about two-thirds; head-
ach and singing in the ears came  on, and an  operation was thought necessary.  The
artery having been compressed, a T shaped cut was made through the coverings,
and the temporal muscle cut through; but the tumour was deeper, and the operator
ascertained it was not aneurysmal, and that the bone was probably  affected.  After
dividing the pericranium, a hard, irregular edge was felt around the swelling.  The
pericranium having been separated, the bone was  found carious to the extent of a
half-dollar; the tumour was seated with a broad base upon the dura mater, and diffi-
cult as it was, Orioli removed as much as possible of the length and breadth of the
fibro-fleshy mass.  Two arteries were plugged, and the patient dressed.  On  the
ninth day the wound was sloughy; the slough separated gradually,  and some pieces
of brain were also thrown off. The  bottom of the  wound now pulsated synchro-
nously  with  the arteries and with the movements  of the brain.   As  the wound
cleansed, there appeared  however on one side a  swelling, similar to  the former,
which was successfully compressed with lint.  In fifty days the cure was complete.
A firm scar covered the part where the whole in the bone was, and the movements
of the brain were felt.  The singing in the ears subsided ; sleep returned, but sight
was completely lost.
  Besides  the above-mentioned writers, the following may also be  consulted :—
  von Siebold, B., Entstehung und  Ausgang einer betrachtlichen und  mit dem
Winddome am Schadel verbundenen  scrophulosen  Speckgeschwulst  auf dem
Scheitel; in Chiron., vol. ii. p. 667, pi. 8, 9.
   Palletta, De Tuberculis ossivoris.  De Tuberculis Capitis, p.  93; in Exercita-
tiones Pathologicae. Mediol., 1820.
   Eck, Kleiner Beitrag zu der Lehre von den schwammigen Auswiichsen an dem
Schadel; in von Graefe und von Walther's Journal, vol. v. p. 105.
  Graff, K., Die Metamorphose der Schadelknochen in  Markschwamme; in  von
Graefe und von Walther's Journal, vol. x. p. 76.
  Cruvelhier, Anatomie pathologique du Corps humain, livr. viii.
  Muller, B., Dissert, de Fungo Durae Matris et Cranii.   Monachii, 1829.
  Blasius, De Fungi Durae Matris accuratiori distinctione.  Hal.,  1829.

  fa)  Ficker, Ueber die schwammigen Auswuchse aufder harten Himhaut; in von Graefe
und von Walther's Journal, vol. ii. p. 218.
  (6) Gazette Medicale, vol. i. p. 735.  1833.
  (c) Bulletino delle Soienza Mediche.  May,  1834. 
426
OF FATTY OR ADIPOSE TUMOURS.
  Hubner, Dissert, de Fungo Durae Matris.  Heidelb., 1832.
  Seifert, Dissert, de Fungo Capitis in universum, et de Fungo Durae Matris in
specie.  1833.
              IX.—OF  FATTY OR ADIPOSE TUMOURS.

      (Lipoma, Tumour odiposus, Lat.; Fellgesehwulst, Germ.; Lipome, Fr.)
  Schreger, Ueber Lipome und Exstirpation derselben; in his Chirurgische Ver-
suche, vol. i. p. 297.
  von Walther, P.,  Ueber die angebomen Fetthautgeschwiilste und andere Bild-
ungsfehler.   Landshut, 1814 ; with two plates.
  von Klein, Ueber die Ausrotung verschiedener Geschwulste; in von Graefe und
von Walther's Journal fur Chirurgie und Augenheilkunde, vol. i. p. 109.
  Brodie, Sir B. C, Lectures illustrative of various subjects in Pathology and Sur-
gery.  London, 1846.  8vo.
  2241. The fatty, or  adipose tumour, depends on an unnatural collec-
tion of  fat,  heaped  up either in the panniculus  adiposus, or between the
plates of the cellular tissue beneath the skin, according to Schreger, in
the mucous bags of the first and second orders.
  2242. These tumours are developed slowly, and without any uneasi-
ness ; they  give to  the  touch a peculiar softness, which cannot be better
compared than to that of a bag filled with cotton ; their surface is irre-
gular, and distinct conglomerations are felt upon them, which are not hard,
and are easily compressed.   When they have reached  a certain size, they
in general grow quickly, and may acquire a very considerable bulk. As
long as the  swelling is small, the skin upon it remains unchanged, but
when it has become very large, the circulation is impeded by the drag-
ging and tension of the skin, the cutaneous veins become expanded, drop-
sical swelling takes place, the skin inflames, especially if the tumour be
seated on any part where it can be affected by chafing  or external injury,
and the inflammation may run  on to ulceration.   The form of a fatty
tumour is in general oblong, and has a neck.
  [That fatty tumours have generally a neck is not,  according to my observation,
correct.  They usually have a broad base, and raise up the skin like hillocks.  Very
rarely they have a neck; and in St. Thomas's Museum is the cast of a very remarka-
ble one, which weighed from fifty to sixty pounds, was attached by a narrow pedicle
to the throat,  and hung down to the man's knees.  John Hunter saw him, when
the tumour was only of small size, and did not think it could be safely removed.
The man died some years after in Shoreditch Workhouse.—j.  f. s.]
  2243. According to  the two-fold origin of fatty tumours already men-
tioned,  {par. 2241,) two different kinds may be distinguished which are
characterized by marked symptoms.
  Those fatty tumours  which belong merely to the panniculus  adiposus,
and are only knobby masses of fat at certain parts, have no well-defined
edges,  but  subside into the  surrounding parts,  {Lipoma diffusum,) are
very soft and easily compressible, and so  connected with the skin  that the
latter can be moved or lifted in folds upon the swelling.  The  fat lies
under the generally thinned corium; no general  sac exists, and some parts
only are enclosed in thin and simple walls.   The fat is similar to that of
other parts of the body, only a little firmer.
  [This is the form of fatty tumour which Brodie mentions as "not well  defined;
in fact there  is  no  distinct boundary to it, and you cannot say where the natural
adipose structure ends and the  morbid growth  begins."  He  relates the case of  a 
KINDS OF FATTY OR ADIPOSE TUMOURS.           427
person with an affection of this kind, "an enormous double chin hanging nearly
down to the sternum, and an immense swelling also on the back of his neck formed
by two large masses, one behind each ear, as large as an orange, and connected by
a smaller mass between them.   *  *  *  Such deposits may probably take place
in any part of  the body, but I have seen them," says Brodie, "more frequently in
the neck than elsewhere." (p. 275-77.)  Not unfrequently very stout persons, more
especially women who have borne children, have  large collections of fat between
the skin and abdominal muscles below the navel, which hang down in a thick fold,
like an apron, to the pubes.  It has been dignified with the name of pendulous belly.
The  female breast also sometimes becomes enormously loaded with  fat, even in
very young women.  Brodie mentions a case of this kind, which grew so large that
it was removed on account of its inconvenient size, which on  dissection turned out
to be "a fatty  tumour, and a chronic mammary tumour, blended with each other,"
and disposed layer on layer, (p. 281.)  But whether  on the  neck, belly, or else-
where, it seems to be merely a superabundant  deposit of fat, a hypertrophy, whieh
can hardly be  considered  a disease, though it certainly  is a great  inconvenience.—
j. f. s.]
   2244.  The other fatty tumours  which arise between the two plates of
the cellular expansion beneath  the skin, from an increased  and altered
vegetation of the raucous bags of the first and second order, are situated
deeper, are covered with the panniculus adiposus, have a defined boundary,
greater mobility, more elastic hardness, and are enveloped in a  proper
cellular  cyst, which is commonly so firmly  connected with the fat that
they can  scarcely be  distinguished.   In general this cyst is very thin,
often still thinner as the swelling becomes larger;  only in rare cases is it
firm,  tendinous,  and  in part cartilaginous.   This  tumour  consists  of
spherical  masses  of fat, which differ from  the   natural  fat, nearly  re-
sembling  a  slice  through  the  brain,  or  through a  lymphatic  gland,
without cavities and  partitions; sometimes they  appear as if composed
of circularly  twisted or radiately disposed plates {a).
  With the opinion of this two-fold form  of lipoma,  which  may be sufficiently
distinguished  by  external examination, microscopic observations also agree.  The
substratum of lipoma is the fatty tissue intermingled with blood-vessels and cellular
tissue in  indefinite proportions.  The  lipoma which  belongs to  the panniculus
adiposus, consists of cellular  tissue, with a few vessels, and sometimes starlike
groups of needle-shaped crystals, (margarin, or margaric acid,)  are found in the fat-
cells.  In the  other form  more bundles of cellular fibres are observed, which spread
between the groups of fat-cells.
  J. Muller (b)  divides  fatty tumours into,  first, Lipoma, in which the fat is found
in the common fatty cellular tissue, and is merely isolated by the walls of numerous
cells thrust together; second, Fatty cysts, in'which  the fat is not contained in little
cells, but partly fluid, partly in form  of fat-corpuscles, is enclosed in one large and
generally thick membranous cyst.  In the former case, the production of the fat goes
on in the ordinary way, as previously in the  healthy body; in the latter there-is, as
it were, one predominant fat-cell, and  its  wall  thickens into a  firm  cyst.  The
lipoma, generally  lobed, is not distinguished  from the ordinary form of fatty cellular
tissue, its cells are roundish and oval, the single difference consists  in the firmness
of this conglomeration of fat-cells, which usually possesses a more or less strong cyst
of thickened cellular tissue, whilst the single lobes  are enclosed in thinner layers of
cellular tissue.  Muller distinguishes, a.  Lipoma simplex;  b. Lipoma mixtum^
where the  insterstitial cellular  tissue  considerably thickened and  membranous,
forms strong plates, which run through the lipoma, rendering it firmer than  the
common  lipoma; c.  Lipoma arborescens, branching productions,  which  consist
entirely of  fatty cellular tissue.   The fat  cyst (Cystis adiposus) is, at least in  the
skin, similar to the Tumor sebaceus.  The  fatty tumour in layers (Cholesteatoma)
consists of  pearly shining leaves or layers of polyhedric cells, without  any lobular
       (a)  Schreger, De Bursis Mucosis subcutaneis,  p. 12.  Erlang., 1825.
       (b) Above cited, p. 49. 
428               FATTY OR  ADIPOSE TUMOURS;
formation.  The tumour, of the  consistence of suet, is surrounded by a membrane
generally  very  thin, rarely thicker than a common cyst.  The cholesteatoma also
occurs as a deposit upon ulcers.  It has not any blood-vessels (a).
   [Fatty tumours of this kind vary considerably in  size between half a pound and
half a dozen pounds; but some examples have occurred of enormous bulk.  Astley
Cooper removed a fatty swelling of the breast which weighed fourteen  pounds and
ten ounces;  it is in the Museum at St. Thomas's.  Copland removed one from a
female's thigh,  weighing twenty-two pounds.   The largest which has been met
with in  this county, is that removed by Astley Cooper (b) from  a Danish sailor
in Guy's Hospital, which covered  all the front of the belly below the navel, and
formed an immense swelling, which after removal weighed thirty-seven pounds and
ten ounces.  It  was a remarkable  circumstance in  this man's case, that notwith-
standing this bulky protuberance, he had done his duty on shipboard till within a
few  days of his  admission.  The tumour is in the  Museum at St. Thomas's.
Lawrence (c)  mentions that a French surgeon removed  a fatty tumour from the
left hypochondrion, which weighed  forty-six  pounds, and was one  of eight in the
same person, the others of which, however, were not so large.  Portalupi (d), of
Venice, removed a large pyriform fatty swelling which hung from the left side of
the neck and chest, measured in length twenty inches and a half, twenty-seven
inches around its upper narrower part, and thirty inches below, and weighed fifty-
two pounds; no blood-vessel of  size was divided, nor was any ligature required;
and in the course of seven weeks, the patient was cured.
   Although  generally seated almost  immediately  beneath the skin,  these fatty
tumours are  sometimes situated  beneath the muscles, and  then give rise to much
difficulty in diagnosis, of which Brodie mentions a good example, where the tumour
Was beneath the trapezius ; in another case the fatty mass was behind the gland of
the breast, which it had lifted up, and  caused great doubt as to the  character of the
disease, till explained by the operation.  He also mentions a case in which a large
tumour in the scrotum lay behind the  testicle, but quite distinct from  it, and gave
the impression of being an omental  hernia,• it was, however, determined to operate
on it, and it was then discovered to  be a fatty tumour connected with the spermatic
cord  within the abdominal ring, which as it had grown, descended into the scrotum,
(p. 271.)
  Among  the Tarest situations of fatty tumours, the tongue may be;mentioned: in
the Museum of  the College of Surgeons there is a  specimen of a  small lobulated
fatty swelling which had been removed from  that organ.]
   2245.  The  causes of fatty tumours are unknown.   Rarely can they be
ascribed to pressure, blows, or any other violence.   They  are  seen at all
ages and in both sexes, though  most frequently in adults; they seem also
to be more frequent in females, though without any relation to  menstrua-
tion.  They generally occur on the shoulders, upon  the back and on the
neck ;  but are, however, observed on other  parts, and even on such as
have naturally very little disposition to  fat.    Oftentimes  several fatty
tumours  occur,  even  in  considerable number  in the same individual.
Not unfrequently is  a fatty tumour congenital, aud then often acquires
considerable size; in this case  too, sometimes the general  coverings are
more or  less  altered, loosened  up, dusky  coloured, beset with large
quantities of and longer hair than natural.  Such have  been  named by
Walther  fatty mother  marks  (Nevus  matemus lipomatodes, Lat.;
Fettmuttermahl, Germ.)  The disease also usually spreads after birth to a
considerable extent.
   2246. Fatty tumours are always to be  considered important diseases, as
  (a) Compare also Vogel, above  cited.—   (c)  Lectures on Surgery;   in  Lancet.
Heyfhxder, De  Lipomate.  Commentatio 1829-30; vol. i. p. 869.
loco in Facultate Medicorum Univers.  lit.   (d) Omodei, Annali Universali, vol. xxviii.
Erlang. rite obtinendo.                   p. 343.  1823.
  (b) Med.-Chir.  Trans., vol. xi.  p.   440.
1624. 
OPERATION FOR THEIR REMOVAL.
429
they enlarge very quickly, spread and run into ill-conditioned ulcers (1).
Small swellings  may  indeed  in  many  instances be  dispersed by the
application of gum ammoniac dissolved in vinegar of squills, by rubbing
in ox gall, nut oil, and liquor of acetate of ammonia (2).   Their removal
with the knife is, however, generally the only certain mode of treatment.
   This operation  is easy and without any danger in those fatty tumours
which have a broad base; but it may be difficult and  dangerous if the
swelling be of great extent, lie in the  neighbourhood of important parts,
or if it have deeply-stretching roots.   Under  these circumstances, it is
Viot often possible to remove all the degeneration, even with the greatest
care, so that either the fatty  growth begins anew, or a  long-continued  ill
conditioned suppuration ensues, and even fistulas, which remain through-
out life.  Not unfrequently the general formative action appears  to  be
increased by the operation, as often not only in the neighbourhood of the
part operated on, but also in distant parts,  where previously  no lipoma
had existed, it sprouts fourth.  It must also not be forgotten, in  reference
to the  performance  of the  operation, that many lipomata are so con-
siderable, and so largely penetrated with  branching  vessels,  that the
operation is attended with considerable bleeding (3).

   [(1)  As regards ulceration, Brodie observes:—"The skin over a fatty tumour
very rarely inflames and ulcerates.  You might a priori expect that the pressure of
the tumour would often produce this effect, but it is not so.  I have, however, known
inflammation to take place in  the substance of the tumour, and an abscess to form irt
its centre."  And he mentions a case in which this happened  in a large tumour  on
the back;  "the abscess never healed, but continued to discharge profusely matter
with an oily fluid floating in it," till the swelling was removed,  (p. 273.)
   He also refers to Astley Cooper's opinion, that "a fatty tumour Will  sometimes
take on the action of a malignant disease, and become a malignant tumour," and is
inclined to agree with it in consequence of a case which he operated on, "composed
of what seemed to be fatty substance, somewhat more condensed than usual; but
that here and there, dispersed throughout the mass, there was another kind of morbid
growth, apparently belonging to the class of  medullary or fungoid disease. It is
reasonable to suppose that if this tumour had been allowed to remain, it Would have
ulcerated, and run the usual course of a malignant disease." (p. 282.)
   (2) In the case of diffuse fatty tumours of the neck, already  referred to, (p. 690,)
Brodie " gave half a drachm of the liquor potassae three times  a day, and gradually
increased  the dose to a drachm, dissolved in small beer;" the result of which, after
some time,  was,  that considerable absorption of  the swelling  occurred,  though
"there  were still some remains  of the tumour, but nothing that was very remark-
able.  I have  seen" he observes, "some other  cases  in which the exhibition of
very large doses of  the liquor potassae appeared to be of great service." (p. 276.)
 For the more common circumscribed fatty swellings, there is not, as far as I have had
opportunity of seeing, any remedy to produce their absorption, Whether they be small
or large, and therefore to be got rid of, they must be removed by the knife. It is
not needful, however, to meddle with them if their size do not  inconvenience the
patient, and so long as they remain stationary, which they  often will for years,
But if they at any time begin to increase, they should be at once removed, as when
this action begins, it generally continues more or less quickly.
   (3) Easy as the removal of fatty tumours undoubtedly is, it not unfrequently hap-
pens that there  is a good deal of boggling from inattention to the simple circum-
stance of  cutting through the cellular c^st surrounding them, to the extent of the
external wound, and fairly into the fatty tumour itself.   If the  cyst be thus opened,
the operation may generally be completed by running the finger or the handle of the
knife between it  and the. tumour, which usually turns out like a kernel from  its
shell, being only here and there held by little processes of cellular tissue, or little
bundles of vessels, which are best torn through, or if too tough and large to admit
this, must be cut with the knife.  If, however, the cyst be not opened, the tumour
   Vol. iil—37 
430                    ENCYSTED TUMOURS.
will not turn out, and must be fairly dissected out with  the knife, which is very
tedious and inconvenient, as almost every  little  vessel divided bleeds freely and
requires tying, the fortner of Which does not  happen, and the latter is  therefore
unnecessary, if the tumour be torn from its cyst, which is an additional reason why
this method  should be preferred.   It occasionally  happens indeed,  that  after the
removal of the tumour in this manner, the cavity  suppurates and heals by granula-
tion; but this is matter of little consequence, and only slightly retards the cure.—
j. f. s.]
  2247.  The removal of lipoma is managed according to the same rules
laid down in regard to encysted tumours.  Ihe wound may be  brought
together, if the base of the lipoma be  not large,  and the whole has been
completely  removed, and united by quick union.   But in large lipomata,
which  cannot be cleanly turned out, when  the wound has been  brought
together, only an imperfect union of the skin with the corresponding sur-
face of the wound  is  produced ; as at eveiy part where little bits of fat
remain, union does not take place, a fatty purulent  l)mph flows out; and,
if its escape be prevented, inflammation of the skin, bursting again of the
united  parts, continued ill-conditioned suppuration, and  fistulas,  remain-
ing even throughout life, are produced (1).  After the removal of diffused
lipoma, therefore, the edges of the wound are to  be kept apart by proper
dressing, till  the discharge  has lost its oily character, and healthy sup-
puration  is set up; and  then  the  Cure  is  to be promoted  by bringing
together the edges of the wound.   When the swelling is penetrated by a
great many vessels, or its roots cannot be removed by the knife  without
great danger,  it may be necessary to  apply a ligature  around its base,
which  must  be  isolated  as  much  as  possible, and  the swelling cut off
beyond it.   Under these circumstances, the destruction of the remaining
substance,, by the use  of escharotics, is  exceedingly difficult, and even
impossible (a).
  The  employment of  a seton for the removal of lipoma, is only fitting when the
extirpation is impossible.  This method, however, is always  extremely uncertain,
as the swelling either does not go away, or soon recurs.
   [(1) I have never seen the inconveniences to which Chelius here alludes, which
may certainly be prevented by attention in properly dressing the  wound, and the
application of compresses, on any part where there is a disposition to bagging of the
pus.  As a general rule, it is also advisable  to follow the roots of the tumour, should
they spread out as  they occasionally do; but  sometimes  this cannot be  managed
without doing mischief, by disturbing important parts ; it is then best to tear through
these roots, as far in as possible, and usually in the course of the cure they suppurate
and disappear.—j. f. s.]
                   X.—OF ENCYSTED  TUMOURS.

(Tumores  cystici, sacculi, tunicati,  Cystides, Lupiae, d^c,  Lat.; Balggeschwuktc,
               Sackgeschwulste, Germ.;  Tumeurs enkystees, Fr.)
  Salzmann,  De quibusdam  Tumoribus  tunicatis extends.  Argent., 1719; in
Haller's Disputationes Chirurgicae, vol. v. p. 383.
  Girard, Lupiologie, ou Traite sur les Tumeurs connues sous le nom de Loupes.
Paris, 1775.
  Chopart, Essaies  sur les Loupes;  in Prix  de l'Academie de Chirurgie, vol. iv.
p, 274.
  Chambon, Memoire sur les Loupes; in Prix de l'Acad. de Chir., vol. v. p. 332.

                         (a) Schreger, above cfted. 
KINDS OF ENCYSTED TUMOURS.
431
  Jacobson, (Praeside Loder,) Dissert, de Tumoribus cysticis.   Jena?, 1792.
  Loder, Ueber die Balggeschwiilste; in Chirurg.-Medic. Beobachtungen, vol. i.
p. 205.  Weimar, 1794.
  Bichat, Traite de Membranes, p. 181.  JNew Edition by Hasson.  Paris, 1816.
  Jaeger, M., Ueber Balggeschwiilste; from the Encyclopaedische Worterbuchder
Medic. Wissenchaft,  vol. iv. p. 634.   Berlin, 1830.
  2248. Encysted  Tumours  are swellings developed in the cellular tissue
of the skin, or in the interstitial cellular tissue of other parts, and charac-
terized by a proper membrane being formed, in the cavity of which there
is a secretion of a peculiar  substance.   That this membrane  does not
result from expansion  and thickening of the  cellular tissue, but  must be
considered as a new formation, which, in reference to its nature  and its
vital peculiarities, agrees with serous membranes, has been clearly shown
by Bichat.  The  circumstance, that  a cyst is formed  around foreign
substances accidently introduced into the body, dose not controvert this
opinion :  as this cyst, manifestly originating from pressure on the cellular
tissue, is not a peculiar secreting organ.
  Meckel (a) may be consulted  in opposition to the opinion advanced by Adams (b),
that  all encysted tumours are to  be considered as animals of the lowest kind, to wit,
as hydatids.
  [(1)  With reference to the formation of  cysts around  foreign substances, John
 Hunter (c) speaks of it  as an example  " of Uie deeper seated parts not so readily
taking on the suppurative inflammation as those which are  superficial;  * * * for
we find that extraneous bodies are in general capable of producing inflammation; but
if these extraneous bodies are  deeply seated, they may remain for years, without
doing more  than producing the adhesive inflammation, by which means they are
inclosed in a cyst, and only give some uneasiness."—(pp. 238, 39.)   An example
of this kind  I recollect having seen several years since.  A medical student in Paris
had, for want of better employment, mixed himself up with some popular dis-
turbance, to  quell which the military were called in, and he received a wound in the
buttock, which soon united, but left some uneasiness and a  defined swelling.   About
three years after, I saw Dupuytren, at the Hotel Dieu, cut  into this tumour, from
which a quantity of glairy fluid escaped; and the  finger being introduced into it,
about an inch and a half of a sabre-point was felt and removed.   But the lodgement
of an extraneous body without producing suppuration is not confined to deep-seated
 parts; for Hunter, very shortly  after  observing in regard  to  pins and  needles,
 which, when having  been introduced into the body, are well known, in general, not
 to produce suppuration, but either lie quietly in  one place, or move over the body
 to an  almost  incredible  distance from the point at which they had entered : that
 "they owe their want of power in producing suppuration, not entirely to situation,
 but  in some degree to the nature of the substance,  metals, perhaps, not  having the
 power of irritation beyond the adhesive;  for  when the adhesive has taken place, the
 part appears to be satisfied;"  he continues,  " this  appears also to be the case with
 the introduction of glass, even in the superficial parts; a piece of glass shall enter
 the skin, just deep enough to bury itself, inflammation shall come on, the wound in
 the skin, if  brought together,  shall heal by the first intention, and the inflammation
 shall not exceed the  adhesive, but rather degenerate into the disposition tor forming
 a sack, by which  means a sack is formed  round  the glass, and no disturbance  is
 given to the irritability of the parts.".—(pp. 239, 240.)  Besides the example which
 Hunter mentions, in proof of  this latter statement, I may refer to the  case of the
 tobacco-pipe in a man's cheek, whieh I have already mentioned (p. 380;) and there
is in the  Museum of the Royal College of Surgeons a portion of a glass mirror,
which by a  fall was driven into a girl's breast, and there remained for many  weeks,
 without exciting suppuration.  These examples prove, and even from his own show-
ing, that Hunter's first statement, of "deep-seated parts not so readily taken on the

  (a) Handbuch der Patholog^chen Anato-   (6) Olservations on the Cancerous Breast.
mie, vol. ii. part ii. p. 13-'.                 London,  1801.   8vo.
                       (c) On the Blood, Inflammation, &c. 
432                      CAUSE AND NATURE
suppurative inflammation as those which are superficial," is not borne out.  Nor has
it yet been explained, how it is that foreign bodies do become encysted, rather than
set up suppurative inflammation, by which, as under common circumstances, they
are expelled from the body.—j. f. s.]
  2249.  Encysted tumours are distinguished according to the consistence
and  nature of  the substance contained in their  cavity, as, first, Serous
Cysts  {Cystes  serosa,  Hygroma,  Lat.;  serbse Balggeschwiilste, Germ.;
Loupes sereuses  ou  aqueuses, Fr.)  (1);  second,  Melicerous Tumours,
(Melicer\s, Lat.;  Honiggeschwiilste, Germ.;  Loupes  meliceriques,  Fr.,)
when the contained substance is  of the consistence of honey  (2);  third,
Atheromatous  Tumours  {Atheroma,  Lat.;  Breigeschwulste,  Germ.;
Loupes otheromateuses, Fr.,) when it resembles pap (3).   To these  kinds
of encysted tumours Abernethy (a) adds a  fourth, in which  the  cavity
is filled with nail or horn-like  substance, which, when  the skin breaks
hardens,  and projecting, as the cyst continues  to secrete, forms a  horn-
like  growth (4).
  [(1)  Simple serous cysts, on the exterior of the body, are not of frequent occur-
rence.   When existing in the neck they are commonly called "Hydroceles  of the
Neck," under which name they were  first described by Maunior (b), who mentions
that the disease had been confounded with bronchocele, on account of its external
characters, and had been noticed without knowledge of its real nature by Heister,
Plouquet, and Petit.   " It consists," he says, " simply of a collection of serous or
lymphatic fluid;  * * *  it is an affection sui generis, tolerably frequent, and not as
has been supposed a rare and unusual form  of bronchocele."  (p. 95.)   Cases have
since been described by Dr. O'Beirne (c) and by Bransby Cooper (d).   They com-
monly originate  in the lower part of the neck, just above the collar-bone, of small
size, but increases in bulk, covering the whole of that side, and even running across
beneath the skin.  Sometimes, however, they make their first appearance below the
lobe of the ear, and get attached to the angle of the  jaw.  As they increase in size
they interfere with swallowing and breathing, so as to cause severe cough and symp-
toms of suffocation.  Fluctuation is distinctly felt, but they are not always trans-
parent, as though sometimes the fluid they Contain is  clear and limpid, it is more
frequently either like Goffee or coffee  grounds, which probably depends on the rup-
ture of some little vessel into their cavity, under the exertion of soughing.  Maunoir
thinks that the cyst is thicker than in hydrocele of  the testicle; and in  one of the
cases mentioned by Fleury (e), it was very hard and resisting, and its interior lined
with a fibro-cartilaginous covering.   In the Museum of the College of Surgeons,
there is a  specimen of one of these serous cysts removed from the front of the neck
by Thomas. Blizard ; it is more than six inches in diameter; its walls thin and fibro-
cellular;  a  portion of it passed behind the collar-bone, and it contained a clear
brownish  fluid.  Also, another attached  to the back of the  tongue-bone, about two
inches in diameter, which contained a brownish yellow, thick grumous, honey-like
fluid, containing abundant crystals of cholestearine.  Simple  cysts are rare  in the
female breast, Brodie says he has seen but two; and in the Museum at St. Thomas's
there is another.   Perhaps here also belong Astley Cooper's (/) cellulous hydatids
of the breast, of which, however, there are generally  several  in the same gland, as
in the specimens in the College Museum.   In  the  same collection  there are also
examples  of a large cyst removed from the thigh, and  of another which filled up the
thyroid hole, projecting  both into the pelvis and the thigh, and followed a kick on

  (a) Above cited, p. 113.                 Medical  and Chemical Science, vol. vi. p. I.
  {b) Memoires sur les Amputations, l'Hy- 1834.
drocele du Cou, &.c.  Geneve. Paris, 1825.   (d) Case of Hydrocele of the Neck cured
The  Memorial was read before the French by Seton,  with Observations; in  Guy's
lnstitut in 1815:  but the report upon it by Hospital Reports, vol. i. p. 105.
Percy was not favourable.                   (e.) Annales de Chirurgie, vol. -\.  p. 377.
  (c) On Hydrocele of the. Neck, with Cases 1844.
 and  Observ.atiqn.i;  in Dublin Journal qf   (/) Illustrations of Diseases of the Breast
                                        London,.1629.  4to. 
OF ENCYSTED  TUMOURS.
433
the part; both these cases were from females (a).  A few years since I had a patient
with a cyst on the auricle, which contained a thick brownish, but transparent glairy
fluid ; this filled again several  times after being punctured, and was cured at last by
stuffing with  lint, and causing suppuration of ihe sac.
   (2) It is probable that these so-called melicerous cysts  merely differ from the
former in the thicker nature of their contents.
   (3) Atheromatous cysts sometimes contain a pultaceous white matter, like  pap;
or, as Home (6) has described  it, "a small quantity of thick curd-like matter, mixed
with cuticle,  broken down into small parts." (p. 101.)  Some such examples  exist
in the College Museum, stated  in the Hunterian manuscripts to consist "principally
of a series of cuticles thrown off," and  "a flaky substance, which seemed to be a
succession of cuticles, being  the same with that which lines the oyst."  Home also
observes:—"Other cysts of  this kind, instead of having cuticle for their  contents,
are filled with hair, mixed with a curdled substance, or hair without any admixture
whatever, and have a similar kind of hair growing upon their internal surface, which
is likewise covered with a cuticle." (p. 102.)  I  have seen in two or three instances
these cysts filled with little bodies, semitransparent, and  resembling grains of boiled
rice  flattened and packed  closely  together, which were  probably scales of cuticle.
Even teeth, more or less perfectly  formed, have been found in a cyst in the orbit, as
happened in a case related by Barnes (c) of Exeter.
   (4) These are true productions of the sebaceous follicles, and have  been already
mentioned (par. 2198, note) in speaking  of Horns.]
   2250. The  nature of the cyst is very various, and has no connexion
with the size of the  swelling.  In   those which contain  serous fluid the
cyst is  generally thin and  correspondingly transparent.  The cyst is often
very firm, tough,  fibrous, may be separated into many layers from the
outer surface, and  often has an almost  horny character.   At  many parts
it is frequently found bony.   The inner surface of the cyst is often smooth
and shining; frequently has  a velvet-like  surface; is  sometimes beset
with true hairs; oftentimes it  exhibits  rather a  muco-membranous struc-
ture, an irregular, folded, net-like surface.   The connexion  of the  cyst
with the surrounding paits is usually but slight, by means of delicate  cel-
lular tissue and few vessels; sometimes, however, a very firm connexion
is found, and the cyst  cannot be well distinguished from its  immediate
investments.
   [" Mr. Hunter considers  the internal  surface  of the cyst to be so circumstanced
respecting the body, as to lose  the stimulus of being an internal  part, and to receive
the same impression  from its contents, either from their nature or the length of ap-
plication, as the  surface of the  skin does from its external  situation.   It  therefore.
takes on actions  suited to such  stimuli, undergoes a change in its structure, and acv,
quires a disposition similar to the cutis, and is consequently possessed of the power
of producing cuticle and hair.  What the mode of action is, by which this change
is brought about, is  not easily determined ;  but from  thesindolenoe of these com-
plaints, it most probably requires a considerable length of time to produce it.  That
the lining of the cyst really does possess  power similar  to cutis, is proved  by the
following circumstances ; that it has a power of  forming a succession  of  cuticles
like the common skin, and what is thrown off in  this way is found in  the cavity of-
the cyst.  It  has a similar power respecting hair, and sometimes the cavity is filled
with it, so great a quantity has been shed by the  internal  surface."   It is further
added :—" What is still more curious, when such cysts  are laid  open, the internal
surface  undergoes no change from  exposure, the cut edges cicatrize, and the bottom,
of the  bag  remains ever after an external  surface.   Different  specimens of the
above-mentioned circumstances are preserved in Mr. Hunter's collection of dis-
eases."  (d).}
  (n) Facet's Catalogue of the  Pathological  crescences of the  Human Body;  in Phil.
Collection in the Museum of the Royal Col-  Trans., vol. lxxxi. p, 95.
lege of Furgeons of England.                 (c) Med.-Chir. Trans., vol. iv. p. 316. 1813^
  (b) Observations on  certain  Horny Ex-    (d) Home, above cited, p. 102.
                                   37* 
434
ENCYSTED TUMOURS.
   2251. Encysted tumours are at first always  small, and  developed
 slowly to a large size.   Their form is generally round, and their  extent
 well defined, if the surrounding parts do not affect their development in
 a decided direction.  They are moveable at their  base; this, however,
 depends on the yieldingness of the  parts surrounding them, and on their
 firmer or looser  connexion with them.   The manner  in which  an en-
 eysted swelling is filled differs, according to the nature of the contained
 substance and of the cyst; the swelling  is elastic, expanded and  yield-
 ing ; a  distinct  fluctuation  is  often felt; sometimes it is firm; the skin
 eovering it is  unchanged.   An encysted tumour, when it has reached a
 certain size, often remains stationary throughoutlife, sometimes it continues
 increasing slowly.   Various symptoms may be produced by the pressure
 of the swelling upon important neighbouring, parts ; if or* a laone  it will
 destroy it by continued pressure.  Nutrition  may also be interfered with
 by several encysted tumours.,
   2252. Sometimes, in consequence of external violence  or from  un-
 known causes, the encysted tumour inflames, and pours into its cavity a
 puriform fluid;  The external  skin reddens,  and  ulcerates,  the cyst
 Bursts, and the fluid contained in its cavity is  discharged.   If the in-
 flammation be-severe, the menabrane forming the  sac is loosened into
 Gellular tissue^ thrown off, and thus a perfect cure«is effected.  But this
 part often remains ulcerated, and very sensitive ; an ichorous ill-condi-
 tioned pus continues to be discharged'; fungous growths spring up, and
 the aperture obstinately resists healing..
   2253. Encysted  tumours are to be considered consequences of an un-
 natural formative effort, of which the- proximate cause is, in most cases,
 not to be determined.   They are frequently congenital, and  then form a
 peculiar kind of nevus?, maternus;  sometimes they are hereditary; fre-
 quently arise in consequence of rheumatic,  gouty, syphilitic, or scrofu-
 lous disease ;  sometimes from external violence, continued pressure, and
 the like.  They may occur  on all parts   of the external surface of the
 body, but are  most commonly developed' where  naturally  the  cellular
 tjssue is in largest quantity.
   2254. A peculiar kind of encysted  tumour-, which most commonly
 occurs under the skin of  the head' and'face, and upon the back, though
 but rarely ins other,  parts, has been subjected  to  particular inquiry by
 Astley Cooper (a), who has fixed  its origin in the obstruction of  a  se-
 baceous,, follicle  of  the  skim, in which  case the tallow-like sebaceous
 matter collects in its cavity, and its walls expands in the cellular tissue
 {Tumor sebaceus.)   The  form, of this  swelling is  mostly  globular; it
 feels firm upon the  head, but on the face fluctuates indistinctly. It often
 presents, at the beginning, a  dusky spot in  its middle, which  is the
 plugged-up mouth of the  follicle, and'from which the  contained matter
 may  oftentimes be  squeezed (1).   When it  has  attained its  ordinary
,siz,e,,from.-;one to two inches  in diameter, it sometimes suddenly sub-
 sides, again begins, increases, and' acquires its previous size.  It con-
 tains a  substance similar  to  coagulated  albumen, which, when the tu-
   fa) Astley Cooper^; in his and Travers's   lipsise, HfiS.—von Walther,  Ueber die
 Surgical Essays, part ii. p. 229—Bae«sgh,  Balggeschwiilste; in  Journ.  fur Chirurg.
 (Proes.. Reichel,") Dissert, de Tumaribus  und Angejiheitk, vol; iv-p. 379.
 Capitis tunicatis post; Cephalagiam exortis. 
SEBACEOUS TUMOURS.                      435
mour suppurates, stinks horribly.  It is rather less moveable than the com-
mon encysted  tumours, and is more  firmly connected with the skin.
Sometimes the cyst contains hair;  sometimes the  swelling ossifies  (2.)
Horny excrescences frequently  spring from these tumours  ; the horn be-
gins growing at  the  open  part of the  cyst, is at first soft and flexible,
but  soon  acquires  considerable hardness,  and  assumes the nature  of
horn (a).   The structure of the cyst varies;  on the face it is usually thin,
thicker on the back,  and thickest on the-head; it also acquires  greater
thickness  in proportion to the length  of time it has existed.   On its in-
terior  the  cyst is lined with  an epidermis.   When  bodies  have  been
artificially introduced, the  cyst  presents many but minute vessels.  Pres-
sure is a frequent cause  of this swelling-;  also  a diseased state  of the
secretion, a deficiency of its wonted  fluidity, a thickness of the substance
secreted in  the follicle,  and flaccidity of its walls.   I have seen a consi-
derable  number  of such swellings after the  suppression of an eruption
on the head.   They frequently seem to be hereditary.
   [(1) The most simple form of  sebaceous tumour, or, more properly speakings
Sebaceous accumulations,  as they are oalled, by Erasmus Wilson, (b,)  is that  com-
monly  seen on the sides  of the nose, and also upon  the face in unhealthy  persons,
and not unfrequently on  the shoulders and back, often in very considerable  number,
varying in  size from that of a pin's head  to  a  pea, the  tops  of which becoming
blackened, have given rise to their vulgar  name " black heads."  Sometimes  they
lie quiet, giving to the face a dirty  ugly appearance ; but if a  gentle pressure  be
made on  either side, the  substance of which they consist  oozes out like little yel-
lowish white worms or maggots, by which name they are also not unfrequently called,
various length and size,  according to the length and distension of the sebaceous fol-
licle. Sometimes they acquire considerable size ; Astley Cooper mentions that he
himself had one on the lower part of the dorsal vertebrae, which had acquired a dia-
meter of about two inches, and  had a small black spot in  its centre, which having
been picked off, he squeezed out a large quantity of sebaceous matter.   Sometimes
these collections, not being  rubbed out, as they frequently are after washing, or not
having been purposely squeezed  out, inflame the  follicles,.and thus  acne is pro-
duced, which commonly terminates in suppuration, covering the face and back with
repeated  crops of pimples, especially annoying-to females.
   Astley  Cooper considers the encysted  tumours-formed on  the head and back to
arise merely from obstruction of the sebaceous follicles, and this opinion is generally
held.  But I have great  doubt of its correctness, for such cysts are always complete
sacs, without the least appearance of ever having  had  any opening ;  they may be
rolled about very freely beneath the skin, to which  they are so  loosely attached, as
well also as to the cellular tissue, that after cutting carefully through the skin, they
may generally be shelled out by running a probe around them, unless having  by
their size irritated  the surrounding parts, they have become adherent  to them, and
specially to the skin, which by degrees  yields  to their  pressure, and ulcerating,
they burst, as the cyst itself, though sometimes  as thick as a shilling, tears very
easily, and may  be split into flakes  resembling recent fibrin.  If left to themselves,
after bursting, these cysts produce troublesome sores, which continue  till the cyst
either comes away  or is  pulled away piecemeal, and then, the  sores heal.  But no-
thing of this kind happens when the swelling  is formed by an obstruction of the
mouth of the follicle; the follicle  either  yields  to the  accumulating sebacin, and
enlarges till, as in Astley  Cooper's  own case, it acquires considerable  size, but
can be emptied by gentle pressure-of its contents, and nothing further happens be-
yond the recollection of  the sebacin. Or the follicle inflames and suppurates, forcing
out with the pus the little  mass of hardened sebaceous  matter, after which the ir>
flammation quickly subsides, and  the follicle resumes its natural office,  without,'
however, any thing which  has the least pretension to a cyet having been discharged.
It, therefore, seems to me  that from  the  different courses these two forms run

   (a) This subject Ins been already considered in treating of Horns.  (6) Above cited. 
436        CURE OF ENCYSTED TUMOURS BY DISPERSION.

through, they are of decidedly different nature.  To this it may also be added, that
the tumours resulting from obstruction of the follicles, have occasionally their con-
tents converted into a projecting horn, in the way which Erasmus Wilson has  de-
scribed, as already noticed ;  but so far as I am aware this never  happens when  the
cyst is  globular, close, and of the recent fibrous character, which I have noticed and
which is almost invariably seated  in the scalp.—j. f. s.]
  (2) The ossification of an encysted tumour or of its contents is very rare; Dal-
rymple (a), however, has mentioned an example of "a small tumour, which he
removed from beneath the tarsal cartilage of the  upper eyelid of a middle-aged man,
which instead of the usual  cheesy matter contained  an apparently earthy or bony
deposit.  This tumour was somewhat larger than a pea, and composed of concentric
layers of hard earthy material, and in form, was rounded, except at the surface im-
mediately  behind  the conjunctiva, where it  was  somewhat  flattened and rough.
*  *  * Upon examination  by the microscope,  the concentric layers of this tumour
were found composed entirely of epithelium scales, closely agglutinated together;  but
instead of the usual transparent and  thin lamina with its central nucleus, they were
thickened and hard, and contained granular earthy molecules, which could be removed
by immersion in weak muriatic acid.  No amorphose earthy deposit existed around
or among the scales, but the whole  was composed of this epithelium  opaque, of a
light-brown colour, with a clear and  large central nucleus."  (pp. 238, 39.)]
  2255.  To encysted tumours  Ganglia {Ueberbeine, Germ.) are  allied;
they are round, of slow  growth, rarely exceeding the size of a pigeon's
egg, and in general, consisting of thick  walled cavities, developed in the
neighbourhood  of joints and sheaths of tendons, containing a fluid similar
to synovia, with a greater or less  number  of  little white  cartilage-like
bodies; in some cases, they must  be considered as partial expansion of
the tendon sheaths, but more generally as actually new productions (b).
They commonly arise  from external violence, pressure, violent straining
of a tendon and the like, on which account they are most frequent on the
back of the hands  and feet;  in  some  instances, they seem to originate
from constitutional causes.   As long as  the swelling is small, it produces
no inconvenience; but when it acquires large size, it inteiftres with mo-
tion;  and if it inflame and suppurate, tiresome ulcers  are produced (c).
   2256.  The cure of  encysted  tumours is  effected in various ways, the
choice of which depends on  their seat and size, their mode of connexion
with the neighbouring parts, their  mobility  or  immobility,  the  nature of
the coverings of the swelling, and  the excitability of the patient.  These
modes oftreatment consist, first, in the dispersion of the swellin <r; second,
in its  complete or partial removal  with  the  knife ; third, in its removal
with the ligature ; fourth, in opening the tumour and destroying the cyst.
Many cases require a combination  of these modes oftreatment.
   2257.  For  the dispersion of  encysted  tumours,  volatile rubbings,
blisters, dispersing plasters, escharotics, and a multitude of other reme-
dies have been  recommended.   Although  it cannot  be denied  that, in
some cases, absorption of the  fluid  contained in the cyst has been effected
by them; yet, however,  these remedies do not produce a radical  cure as
the cyst remains, and except such inflammation takes place that the whole
cyst be  destroyed and thrown off", no  cure  is  effected.   This method is
therefore inefficient, and not to  be recommended.
   2258.  The removal of encysted tumours with  the knife,  is in  general
the most fitting mode  oftreatment, if the  nature and seat of the swelling

  (a) Med.-Chir. Trans., vol. xxvi.  1843.
  (b) Mkckel, above cited, p. 158.—J.  Cloquet ; in Archives Gener. de Mddec. 1824. vol.
iv. p. 232.
  (, c)  Ganglia have been already noticed at p. 179 of this volume. 
TREATMENT OF ENCYSTED TUMOURS.          437
permit it without danger  of severer injury.  The mode of proceeding
varies.  If the tumour be  seated on a thin stem, an assistant draws back
the skin around  it, and the  operator  removes the tumour at its base
with one  or  more strokes of the knife.   By drawing back the  skin, as
much of it is  preserved as is sufficient to cover the wound and allow the
bringing together of  its edges.   If the tumour be not  large, the skin
moveable upon it and natural, a longitudinal cut should be made through
the skin, the  ends of which should reach a few lines beyond the circum-
ference of the swelling.  The edges of the wound are then separated from
the cyst with  the  blade or handle of the knife, or with the  finger, care-
fully avoiding injury  of the cyst, which being  seized with a hook and
lifted up from the bottom, is to be cut off* cautiously with some strokes of
the knife.  If the skin upon the swelling  be diseased, or if the tumour
be of very large  size, it must be included in two semilunar cuts at a
proper distance from its base, so as to preserve sufficient skin for covering
the wound.   Whilst the cyst is  being  isolated, an assistant should con-
stantly sprinkle cold water on the edges of the wound or sop up the blood
with a moist sponge.   If the vessels spiut forth, they must be compressed
with the finger, and tied 'after the operation is completed.  If the cyst be
wounded and the fluid escape, it is difficult to remove it entirely.   If it
be firm and hang loosely, it may be torn out with the  forceps.   When
the whole cyst has been removed, it  must always be endeavoured to bring
the edges of the wound together and  produce union.  But, in cases, where
the cyst has been removed only on one side, where the parts are very lax
and yielding, the extirpation is difficult, and many cuts must be made in
various directions, the wound  filled with lint, and  its edges only drawn
together when the bottom is covered with  granulations.
   2259. Tying the encysted tumour, applies to those cases in which  the
vessels running to the swelling are very large  and numerous, and great
danger of severe bleeding is to be feared; or when extirpation is dangerous
on account of the neighbourhood of important organs, especially blood-
vessels.   The tumour is to be tied  immediately at its base, if that be not
too broad, or a cut is first made in the skin at the base, and in this, a
ligature  applied  with a loop-tier,  and daily tightened  till the tumour
come off.  This method is always very tedious, accompanied with much,
often very great pain,  and when the  swelling begins to putrefy, the stench
is often unbearable.
   2260.  Opening the cyst, and removing it by suppuration or with caustic,
is performed in different ways.   First. In many cases when the connexion
of the tumour with the neighbouring parts  is not very firm, it is sufficient
to cut into the swelling with either a single longitudinal or with a cru-
cial cut, to empty its  contents and fill it with lint till suppuration come
on, when the loosened  cyst can be removed either piecemeal or entire.
Second. The tumour is opened with a lancet, or with caustic, by applying
oil of vitriol, or butyr of antimony, and scratching the skin with a needle
till the cyst be penetrated, then  its  contents are  emptied, and for some
days its interior must be  irritated  by frequently introducing a probe.or
touching it with either of the just-mentioned escharotics,  after which the
cyst separates and can be removed.   Third.  A seton, smeared with some
irritating ointment, may be passed  through  the greatest  diameter of the 
438                TREATMENT OF GANGLIONS.
tumour to produce the separation and death of the cyst.   Fourth.  The
swelling may be punctured with a trocar, its contents allowed  to  flow
through  the canula, and some  irritating fluid injected  and allowed to
escape, when the swelling has been filled and become painful.  Soothing
poultices are then applied, and when the swelling is soft and fluctuating,
an opening must be made through which the pus usually collected in the
cyst escapes.   These modes of treatment as well as the  ligature, may be
employed under the same circumstances, and especially when the cyst is
not very thick.   I have often made use of the first and second methods
in encysted tumours of the face, and frequently after emptying have pulled
out the cyst; they have the advantage of leaving a smaller scar than that
of extirpation (a).
  2261. When the tumour has its  roots very deeply seated among im-
portant parts,  which  must be injured  by complete  removal, a  mixed
treatment must be had recourse to.   First. The cyst must be laid  bare
at its base as far as  possible, without injuring any important vessel, a
ligature  applied around, and the tumour cut off in front of it.   Second.
As much of the cyst  must be removed as can be done safely,  and the
remainder destroyed with caustic.   Third. The cyst must  be opened,
filled with lint, and when it begins to  crumple  together, it must be
attempted to separate  it from its  bed.   Fourth. When the root of the
tumour cannot  be got  at without a dangerous wound, it  must be isolated
as far  as possible, drawn up, and a ligature applied with a loop-tier.
These mixed  modes of proceeding are very often required in encysted
tumours of the neck (6).
   2262. Encysted tumours caused by a stoppage of a sebaceous follicle,
may at first, when the follicle is merely a spot filled with blackish hardened
tallow-like substance, be emptied by introducing a probe into the stopped
opening, and then squeezing out the substance.  If force be requisite to
squeeze  it out, it is better to  enlarge the opening with a cut.  Frequent
squeezing prevents the refilling of the follicle.   The  removal of these
tumours from  the head is not always free from danger.  It is, however,
unnecessary to  dissect them  out, unopened;  a cut may  be made, the
contents emptied, the cyst seized with a hook or forceps, lifted up, and
separated (1).   When a horny growth has been formed in the follicle, it
will be necessary, to  prevent its recurrence, to remove the cyst with the
horn (c).
   [(1) As I have already mentioned, these cysts upon the head, if not adherent from
inflammation, will readily shell out, if the skin only be cut through; and it is more
convenient to remove them whole, than after opening them as Chelius recommends.
—j. f. s.]
   2263. The  treatment of ganglions must be guided by their condition.
If still recent, their dispersion should be attempted by rubbing in volatile
ointments, or turpentine, by repeated application of tincture of iodine, by
the use of mercurial and hemlock plasters, by blisters, by constant pressure
with a metal plate and tight bandage, and the like.  If they will not be
so dispersed,  and the  cyst be  thin, its subcutaneous  rupture  may be

   (a) Erdmann; in Zeitschr. filr Natur und  tion der  Balggeschwiilste am  Halse und
 Heilkunde, vol. i.  part iii. p. 304.           uber eine neue Methodedieselbe mitSicher-
   (b) Brunninghausen, Ueber die Extirpa-  heitzu verrichten.  Wilrzburg, 1805.
                     (c) Astley Cooper, above cited, p. 241. 
TREATMENT OF GANGLIONS.
439
attempted by pressure with the thumbs, upon which the fluid escapes into
the cellular tissue, and by continued application of pressure is prevented
collecting again; this practice I have usually employed with success(1).
When the cyst is more tough, it is best, after drawing the skin aside, to
open it with  a puncture, squeeze out its contents, and then allow the skin
to return to its place, so as  to  prevent the  entrance  of  the  air, and to
effect the union of the walls of the cyst, and hinder the  return of the com-
plaint by  careful  bringing together, and by the continued use of moderate
pressure.   For the purpose of more certainly preventing the entrance of
the air, the subcutaneous puncture (a) has been recommended ; in doing
this, the skin is  drawn back, and a cataract-needle  thrust obliquely into
the  swelling, the fluid  pressed into  the  cellular  tissue,  and  a bandage
moistened with lead wash applied; and on  the refilling  of the sac this
operation  must be repeated.   As with these various methods the return
of the ganglion is still not unfrequent, it has been  advised, in  addition to
the subcutaneous puncture, to cut through the walls of the cyst in every
direction.   According to Barthelemy (6), the skin having been raised
 in a fold, the point of a thin lancet, an  inch  long, curved towards the
handle of the instrument, and having a cylindrical stem, should be intro-
 duced, and thrust forward, so astp divide the ganglion into halves; and
 the  instrument then carefully withdrawn, to prevent the  entrance of the
 air.  The contained fluid escapes into the cellular tissues and disappears
 under  the use of a proper compressing bandage.   Malgaigne (c), after
 making the swelling tense, penetrates it with a straight narrow bistoury,
 flat and parallel  to the skin, at  the lower  broadest part of the  tumour, so
 far that the point of the bistoury passes through the upper part of the cyst
 without wounding the  skin.  He then turns the blade on its back, and
 thus keeps the lips of the little wound asunder, for the purpose of empty-
 ing the fluid, which is also assisted by pressure.  After this  the knife is
 again laid flat, and its point made to describe a quadrant on the left side
 of the swelling, so as to cut through every thing beneath the skin, and
 extend a little beyond the bounds of the ganglion.   The  knife is then
 turned to the right, and the  same done there.  To conclude,  the point of
 the knife is  pressed down, and  carefully carried through the bottom of the
 cyst, so as to avoid injuring the tendons  beneath.  The  swelling is now
 squeezed to empty all the synovia,  and then  covered  with pieces of
 sponge and compresses, or with pasteboard, to keep up regular pressure.
 According to Hennemann (d), an  assistant  should place  the tip of his
 right finger firmly on the skin beyond the ganglion, and  draw it towards
 him as much as possible, to prevent the parallelism of the wounds, whilst
 the operator holding Dieffenbach's tenotome, like a pen, places it nearly
 perpendicularly close to the tip of the assistant's  finger, at the lower part
 of the tumour, thrusts it in, sinking the handle more and more, to the
 furthest  and innermost part of the cyst, in  the  axis  of the limb.  Then
 with the left forefinger, the extremity of  which must be guarded with a
 piece of lint to  prevent it being wounded, he finds the point  of the knife,

    (a) Cumins ; in Edinburgh Med. and Surg.   (c) Bulletin de Therapeutique. Jan. 1840.
 Journal, vol. xxiv. p. 95.  1825.           p. 39.
    (6) Gazette Medicale de Paris, vol. iii. p.   (d) Ueber eine  neue.Rtihe subcutaner
  773.  1839.                          Operationen, p. 145. Rostock und Schwerin, 
440
HYDATIDS.
 and raising the handle a little, thrusts it  as deeply as possible into the
 bottom of the ganglion, and completely through it into the cellular tissue
 beneath, and brings it back still accompanied by the finger uninterruptedly,
 cutting upwards and outwards towards the puncture, but without wound-
 ing the skin.   He then places the blade of the knife flat as at first, and
 divides the sac horizontally right and left.   This done, a piece of whale-
 bone as thick as paper, and barely a quarter of a line broad, is passed in
 upon the  blade of the knife, so as to keep  up the constant escape of the
 synovia;  this is properly fixed, and a cold  wash applied.   On the fourth
 day the whalebone is removed, and pressure made, which if the patient
 can bear it, should be continued for  eight days.  Further  experience is
 requisite  to decide whether by this mode  of subcutaneous division, the
 return of the ganglion is more certainly prevented, than by mere puncture,
 and whether more serious symptoms are not to  be dreaded.   It must not
 be  forgotten that the  principal object  in this mode  of  treatment, is most
 carefully to prevent the entrance  of  the  air into the cyst, but this, with
 the various turnings  and movements of the knife, &c, seems  scarcely
 possible.
  Extirpation of  the ganglion, which  may be  necessary if its walls  be
 very thick and tough, and the above-mentioned plans  have been unsuc-
 cessful, must be performed in the same  way as removing  encysted tu-
 mours, and with great care, that none of the tendons are wounded.   The
 edges  of the wound must always be  brought together as closely as pos-
 sible to prevent the admission of air (2).
  [(1)  It is not often that a ganglion can be broken by pressure with the thumbs; but
it may in general be  managed by a smart blow with a  book or a piece of flat board.
  (2) I can hardly think the,removal of a ganglion ever needed, and should be very
 sorry to undertake such operation.—j. f. s.)
                         XL—OF HYDATIDS.

           (Hydatis, Lat.; Hydaliden, Germ.; Kystes hydatiques, Fr.)

  Schroeder, Th. G., De Hydatibus incorpore animali, praesertim humano repertis.
Rintelii, 1790.
  Ludersen, De Hydatibus.  Gottingae, 1808.
  Laennec ; in Bulletin de la Faculte de Medecine, No. 10.  1805.
  Rudolphi, Entozoorum, seu Vermium Intestinalium Historia naturalis.   Amstelo-
dami, 1808-10.
  Bremser, Ueber lebende Wurmer im lebenden Menschen.  Wien, 1819.
  Cruvelhier; in Diet, de Medec, vol. i. p. 465, Article, Acephalocystes.  Paris,
1832.
  2264. Hydatids, in some respects, range with encysted tumours; they
occur as roundish, oval, or otherwise  shaped serous vesicles, containing
lymph, either singly or collected  together in the different organs of our
body, either loose in the cavities, or surrounded with a second covering,
which connects them with  the surrounding parts.    These hydatids are
living animals, as shown in part by their having  decided organs,  and
being capable of self-motion, nutrition, and reproduction, (Rudolphi,)
and, in  part, that they are quite loose and  unconnected  with the cover-
ing by which they are surrounded.   These hydatids are divided into two
classes; first, those  in  which, besides their bladder-like  expansion, de- 
KINDS OF HYDATIDS.                   441
 cided organs are observed, Cysticercus, Cenurus, and Echinococcus,  of
 which the first and last only are met with in man ; second, those in which
 no other organ besides the vesicle has been discovered, as the Jicepha-
 locystides.
   2265. The  Cysticercus  Cellulose  {Blasenschwanz des Zellgewebes,
 Germ.) is met with in the cellular tissue of the organs, between the
 several layers of muscles, in the brain and its vascular network, beneath
 the conjunctiva,  in  the  chambers  of the  eye  floating in the  aqueous
 humour, and the like.   Its size is that of  a pea or bean, is  most com-
 monly elliptical, rarely globular, and consists of a delicate bladder filled
 with serum, on which  the  retracted extremity of the head may be dis-
 tinguished as a dusky body, but can be projected by squeezing; and its
 quadrangular shape with four suckers, and a conical trunk, armed with a
 double row  of hooks, are then observed.  The neck is short and nar-
 rower than the head, and the part next the vesicle.
   2266. The Echinococcus hominis {Hulsenwurm, Germ.) attains the size
 of a walnut, and even that of the fist, occurs for the most part only  in
 the organs of reproductive life, and  presents  in its  interior, numerous
 little worms as big as grains of sand or of millet seed, on each of which,
 if examined with the  naked eye, may be  perceived a single circle  of
 hooks and suckers.
   2267. The Acephalocysts exist  as large or small vesicles, from the size
 of a lentil to that of a child's head, and of various number and colour.
 Where developed, they are always surrounded with a more or less tough
 membrane, in which are found bladders of different number.   This mem-
 brane is generally very firm, sometimes at certain parts fibro-cartilaginous,
 cartilaginous, or even bony, and its thickness proportionate to its size,
 and the time it has existed; it is often closely connected with the sur-
 rounding parts, especially in parenchymatous organs, sometimes only
 loosely so, when in the midst of an organ having much cellular tissue, or
 when in the neighbourhood of a cavity.   The inner surface of this mem-
 brane  is lined  with another membrane, frequently  smooth,  sometimes
 uneven, wThich exhales a transparent, limpid, yellowish, purulent, thick,
 turbid fluid, in wrhich the hydatids swim singly or in great number, even
 as many as  up to 700 or 800.  The membrane of the hydatid  itself  is
 elastic, extensible, contracts after its contents are emptied, is  sometimes
 so  delicate that  it tears with the  least touch, and sometimes thick and
 capable of being separated into four or five layers.   It is never attached
 to its covering.   The fluid in it  is commonly as limpid as pure water,
 except that it contains  a certain quantity of albumen; it has for the most
 part the same appearance as that of the covering in which it is contained;
 it has, however, been found transparent, whilst that of the membrane was
 purulent.
  2268. Acephalocysts are developed in all organs, in the liver, ovaries,
brain, kidneys, lungs, muscles, bones, and  the like, and  the  danger of
the disease depends on the importance of the organ.  Their  symptoms
are always indecisive, and afford  a more or less probable conjecture;
also when they have  been once present in  an  organ and  been voided,
the same symptoms may  recur  (1).    Only when such  swellings are
quite superficial, they may, perhaps, be  distinguished by their unequal
  Vol. hi.—38 
442
TREATMENT OF HYDATIDS.
fluctuation, and on closer examination with the cold hand by their pecu-
liar movement.  Sometimes in such swelling, a peculiar feel of rubbing,
a kind  of quivering on  touching this vesicle in the examination to  dis-
cover fluctuation, may be  perceived.  Many have  doubted this; Pigne
has, however, twice noticed it, and considers it a decisive  character (a).
  (1) Thus pain in the region of the kidney has been observed, and  the escape of a
quantity of hydatids with the urine ; then  follows a cure,  till the symptoms set in
again and announce the speedy discharge of hydatids (b).
  [1 have  seen two examples of acephalocysts; the first was in the left side of the
neck, immediately above the collar-bone, between the sternomastoid  and trapezial
muscles, in a boy about six years old ; it was about the  size of a hen's egg, trans-
parent, and unattended with pain; its true nature was not known, and it was sup-
posed to be merely a watery cyst.   A puncture was made in it, and about an ounce
of clear fluid discharged ;  the lips of the wound were brought together, and it soon
healed.  But in the course of three or four days, the part again swelled, the skin
inflamed, suppuration took place, the wound opened, and a portion of the supposed
cyst protruded, which being gently drawn out, was found to be an acephalocyst; a
cure soon followed.  The second case had several of these animals, each contained
in its proper cyst in the cavity of the belly and attached to the doublings of the
peritonaeum ; one of them large  enough  to contain a pint of fluid, was situated be-
tween the  base of the bladder and the rectum, and filled  up  the cavity of the pelvis,
thrusting the bladder upwards  above the symphysis pubis, and by the pressure it
made on the lengthened neck of the bladder, causing retention of urine, for the re-
lief of which, it was necessary to dut into the perinaeum, when the urine was drawn
off;  but the catheter continually failed in  the performance of its duty till an enor-
mously long one was passed ; the patient suffered much, and died in about a week,
when the cause of difficulty was explained by the position of the acephalocyst, as
above mentioned.—j. f. s.]
   2269.  The mode of development of these hydatids is unknown; when
existing  in large quantity, they are  often produced anew,  of  various
number and  size, in the cavity of each hydatid.  They not unfrequently
occur after external injury, as blows, falls,  and  the like;  frequently,
however, without any  external cause.   What internal diseased action is
under these circumstances operating is unknown.  They frequently die;
the fluid  then loses its transparency, thickens, and  becomes yellow; the
vesicle crumples up, and the thickened fluid is changed into a fat-like or
earthy substance.  The membrane  often  inflames, fills  with pus,  the
Vesicle dies, and its remains swim in the pus.   Sometimes they make
their way into an excretory duct and are discharged;  sometimes into a
serous cavity, where  they  quickly  excite fatal inflammation.  "When
enclosed in a bone, they so thin its substance that fracture  occurs on  the
slightest occasions,  as  Dupuytren  observed in the  upper arm,  and
Wickham in the shin-bone  (Pigne.)
   [There is in the Museum at St. Thomas's an excellent example of acephalocysts
filling the medullary cavity of the upper arm.  The bone had been broken probably
from its having been weakened by the absorption of its shell, from the pressure of
these animals; the fracture could not be made to  unite, and after various attempts to
that object, amputation  was decided on, and performed by Boott  of Lincoln; the
 saw had not penetrated a qnarteT of an inch when the bone snapped beneath it, and
 out gushed  a heap of acephalocysts; the shell of the  bone was generally thin as
 writing-paper.  The patient recovered.—j. f. s.]
   2270.  The treatment of hydatidous swellings, when external, simply
 consists  in their removal.  In doing this, the thin vesicle  is generally

     (a) In his  Translation of this work.
     (6) Viglia Vallex ; in Bulletin de la Soctete Ana'.omique de Paris, p. 3.  1830. 
CARTILAGINOID BODIES IN JOINTS.
443
torn; the remains must be removed with  Cooper's scissors, and the
wound  cured by suppuration,  in  which, whatever  remains is thrown off
during  that process.   If the hydatid be removed uninjured, it shows evi-
dent movement, when put in warm water.
  The swellings which are considered serous and hydatid-like, and containing in
their interior a varying number of  cartilaginous bodies, and especially developed on
the wristband ankle-joints, and which Iconsider, as diseased changes of the mucous
bags, have been already treated of (par.  1870.)
           XII.—OF CARTILAGINOID BODIES IN JOINTS.

(Mures in  Articulis, Corpora seu Concrementa fibrosa seu cartilaginea Articuhrum,
      Lat.; Gelenkmause, Germ.; Corps cartilagineux des Articulations, Fr.)
  Par^ei, Opera, lib. xxi. cap. xv.
  Monro; in Medical Essays and Observations of Edinburgh, vol. iv. p. 244.
  Simson;  in same, p. 246.
  Reimarus, De Tumore Ligamentorum circa Articulos, Fungo Articulorum dicto.
Leid., 1757.
  Ford, Edward; in Medical Observations and Inquiries, vol. v. p. 329.
  Home, Everard; in Transactions of a Society for the Improvement of Medical
and Surgical Knowledge, vol. i. p. 229.
  Desault; in his OEuvres Chirurgicales, vol. i. p. 288.
  Biermann, (Praes. Heilmann,) Dissert, de Corporibus juxta Articulos mobilibus;
subject. Observ.  Wirceb., 1796.
  Abernethy, John, On the Removal of loose substances from  the Knee; in his
Surgical Works, vol. ii. p. 213.
  Gunther, Dissert, de Muribus in Genu.   Duisb., 1811.
  Lander, Einige Bemerkungen iiber die beweglichen Concremente in den Gelenk-
kapseln; nebst  zwei Beobachtungen iiber  die Ausschneidung soldier  Korper aus
dem Kneigelenke; in von Siebold's Chiron, vol. ii. p. 359.
  Larrey, Notice sur les Cartilages mobiles et contre nature des Articulations; in
his Memoires de Chirurgie Militaire, vol. ii. p. 421.
  Schreger, Beobachtungen und Bemerkungen iiber die beweglichen Concremente
in den Gelenken, und ihre Exstirpation.  Erlangen, 1815.
  Kohler, Dissert, de Corporibus alienis in Articulis obviis.   Berol., 1817.
  Hancke; in von Graefe uhd von Walther's Journal, vol. xxvii, pt. ii. p.  449.
   2271. Cartilaginoid bodies are sometimes formed within  the capsules
of joints, and are either loose in the cavity,  and can change their place
in  every direction, or  are attached to the  capsule by a  neck, and vary
considerably in regard to their  nature, size and number.
   2272. These bodies are most commonly noticed in the  knee-joint; but
they have been seen in the  ankle-elbow-jaw-shoulder-and wrist-joints.
They have generally an oblong flattened form, with rounded edges,  and
a  smooth glossy surface; they are, however,.met  with round, flat,  and
even  very irregularly  shaped.  Sometimes  they are very soft, frequently
almost cartilaginous, sometimes bony, "but  much more commonly carti-
laginous and bony together, and then have  a bony nucleus.  Such" as are
quite loose have often a  peculiar, completely  unorganized,  appearance;
are rough, granular, and have the exact shape of the space they occupy.
These  bodies vary in size from that  of a grain of hemp to  that of an
almond, and larger; the ordinary size is that of a large bean.  In general
there is only found one such body, though frequently several and even a
great number.   I have seen in one person three, and in another two. 
444
CARTILAGINOID BODIES
   2273. The symptoms which these foreign  bodies in the cavities of
 joints produce, vary according to their size, form, seat of their develop-
 ment, and according as they are loose in the joint, or still attached by a
 neck.   If such body be not large, and if it be developed in that part of
 the joint where it is unaffected- by the  rubbing together of the ends of
 the bones, and if it be attached by a short stem, it may  exist for a great
 length of time without  producing  any  symptoms;  but if  the  stem to
 which'the body is attached be longer, so that  in the  different motions of
 the joint it get between the ends of the bones, violent pain and sudden
 incapability of moving the joint are produced, whieh symptoms do not
 cease till the foreign body have again escaped from  between the bones.
 The slightest motion is often sufficient to cause this pain.  So long as it
 remains attached  by the  stem,  can the patient  precisely point out where
 it gets between the ends of the bone.   In  the knee-joint  these bodies
 are generally found on one. or other side of the knee-cap, and  can be
 distinctly felt  and pushed forwards.  If the  body  be  quite loose, its
 position is very variable; it gets into different parts  during the various
 movements of the joint;  and  even the patient himself can,  by pressure
 on the joint,  and by some particular movement, push it into  any position
 he pleases.   These symptoms  arise either gradually after previous vio-
 lence, which has been  followed by consequent inflammatory swelling of
 the joint or,, wdien, without any injury there has been  more or less severe
 pain, with or without swelling, and which is commonly taken for a rheu-
 matic affection.  Frequently the pain connected with these foreign bodies
 is very severe and constant,  and accompanied with inflammatory swelling
 of the joint, or an excessive accumulation of synovia.
   The symptoms which these concrements, when not appearing externally, cause,
 may be easily mistaken for an arthritic or rheumatic  affection.  The diagnostic
 characters of the former are, when besides the  patient having never been subject of
 those diatheses,  the pain  comes on suddenly, and  immediately after moving the
 joint; and when the attacks have  already frequently occurred  after any decided
 movement, if it subside whilst the joint is kept perfectly at rest in a certain pos-
 ture;  if it return on motion, or the slightest attempt at changing position, neither
 day-time nor the state of the atmosphere influencing it; when the swelling is dis-
 sipated by rest, but the movements are not proportionally more  free; and lastly,
 when the patient, who has already suffered these symptoms, again recovers the free
 use of the joint immediately after some accidental movement (a).
   2214:. The commencement of these cartilage-like  bodies  in joints, is
 commonly, but not always preceded by external violence.    Opinions
 vary considerably in regard to  their peculiar mode of formation.   Some
 persons (Reimarus, Monro) think  they are pieces.of cartilage  broken
 off"; Theden (6) believes them  to  be the joint-glands  torn  off' by vio-
 lence ; Bichat holds them for a change of a portion of the synovial cap-
 sule into cartilage ;  Hunter (c) supposes them to have  been originally
 extravasated  blood which has become organized, and  assumed the nature
 of the part with which it was connected ; Sander {d) holds them  to  be
 precipitates from the synovia; Laennec is of opinion that these bodies
 are formed on the outer surface of the synovial  membrane, and gradually
press into the  cavity of the joint, the synovial membrane with which they

  (a) Schreger, above cited, p. 14.          (c) Home, above cited, p. 232.
  (6) Neue Bemerkungen und Erfahrungen.   Id) In Die. des Sciences Medicales, vol.
 vol. i. p. 99.                           iv. p. 127, Article Cartilage. 
IN  JOINTS.
445
are covered yielding and forming a stem by which  they are  attached.
This stem is,  in consequence of  the displacements the foreign body suf-
fers, torn through,  and  the body is then  found  loose in the joint.
Richerand (a) imagines that some of these bodies are organic formations,
vicious growths of the synovial membrane,  whilst others on the contrary
are inorganic  concretions.   Schreger is  of like  opinion, and considers
the inorganic  as the result of plastic matter deposited on the exterior, and
either  a new formation, which increases, according to the laws of elective
attraction, from the  unnaturally mixed synovia, or  as  incrustations, to
which  their  lamellar structure  upon  a section through  them  leads, of
which sometimes coagula of lymph, sometimes parts of the natural appa-
ratus of the joint,  form the base.   Here also belong those bodies which,
previously connected  by a stem, have been  detached, as after  that  the
organic vegetation ceases,  and their increase is subjected to  the laws of
general attraction, so  that they are  built up of homogeneous  matter from
the surrounding fluids of the joint.   The origin of organic after-products,
depends on a change  of the chemical relations of the joint set up by dys-
crasy,  or  mechanical violence ; they are living growths of the glandular
fat-apparatus, of  the  cartilage  overspreading  the  joint-surfaees  of  the
bones, even of  the joint-surfaces themselves; they are  in general of a
tophical nature, sometimes sarcomatous, or  penetrated with  masses  of
bone;  those become bony which spring from the bone ; they are attached
either  firmly  or loosely by their  base, or  are entirely loose, though  on
account of their rough surface they can never be so moveable  as the  in-
organic concretions.   The joint is in these cases always more or less  in-
flamed, or even the subject of actual degeneration ; whilst, on the con-
trary,  the formation of the inorganic  concretions, little, if at all, inter-
feres with the integrity of the joint.
  [In St. Thomas's Museum there are  several examples of these foreign bodies
from joints and  ganglions, which support Hunter's notion, of their formation.   In
one, there are numerous  small  flattened discs, not exceeding a pea  in diameter,
which  were evacuated from a swelling on the back of the hand  that had probably
been part of a tendon-sheath, and had inflamed.  They are composed  of fibrin or
albumen, and have hollow centres.  In another, in which many  little  bodies were
in the wrist-joint  about the size of flattened peas, their surface is a  cartilage-like
appearance, and, when cut through, their substance is seen to consist of concentric
layers of fibrin, with a small central  hollow.  In other preparations of larger size
the central hollow has disappeared, and the whole  mass  seems  homogeneous, and
resembles cartilage.   There is also a fine example of the result of synovial inflam-
mation of  the knee-joint, in which a large portion of the  cartilaginous  covering of
the joint-ends of the bones has been destroyed ; but on several parts of the synovial
capsule numerous bunches of grape-shaped growths, with rnore or less thick stems,
have formed, and one of these as big as  a bean has become detached, and is loose
in the cavity of the joint.  I do not think, however, that this condition can be fairly
taken as an example of the ordinary mode of production-of loose cartilages,  though
it certainly explains  the process very well.—j. f. s»]
  2275.   Of these several opinions Laennec's seems best to point  out
the progressive growth of these  bodies.;  and.  to show  the  relation be-
tween  them and those bodies, which are  in. like manner developed on
the surface of the testicle and its vaginal  tunic, and are sometimes firmly
attached,   sometimes  quite loose.   It  is  perhaps  also  not  improbable
that those foreign bodies, in joints which have not a trace of membranous
           (a) Nosographie €hirurgt«ate, vol. ii. p. 349.  Fifth Edition.
                                    38* 
446
OPERATIONS  FOR REMOVAL
 covering, whose surface is rough, powdery, their texture rather lamellar,
 and which  have  the  form  of the  space in which they are lodged,  are
 produced in the same manner, and that their previous structure is only
 changed by the rubbing of the  joint-surfaces, after they have been long
 contained in the joint from which they have separated.
   In other respects Laennec's opinion is not to be considered generally
 satisfactory, inasmuch  as  experience has  proved  that portions of  the
 joint-cartilages are detached, or little exostoses formed around these car-
 tilages,  and may be broken off by accident (a);  although Reimarus and
 others incorrectly assume this as the general mode of their origin, which
 Morgagni has denied, since the erosions frequently observed on the car-
 tilaginous surfaces have no  connexion at all with the origin  of  these
 bodies,  which  are in  general of spherical form, and greater  thickness
 than the joint-cartilages.   Whether  these bodies still grow after  their
 detachment, and increase by the attraction of certain parts  of the syno-
 via  is  not to  be contradicted;" the  opinion, however, is doubted  by
 many (b).  Many of these bodies  are certainly formed by concretion of
 the  albumen  in the synovia, and  are to be placed in the same  rank
 with the foreign bodies which  occur in great numbers in the mucous
 bags.
   2276. When these foreign bodies cause severe symptoms, lie at some
 accessible part of the joint, or can be brought and fixed there,  the  most
 certain remedy  is  their  removal, by opening the capsule  of  the joint.
 The  serious  and  even  fatal  symptoms which have  been  noticed  after
 small wounds into joints,  and   not  unfrequently after  this operation,
 have led to the preference  of fixing these bodies to some one part of the
joint by close bandaging, and so to  prevent their getting between the
joint-surfaces, and thus  causing  pain.   Although  in many cases these
 bandages are of no use, and even increase the pain, yet should they  be
 tried, as in several instances they effect not merely momentary but  per-
 manent relief.
   2277.  Before the operation is performed, it must always be ascertained,
 by careful examination, whether there be not several such bodies in the
joint.   If the joint be painful and inflamed, this must first be got rid  of
 by strict rest, leeches,  cold applications, and the like.   Schreger,  in
 reference to  the above-mentioned  division of foreign bodies in joints,
 observes, regarding the prognosis, that in the first kind of these concre-
 tions the operation produces no dangerous reaction, when the structure  of
 the joint is healthy, or at least its interior life is not affected ; but in the
 second  form, their removal is  useless, accompanied with dangerous
 symptoms (c).
   Care should be taken to distinguish between these two different conditions; the
 benignant is free from pain, exeept when the concretion gets out of place; the malig-
 nant is accompanied by constant pain, even when the after-formation rests on the  outer
circumference of the cavity of  the joint.  The former bodies are loose, and move-
 able to various  parts of the joint; 1hese  excrescences, on the contrary, are attached
to the surfaces of the joint, whence they grow, and therefore remain in the same place,
and are incapable of having their situation altered by pressure orby the motions of the
joint.  If the former be connected by a fibrous adhesion, or  separated by secretion
  (a) Brodie; in Med.-Chir. Trans., vol. iv.    (6) Samuel Cooper, On the Diseases  of
p. 276.—Schreger,, above cited, p. 8.       Joints, p. 34, London, 1807.
                            (c) Above cited, p. 11. 
OF  CARTILAGINOID BODIES FROM JOINTS.        447
from their base, the motion of both indeed is restricted, but always, though slight,
still observable;  whilst, on the contrary, the latter never move from their place of
origin, and the form of the two sides of their opposite  surfaces produces the sensa-
tion of their previous junction.  Lastly, when examination proves the joint to possess
its natural integrity in the former, there is in the latter always more or less change
of form, that is, a partial chronic swelling of the joint-ends of the bone, or of the
capsular ligament,  perceptible.
  2278. The operation on the knee-joint is performed in the following
manner.  The patient being seated on a table in the horizontal posture,
the foreign body is pressed to the upper part of the knee-joint, on one or
other side, according  to  Abernethy,  on  the  inner, but  according to
Schreger, best  on the outer side, towards the  condyle of the thigh, and
fixed with the  fingers of the left hand, so that it cannot escape;  if there
be several bodies, they must all be  fixed in the same way.  An assistant
now draws the skin as much as  possible upwards, and the  operator makes
with  a convex bistoury a vertical cut through the skin and capsular liga-
ment, of sufficient size for the  foreign body to be easily  pressed out, or
removed with forceps.  If the  foreign body slip away the very moment
the cut is made, which I  have  seen, it must directly be brought back to
the cut, but  the  wound must be at once closed, if this cannot be easily
and quickly done.   When the foreign  body  has  been removed,  the
wound must be cleaned^ the parallelism between the  internal and external
wound got rid of, by letting go the skin which had  been  drawn up, and
then closed most carefully with  sticking plaster.   The  limb  is to be kept
strictly at rest.   If no inflammatory symptoms  come on, the wound
unites in a few days  by quick  union ; but if inflammation should set in,
it must be counteracted  by  active antiphlogistic treatment, as  leeches
and cold applications.
  [In the cases in  which I have operated, the loose substance was placed most con-
veniently in the little cleft between the edges of the condyle, and the head of the
shinbone, and the margin of the knee-cap ; and instead of drawing the skin up, as
Chelius recommends, I drew it tightly to one side.  I do not know, however, that
it is of material consequence in which direction the skin is drawn ; and the best rule
would seem to be,  to draw in  that direction in which the skin yields most readily,
so as to keep the outer and inner wounds farthest apart.  This will  principally de-
pend on the size and seat of the loose substance, which will also decide whether its
removal shall be effected on the inner or outer side of the knee-cap.  The operation
applies  only to the loose cartilaginous  or bony bodies, and not  to the malignant
growths  to which  Schreger  refers, for which  amputation  is the only remedy.—
J. F. S.]
   2279. Schreger  alone has  hitherto  removed these bodies from  the
shoulder-joint.   The mode of operation must be directed by the seat of
the concretion.  The operation would be unsafe if performed in the arm-
pit ;  attempts should therefore  be  made to  press and fix  the loose body
above and before, or above and without, the short head of  the m. biceps
flexor cubiti.  The arm must be pressed to the  trunk;  an  assistant draws
the skin as much as  possible  inwards, and the  operator then makes with
a convex bistoury a cut through the skin and deltoid muscle, directly upon
the body, and  in the course of  the fibres of that muscle, ties the divided
circumflex humeral artery, and having stopped the bleeding,  opens  the
capsular ligament, and removes the foreign body.   The treatment of the
wound is managed in the  same way as in the operation on the knee-joint. 
448                  SARCOMATOUS TUMOURS.
  The removal of similar bodies from other joints, as the elbow and the like, is con-
ducted in the same manner.
  2280.  To diminish the danger in the removal of these foreign bodies
from joints, by preventing the entrance  of the  air, the subcutaneous
operation has been proposed, by two stages and  at  different periods of
time (1).  The foreign body having  been fixed in the  above-mentioned
manner, a transverse fold of skin  is made at the part,  through the base
of which a narrow bistoury is carried  under the skin, and by one or more
strokes all the parts covering the body are divided.  It is then pressed
out of the capsule of the joint into the subcutaneous tissue, where it is
fixed with a bandage.   Some days after, when  the subcutaneous  cut is
perfectly healed, the  foreign body is removed by simply cutting through
the skin.  Further experience is required to prove whether serious symp-
toms can always be  prevented by this mode of operation,  as the cases at
present given lead to expect.
  (1) Goyrand (a) has removed two loose cartilages, one behind the other, from
the knee-joint in this way, without any symptoms arising,  notwithstanding the unfa-
vourable condition of the patient.  Syme (b) has  also operated successfully in the
same way.
                XIIL—OF SARCOMATOUS TUMOURS.

 (Sarcomata, Tumores sarcomatosi, Lat.; Fleischgeschwiilsle, Germ.; Sarcomes, Fr.)

  Abernethy, above cited.
  Lawrence, Observations on Tumours; in Med.-Chir. Trans., vol. xvii.   1832.
   2281. Sarcomatous tumours have the  feel of  homogeneous,  rather
hard, painless swellings, the interior of which present an homogeneous,
flesh-like substance, and are developed either as special tumours at one
particular part of the body, or by the conversion of any one organ, as for
instance, the  gland of the breast, the parotid gland, the testicle, and the
like, into this particular substance.
  [Two kinds  of tumours are included in this division, which differ in their nature
according to their situation.  The first kind, which Chelius notices, are in reality
only excessive  or hypertrophic growths of the cellular tissue connecting the skin
with the underlying parts, and which were well designated by Astley Cooper, as
Cellular Membranous Tumours .• they are generally attached by a neck, have com-
monly a pear-like shape, are weighty, hang down, and are found  on different parts
of the body, but not of  very frequent occurrence, and sometimes acquire enormous
size.  Lawrence (c) removed one from the buttock of a female, which " had com-
menced at the posterior part of the left labium pudendi, and had extended gradually
along the buttock and behind the  os coccygis."  It was twice as large as an adult's
head, " its greatest  circumference was  thirty-two inches, it was twenty-one inches
round at the basis, eleven inches from the  latter to the middle of its  inferior edge,
and eight in the line of the basis from the coccyx towards the trochanter." The root
in the labium could  not be removed, and after  some time a fresh  growth occurred,
and the tumour attained a third of its  former size.  It was subjected to a second
operation, the root followed, and the swelling completely eradicated.  I have seen
similar  tumours, though of less size, two or three times on the labia pudendi, which
parts seem rather more  subject to them than others.
  A very remarkable instance of repeated and  quick reproduction of one of these

  (a) Gazette Medicale de Paris, vol. ix. p.    (b) Principles of Surgery,  p. 231.  8vo.
329.  1841.                           1842. Third Edition.
                      (c)  Med.-Chir. Trans., vol.  xvii. p. 11. 
SARCOMATOUS TUMOURS.
449
tumours, occurred to ray colleague Mackmurdo two or three years since.  It grew
from  the under surface of the urethra of a woman, and was as large as an orange.
It grew again rapidly, and was again removed at the end of a month, having become
larger than at first.  In five days it had re-formed and was  as large as before, then
continued growing more slowly;  and at the end of three months, having increased
considerably  beyond the size of the former tumours, was a third time removed, and
has not since returned.
   Sometimes the neck by which they are attached becomes considerably lengthened:
in St. Thomas's Museum, there is an instance in which the neck is about six or
eight inches long, and the tumour as big as the fist.
   Occasionally, instead of having any neck, the whole cellular tissue of an entire
limb  may grow enormously;  I recollect an instance several years ago, removed by
Astley Cooper, in which along the  inner margin of each arm, one more so than the
other, a long swelling of  this kind extended from  the middle of the upper  arm to
the wrist, about two hands' breadth  deep, and having  the  appearance of a hanging
sleeve.
   Confused with these simple overgrowths of the cellular tissue, are those enlarge-
ments of the prepuce and scrotum, which correspond to the overgrowths of the pre-
puce  of the  clitoris and of the nymphae, and depend  on slow inflammation with
adhesive deposit in  the cellular tissue.  In the prepuce, this condition in which  the
cellular tissue is filled with a firm semitransparent jelly-like substance, frequently
follows severe  external gonorrhoea, and can only be got rid of by cutting it off.  I
have  also seen the  same conversion  of the cellular tissue of the face, in which  the
eyelids  were  so completely filled that their apertures were simple transverse slits,
and the  woman was  scarcely able even to see the light.   In this case I removed some
deep  slices (which were semitransparent, tough, and did not ooze out any fluid when
squeezed) about a third of an inch in width, at two or three intervals, from below
the lower lid, and hoped that  the fluid contained in the  intercellular spaces would
have  escaped through  the wounds, but it did not, and  the wounds healed quickly
with  but little relief, as at  the present time, ten or a dozen years after the operation,
her face is nearly in the same condition as at first.  The enlargement of the scrotum
of this kind is a very common occurrence in warm climates, and sometimes becomes
very  enormous. Titley (a)  removed successfully the  scrotum of a  negro at  St.
Christopher's, which weighed seventy pounds.  Delpech (b) removed the scrotum
of a native of Perpignan, of  which the weight was sixty French pounds; and Liston (c)
many years ago removed  a similar  swelling from a young man of twenty-three,
which had been growing twelve years, and weighed nearly fifty pounds.  In com-
parison  with  these the scrotum of the French Foreign Minister, Delacroix, which,
weighing from  twenty-six to twenty-seven pounds,  was  removed by Imbert  de
Lonnes (d), and at the time made great noise, was trivial.
   The  second form of Sarcoma, of which  Chelius speaks, as  attacking organs, is
very  different from the overgrowth of the cellular tissue, and is the result of inflam-
matory  action, by which the cellular tissue is filled with adhesive matter.  In the
testicle it is the true or simple sarcocele, and is not malignant.   It has  some resem-
blance  to the enlargement of the  nymphae and scrotum already referred to, but the
deposited matter is more  opaque, and  so  thickly deposited, that the structure  of
whatever organ it is lodged in,  is more or  less completely lost, and when cut into
has an almost scirrhous appearance.—j. f.  s.]
   2282. The form of  these swellings is various, sometimes they have a
neck.   In general they grow quickly and attain an enormous size.   They
have a doughy feel, and bear even a severe examination without pain.
Whilst the tumour is small,  the  skin covering it has its natural character ;
but  when it  has  reached a large size,  the superficial veins swell con-
siderably, the skin becomes tight, inflames, and ulcerates.  This ulcera-
tion usually brings about a partial and sometimes total destruction of the

  (a)  Med.-Chir. Trans., vol. vi. p.  73.        (c) Practical Surgery, p.  344.  Fourth
  (b) Clinique Chirurgicale de Montpellier,  Edition, 1846.
vol. ii.  1828.                            (d) RicnERAND.Nosographie Chirurgicale,
                                       vol. iv. p. 315.  Fourth Edition. 1815. 
450                  lardaceous tumours.
swelling, and the effect  on the  constitution is consequently in general
very considerable.  During the progress of sarcomatous tumours, various
diseased changes may occur in the mass of which they oonsist.
  According to microscopic examination, desmoid, sarcomatous, steatomatous, chon-
droid and fibroid swellings have been classed together as fibrous tumours, as in their
perfect state they consist of fibres which  interweave  them in  all directions, or are
disposed with a certain degree of  regularity, sometimes without any other element,
even without  vessels, and sometimes only sparingly traversed by vessels.  The
fibrous structure is  not always distinct; in tumours of this kind, still in a state of
development, there is often a formless mass, the blastema for fibres to be subsequently
produced, or blackish cells.  (Vogel.)
   2283.  The cause of these tumours is  always previous inflammation, or
at least an increased degree of vascular activity, which is produced either
by external violence, or dyscrasic  affections,  especially  scrofula  and
syphilis.   In consequence  of these  processes,  there  is a  deposition of
plastic exudation, into which vessels shoot, or the  nutrition of any  one
organ is greatly increased, and on the continued deposit of an homogene-
ous substance,  and great development of  the vascular system the further
growth of the swelling depends.
   2284.  The  treatment  may, at the commencement  of these  tumours,
prevent their  growth by diminishing  their unnatural  vital  activity, or
may effect their diminution, by repeated application of leeches, by con-
tinued cold bathing,  purgatives,  compression,  and  the like.  If  the
swelling become larger,  it must be  removed by extirpation, or by tying
the vascular trunks going to it, or  it may be diminished by introducing
a seton :  under which last treatment it is destroyed  partially by suppura-
tion,  partially by the inflammation which  obliterates its nourishing ves-
sels.   Extirpation is managed in the same  way as the removal of encysted
tumours.
   [The removal of these swellings by the knife is infinitely preferable to the intro-
duction of a seton or to tying the nourishing vessels, either of which is very tedious,
very tiresome, and the latter often very offensive to the patient frorn the  sloughing
which ensues, and very uncertain, as the  vessels which afford the principal nutri-
ment  may be too deep to be got at.—j. f.  s.]
                 XIV.—OF LARDACEOUS TUMOURS.

          {Steatomata, Lat.; Speckgeschwiilste, Germ.;  Stealomes, Fr.)

  Chopart, Essaies sur les Loupes; in Prix de l'Academie de Chirurgie, vol. iv.
p. 274.
  Gendrin, Memoires sur les Caracteres anatomiques des Loupes designes sous le
nom de Lipome et de Steatome; in Journal general de Medecine, 1828, vol. ciii. p.
210.
  Chelius, in Heidelb. klin. Annalen, vol. iv. part iv.                     _  ,
  Heyfelder, De Steatomate, Commentatio par loco in Senat. Acad. Erlang. rite
obtinend.
  2285. Lardaceous Tumours are  more or less large but firm swellings,
consisting of different,  but  generally globular masses, which  contain
within them  in  differently formed  spaces, a whitish,  tallow-like, more or
less firm substance, developed either in the cellular tissue beneath the
skin,  or the interstitial tissue of an organ. 
LARDACEOUS TUMOURS.
451
  Boyer (a), who, like many other writers, has under the name of Wens (Loupes,)
classed all circumscribed and painless swellings which  are situated in the cellular
tissue beneath the skin, and formed of a more or less consistent substance, contained
in a proper sac, or in several spaces of the cellular tissue, distinguishes the wens
which have a cyst into  those formed  of  degenerated fat,  which, deprived of its
natural colour, becomes white and hard, is contained in  the expanded spaces of the
cellular tissue, and mixed with a greater or less quantity of lymph, (Steatoma,) and
into those, in which the fat retains its natural condition,  and only acquires a greater
degree of consistence (Lipoma.)  But the  substance of a steatome is not to be  con-
sidered as merely degenerated fat;  it is distinguished, in addition to the difference
of substance, by other relations of  its internal formation, and especially, as Boyer
himself states,  from fatty swellings, in that it exclusively possesses the ruinous
peculiarity of degenerating into cancer.
   2286. The external form of steatome is very various ; although round,
it still exhibits different projections and irregularities ; its greatest extent
is in general immediately above its stem, which is commonly thinner, and
but  rarely broader than the  rest of the swelling.  The tumour is heavy,
does not yield to pressure, consists of several connected hillocky masses,
in the interspaces of which thexe is greater  softness  and yielding than on
its top.  The skin covering it is  at first natural,  moveable,  especially at
its neck, if the tumour be liable to dragging.  At the neck  of the swell-
ing,  oftentimes  one  or several projecting  cords  are observed, which
spread like roots beneath  the skin; and the latter,  wrhere corresponding
to them, is hard, reddened, and very tense.   The growth of a steatome
varies; in general it increases slowly, and  at first its progress is accom-
panied with no  other inconvenience than  that  produced by the weight
and dragging of the swelling.
   2287. As the growth of the tumour proceeds,  the skin, earlier or later,
reddens on the  projecting  parts,  becomes  tense, thinned and adhering.
Usually  violent stabbing and burning pains attack the whole swelling,
and spread into the neighbouring parts.  The tumour at last bursts at
this  part,  forms a dirty ulcer,  from which  a thin stinking  ichor is dis-
charged, together with the  grayish remains of the steatome.  The ulcer
spreads, and the same changes attack other parts of the swelling;  often-
 times fungous  growths spring from the ulcer,  and frequent bleedings
 occur.  The root-like cords on the neck of the steatome become harder;
 the neighbouring glands swell; the  cancerous degeneration proceeds in
 all  directions, and the patient  sinks  under  the continued violent pain of
 hectic consumption.
   2288.  On examining a steatome, so long as the skin covering it is un-
 altered, dnd  degeneration  has  not yet begun, there is found beneath it,
 a pretty thick layer of perfectly natural  fat which  penetrates the spaces
 between the several  parts of the  swelling.   In this fatty  mass, there are
 frequently encysted  tumours, connected,  however, with the principal
 swelling.   Beneath the layer of fat  there  is  a  pretty firm  cellular layer
 immediately investing the  tumour.  This  cellulo-fibrous capsule, which
 sends some  cellular streaks through the layers of fat to the skin,  is so
 firmly attached  to the steatome  that it cannot be  separated without in-
juring it;  it  sinks deeply between the several parts of the swelling, and
 thus forms the single tumours  which, connected beneath each other, rise

    (a) Traite des Maladies Chirurgicales, vol. ii. p. 404.  Paris, 1822.  Third Edition. 
452
LARDACEOUS TUMOURS.
 either in a parallel direction, or disposed around the neck of the steatome,
 separate externally from  each other.   The lobes of the tumour, when
 not completely bare of cellular tissue and fat, have considerable firmness,
 and nearly the resistance of fibro-cartilage ;  some of the lobes  are, how-
 ever, often soft and elastic.  If the swelling be cut through vertically,
 the formation of the various cells or cavities by the processes of the cel-
 lulo-fibrous capsules, which are filled with the substance of the  steatome,
 is  perceived.   This substance  itself is firm,  dull  white like lard  but
 firmer, and without vessels.   At the neck of the steatome,  more or less
 numerous roots are seen penetrating to a certain depth, and exhibiting
 the same characters as the tumour, that is, surrounded with cellulo-fibrous
 membrane, which accompanies them  to their origin, where is found a
 layer of very vascular cellular substanpe, of a dull white colour and fibrous
 nature, filled  in part with steatomatous matter and yellowish fluid, and
 surrounded with a thick layer of fat.  The roots oftentimes do not extend
 so deeply, and if the swelling be situated in  a yielding part, they  are, by
 the weight of the swelling, completely drawn into its neck.   The often
 pretty large vessels penetrate  through the midst  of the roots into  the
 swelling, and spread in the walls of the  smaller tumours; whilst other
 vessels spread in the fat and skin surrounding the swelling.
   2289.  When degeneration and softening have already begun  in  the
 steatome, larger branches of vessels are  observed in the walls of  the
 swelling, and in the yellow spots of the steatomatous substance; at  the
 same time, also, there  is  an infiltration of turbid, milk-like, and  yellow
 fluid, which can be emptied by pressure.   In the further progress of the
 softening, the substance filling the  cells becomes jelly-like, the walls of
 the  cells thicken, and are bluish-white, and  the vessels distributed in
 them are very distinct.  The  softening  is not alike  in  all the several
 swellings, and not even in one and the same swelling'.   When ulceration
 has began, the walls are  tearable and  bluish-white, and the substance
 contained in the cells is nothing but a grayish-white, dirty, semitranspa-
 rent pap.  The fat around the ulcer beneath the skin wastes;  there  is
 observed a not deep but distinct  scirrhous or brain-like  layer;  the vas-
 cular injection  in  the cellulo-fatty tissue wastes to the  extent of five or
 six lines, and the fat in equally considerable quantity  retains  its natural
 condition, but is mingled  with more serosity (a).
  Heyfelder (b), from his microscopical examinations, has proposed four varieties
 of steatome; first, the true fibrous swelling merely consisting of stretched fibres, and
 of them alone; second, those of which the greatest part is made up of the stretched
 fibres, but present also a cartilaginous  and bony structure; they approach the chon-
 droid tumours ;  third, those containing stretched fibres and fat, and are intermediate
 to lipoma and fibrous swellings ; and, fourth, those which are composed of stretched
 fibres, cells and nuclei, and must be enumerated with malignant tumours (c).
   2290. Steatomatous  tumours are developed often without any known
 cause, and often in persons whose otherwise good health and appearance
lead to no supposition  of  so considerable  ailment of their formative life
 as is shown in the progress of steatoma.   Mechanical influences, as blows,
pressure and the like, often cause it; though, probably, there is always a

  (a) Genorin, above cited.                (c) Compare the above with the note topar.
  (b) Above cited.                      2282. 
                        MEDULLARY FUNGUS.                    453

previous disposition  in  the body thereto present.   Of  the several dys-
crasies* the scrofulous seems most frequently to encourage the growth of
steatoma.
   2291. The  treatment of steatoma  consists simply  and solely in  its
removal with the knife, and the result of the operation is  the more safe
according as it is earlier performed, the more complete the removal of all
degeneration  dependent on the seat and condition of the tumour, and the
less the constitution is affected.   When already a general reaction upon
the whole body appears, when softening and ulceration have  set in, there
the prognosis  is always doubtful, because after the  operation the swelling
frequently is produced anew upon the scar or in some other part«(l).
   In conducting the operation, the same rules given for  the removal of
encysted tumours are applicable, with  the special direction, that after the
operation, the bottom of the wound is to be very closely  examined, for
the purpose of removing most carefully every infected part.   It is always
proper to establish an issue previous to the operation, and to keep it up
after the wound has healed ;  at the same time  also, a suitable  mode of
living and treatment, fitting  to the existent general ill condition  of the
health  must be  adopted.   It is still to be remarked, as  a peculiarity of
steatomatous  tissue, that it heals quickly when injured, in  which  case
numerous granulations form {a).
   (1) Boyer (b) supposes  that cancerous degeneration of steatoma is so much more
to be feared, the larger the  quantity of lymph contained in it.
                   XV.—OF MEDULLARY FUNGUS.

    (Fungus medullaris, Lat.; Markschwamm, Germ.; Fongus Medullaire, Fr.)

  Burns, John, Dissertations on  Inflammation, vol. ii. p. 302.  Glasgow, 1800.
8vo.
  Hey,  William, Practical  Observations on Surgery,  with  Cases, chapter  vi;
London, 1803.   First Edition.  8vo.
  Freer, George, Observations on  Aneurism, and some Diseases of the Arterial
System.  Birmingham, 1807.  4to.
  Abernethy,  John, Surgical Works, vol. ii.  London.
  Wardrop, James, Observations on Fungus hematodes, or Soft Cancer, in several
of the most important organs of the Human Body.  Edinburgh, 1809.  8vo.
  Laennec ; in Diet, des Sciences Medicales, Article Encephaloides, vol. xii. p. 165.
  Breschet ; in same, Article Hematode, vol. xx. p. 126.
  Meckee, Handbuch der patholog. Anatomie, vol. ii. part. ii. p. 297.
  Maunoir, Memoire  sur les Fungus  Medullaire et hematode.   Paris et Geneve,
1820.  8vo.
  Bartcky, Observatio singularis Fungi medullaris in Corde.  Prsef. est Dzondi.
Halae, 1821.
  von Walther, Ueber Verhartung, Schirrhus,  harten und  weichen Krebs, Me-
dullar-Sarkom,  Blutschwamm, Teleangiektasie  und Aneurysma per anastomosin;
in his Journal fur Chirurgie und Augenheilkunde, vol. v. parts ii. and iv.
  Hasse, Dissertatio de Fungo medullari.  Berol., 1824.
  Gunther, G. B., Diss.  Analecta ad Anatomiam Fungi medullaris.  Lips., 1824.
  Nisle, Beitrage zur Lehre von Blut- und Markschwamm; in  Horn's Archiv.,
1829, part v. p. 813.
  Baring, O.,  Beobachtungen und  Bemerkungen  iiber den  Markschwamm;  in
Holscher's Hannov. Annalen, vol. i. part ii.

         (a) Gendrin, above cited.              (6) Above cited, p. 345.
  Vol. iii.—39 
454
MEDULLARY FUNGUS.
  Meyen, Untersuchungen iiber die Natur parasitischer Geschwiilste im mensch-
lichen Korper, insbesondere iiber den Mark- und Blutschwamm.  Berlin, 1808.
  Travers, Benjamin, Observations on the Local Diseases termed Malignant; in
Med.-Chir. Trans., vol. xv. p. 195, 1829.
  Walshe, Walter Hayle, M.D., The Nature and Treatment of Cancer.  Lon-
don, 1846.  8vo.
  Carswell, Robert, M.D., Illustrations of the Elementary Forms of Disease.
London, 1833.  fol.
  Muller, John, and Vogel, J., above cited.
   [Stevens, A. H., On Fungus  Heematodes of  the Eye, in Med. and
Surg. Register, p. 117, vol. i.—g. w. n.]
   2292*  Medullary Fungus (Soft  Cancer of the older writers, Spongoid
Inflammation, Burns ;  Fungus hematodes, Hey  and Wardrop ; Ence-
phaloide, Laennec ; Hematode, Breschet ; Medullary Sarcoma, Aber-
nethy ;  Medullary Cancer,  Travers;   Cephaloma,  Carswell; Fun-
goid Disease, Astley Cooper ; Encephaloid, or Soft  Cancer, Walshe)
is an unnatural production, which begins as a little, defined, smooth and
even swelling, at first firm, though not hard, and over which the  skin is
unchanged.   As it enlarges the tumour becomes more elastic, and some-
times gives an illusive feel of fluctuation.  The skin covering the swell-
ing  gradually becomes thinner, adheres to the tumour, and at last burst-
ing, a bloody ichor, escapes ; through this hole in the  destroyed skin a
reddish  fungous substance  pushes  up, continues increasing, and being
girt by  the round opening of the  skin, the edges of which continue thick
and unaltered, a longish neck is produced.   This fungous growth bleeds
on the  slightest.touch, and  by the spontaneous tearing  through  of the
numerous vessels,  which pass to   its  surface,  frequent  bleedings  are
caused.  Often pieces of the  tumour are thrown  off, and then exceed-
ingly stinking grayish ichor escapes in large quantity.
  [Dr. Thomas Young (a) has included under his genus Carcinoma, or  Cancer,
" an  uneven  tumour, with sharp lancinating  pains, tending  to  ulceration ;"' two
species, " C.  scirrhosum, Hard  Cancer,  and  C. spongiosum,  spongy and  readily
bleeding, Bleeding Cancer" (p. 346) ;  the latter of which is the disease now to be
treated of.  English  writers have, however, generally, with the exception  of Tra-
vers and Carswell  and more recently Walshe, described and  held them as dif-
ferent diseases.
  " We may consider," observes Travers, " Carcinoma as a genus of the order,
' malignant diseases.'  Its  species are first  the scirrhous, second  the medullary.
Their respective modifications and varieties are to be referred to those of structure."
(p. 200.)
  Carswell  says:—" In the genus Carcinoma I propose to comprehend those dis-
eases which have been termed  scirrhous;  common vascular or organized sarcoma;
pancreatic, mammary, and medullary sarcoma, and Fungus haematodes.  The follow-
ing reasons may be assigned for thus  grouping together, under the generic term of
 Carcinoma, so many diseases  generally described  as  differing widely  from  that
which is commonly known by  this  designation:—First.  They often present, in the
early periods  of their formation, certain characters common to all of them, however
much they may differ frcm each other in the subsequent periods.  Secondly. They
all terminate in the gradual destruction or transformation of the tissues which they
affect.  Third. They have all a tendency to affect several organs in the same indi-
vidual.   Fourth, They all possess, although  in various degrees, the same repro-
ductive  character. Such are the more remarkable phenomena which, considered
 anatomically, and in a general  point of view these diseases present in common with
 one another.  *  * * More in detail.  * *  *  They present  differences, some

   (a) An Introduction to Medical Literatue, includ'ng a System of Tr-clical Xosolofj.
 Londoi, 1823.  8vo.  Second Edition. 
MEDULLARY  FUNGUS.
455
of which are of considerable importance,-others much less  so.  *  *  *  The dif-
ferences to which I allude, are referable to two states  of heterologous deposit,  to
which the diseases  in question owe their origin.   The first is that in which this
deposit has little or no tendency to become organized.   Its  form and  arrangement
appear to be  determined  chiefly by external circumstances;  and its formation and
subsequent increase are entirely dependent on the nutritive function of the organ in
which it  is  contained.  In the second  state this deposit exhibits on the contrary
a greater or less tendency to become organized.  Although it may, at first, assume a
determinate form and arrangement, in consequence of the influence of external circum-
stances, it possesses in itself properties by means of whieh its subsequent arrangement
and development are affected, independent of the nutritive function of  the organ in
which it is formed, except in so far as the materials of its growth may be derived from
this source.   On account, therefore, of these two opposite states of the Heterologous
Deposit, Carcinoma may  be  divided into two species, the first of which I shall call
Scirrhomt, the  second Cephaloma.  *   * *   In these two species of carcinoma,
the Heterologous Deposit presents itself under various forms which may be regarded
as so many varieties of each  species.  The varieties of scirrhoma  are determined
chiefly by the relative quantity of the Heterologous Deposit, the manner in which
it is distributed, and the difference of colour and consistence which it presents.
*  *   *  The principal varieties of cephaloma (medullary fungus)  are  derived
from the appearances  which the heterologous  deposit presents, either in different
organs or  at  different stages of its development," as the common Vascular, or Or-
ganized Sarcoma, of Abernethy ;  his Mammary Sarcoma and Medullary Sarcoma
(the latter being the Matiere Cerebriforme, orEncephaloide, of Laennec ; the Spongoid
Inflammation of Burns;  the Milk-like Tumour of Dr.  Monro;  the Soft Cancer  of
various authors ; the Pulpy Testicle of Dr. Baillie); and Fungus haematodes of Hey
and Wardrop,  which is the Fungoid Disease of Astley Cooper.
   Walshe's views in respect  to medullary fungus and  scirrhus forming  but one
genus, are much the same as Carswell's, but they differ in regard  to  Colloid,  or
Jelly-like Cancer, which Walshe holds as a distinct species,  whilst Carswell con-
siders it merely a variety of his scirrhoma.  "A single  genus of formations repre-
sents," says Walshe, "the subdivision  of Infiltrating Growths; this genus is Can-
cer.   It comprehends some important species agreeing in essential characters, both
as  respects  their  natural similitude  and their  dissimilitude to  Non-infiltrating
Growths, (p. 4.)  To our  countryman, the late Dr. Young, belongs in reality the
merit of having been the first to unite scirrhus (Carcinoma scirrhosum) and encepha-
loid, (Carcinoma spongiosum,) as  species of a genus, cancer  or carcinoma; but his
example has  been very slowly followed.  English writers,  with the exception  of
Mr. Travers, more keenly perceptive of the  differences  than of the  analogies  of
these products, have almost to the present day continued to define cancer as ulcerated
scirrhus, and  separate  encephaloid completely therefrom, under the titles  of medul-
lary sarcoma, fungus  haematodes, fungoid disease, &c.  Nevertheless,  opinion had
been  silently undergoing a  change among us; we had  been  gradually learning  to
recognise the practical truth and importance of Dr. Young's nosological arrangement,
when Dr. Carswell deprived us of all excuse for wavering by satisfactorily proving
its  justness.   But this is not all;  the inquiries of Laennec, followed by those  of
several of his contemporaries and successors, distinctly established the close alliance
of another morbid formation, originally described  by that  acute observer under the
title of tissue, or matiere  colloide, to scirrhus and encephaloid."  Differences of opi-
nion have been held as to the relationship of these.  "I some few years past ven-
tured," says  Walshe, "to  assign to colloid the rank of a species in juxtaposition
with scirrhus and encephaloid.  The additional experience I  have  since acquired,
has still more  fully convinced me of the correctness of the views on which this
arrangement  was founded."  (pp. 7, 8.)   Hence he divides Cancer, or  Carcinoma,
into the three species, Encephaloid, or soft Cancer; Scirrhus, or hard Cancer; and
Colloid, or jelly-like  Cancer (p. 10.)]
  2293.  So long as the swelling  is small, it  usually causes  no incon-
veniences, but with its enlargement becomes more sensitive ; sometimes a
violent pain shoots  through it, and in general when ulceration takes place
severe pain is produced.   The neighbouring glands  swell  often to  con- 
456
MEDULLARY FUNGUS OF BONE.
siderable size.   Sometimes these glandular swellings occur when the
original  swelling is still  small, and sometimes not, although it be very
large; they appear also in parts which have no immediate connexion, by
means of the absorbents with the originally diseased part.  The fungous
structure appears only to be found in the original tumour.  In more ad-
vanced stages of the disease, the powers are depressed by the often recur-
ring bleedings, and the copious flow of ichor, and at last the patient sinks
from the colliquative symptoms.  The continuance of the disease is un-
certain ; it, however,  usually proceeds more  quickly than cancer.
   2294. This disease may occur in every organ of our body ; it has been
observed in the ball of the eye, on the limbs, in the  female breast, on the
parotid, on the thyroid gland, on  the testicle and the ovary;  in the liver,
spleen, and kidneys; in the lungs, in the heart, in the mucous bags, and
other parts.  In  these different seats of the disease the symptoms differ
more  or less,  which  especially applies to  the  eye-ball.   Of the other
cases the development of the disease has especially a nearer connexion
in the testicle and  in the bones.
   2295. In the testicle, medullary fungus begins either with swelling of
the gland itself, or  in the epididymis, in consequence of which the testicle
assumes an oval or rounded form,  and  it is difficult to distinguish  Ihe
testicle and epididymis from each other.  Neither irregularity nor change
is observed in  the  tissue of the testicle; the hardness, however, is at first
in general great, but the pain trifling.   When the tumour has increased
considerably, it becomes softer, and the feel of its containing fluid is ex-
ceedingly delusive.  In its  subsequent course the  swelling is  at some
parts hard, and at other parts very soft, as if it would soon burst.   The
veins  of the scrotum  swell,  and the skin becomes discoloured.   The
glands of the groin on the affected sides, or upon both sides swell up and
the tumour proceeds along the spermatic cord into the belly.   The reac-
tion of this disease upon the general condition of the patient is  so great
that death may ensue  even before  the ulceration and protrusion of the
fungus.
   I have seen a case, in which a puncture having been made into a medullary fungus
of the testicle by another surgeon, with the object of performing the palliative cure
for hydrocele, although the puncture remained open till I  subsequently performed
castration, and bloody ichor continued flowing, yet no fungus appeared.
   Upon medullary fungus of the testicle, may be consulted—
   Gierl, M. Ueber den  Fungus, die  Struma Testiculi, u. s. w.;  in Neue Chiron,
vol. i. p. 273.
   Cooper, Astley, Observations on the Structure and Diseases of the Testis, p. 116.
London, 1835.  4to.
   Hertzberg, Ueber Schwamm des Hodens; in von Graefe und von Walther's
Journal, vol. xiv. p. 283.
   Baring, Ueber Markschwamm des Hodens.  Gottingen, 1833.
   Curling, Blizard, A Practical Treatise on the Diseases of the Testis, &c.  p. 337.
London, 1843.  8vo.
   2296. All the bones may be attacked with medullary fungus, which may
originate either between  the external surface of the bone and the perios-
teum, or in the interior of the bone (1).   In the former case there appears
a  small, hard,  and generally  painless tumour  beneath the  periosteum,
which softens as it increases, displaces  the parts, interferes  with  or de-
stroys the functions of the limb to various degrees, becomes painful, and
may grow  to an  enormous  size.   I  have seen two cases in which the 
MEDULLARY FUNGUS OF  BONE.
457
swelling occupied the whole thigh-bone, the periosteum was raised five or
six inches, but the  surface of the bone was little changed.   The bone is,
however, frequently, and especially about the circumference of the swell-
ing, beset with many fine needles or plates, which spring like rays  from
the surface of the bone, and  penetrate into the interior of the  swelling.
If the fungus be developed  in the  interior of the bone,  it not merely
fills up its tube, but renders the bony tissue atrophic, so that it is merely
surrounded by a thin shell of bone, which is  ultimately burst  through;
such bones, therefore, break  on the slightest injury.—(Muller.)
   [(1) Medullary fungus of bone has been well  described by Astley Cooper (a),as
a species  of exostosis, under the name, according to its beginning in one or other part
of the bone, of Fungus Exostosis  of the Medullary Membrane and Fungus periosteal
Exostosis.
   2297. The examination of the tumour after death, or after its removal,
presents different results, according to the degree of its development. In
the interior there is found a  soft substance, which is often scarcely dis-
cernibly divided into larger and smaller lobes by fine cellular tissue, homo-
geneous, milk-white, at some parts usually a  little reddish,  resembling
the medullary substance of the brain, and when cut into thin layers semi-
transparent.   Its consistence is similar to that of the human brain ; its
tissue, however, is  generally little  connected, and it easily breaks be-
tween the fingers.   In proportion  as  the substance is  more or less
loosened up it exhibits  more  or  less resemblance to  certain parts of the
brain; but most commonly it has the  nearest  resemblance to  the some-
what softened brain of a child.  On the surface  of this substance  run  a
quantity of blood-vessels, the trunks of which spread upon the surface
and in the depressions of the swelling, and the  branches  penetrate into
its substance.  If the tumour be examined in an advanced state, when it
has already attained a tolerable size, its  substance has a very different
appearance at different  parts.  It sometimes  resembles pus, and is of a
whitish  or reddish-white colour;  in consequence of the  outpouring of
blood and a greater development of the vessels, certain parts have often
a dusky-red colour, and appear like  lumps of clotted  blood.   Sometimes
the substance  is so mixed with  blood  that it has no longer  any resem-
 blance to brain,  but has a  reddishr blackish colour, and  has the consis-
 tence of partially-dried and tearable  dough.   Some pieces  are  often
 dusky yellow, and resemble  yolk of egg in consistence and colour.  In
 general, however,  certain parts still retain  their brain-like  character.
 Some firm cartilaginous, and even bony spots, are often observed  in the
 substance;  and the latter is  especially noticed when  the  disease occurs
 in the eyeball.
   The chemical examination of  the brain-like  substance, shows that it consists  of  ,
 albumen, fatty matter, osmazome, lime, magnesia, phosphate of potash, sulphur, and
 phosphorus, and consequently, as regards its elementary parts, it is similar to the
 substance of the brain.—(Maunoir, Bartcky.) According  to Brande's (6) state-
 ment, the principal element of medullary fungus is a peculiar fibrous matter, partly
 insoluble in acetic acid.  The fat which the fungus contains, cannot be converted
 into soap, and contains phosphorus, like the fat of the brain.

   (a) In  his and Travers's Surgical Essays, part i. p. 179, and p. 194.  Third Edition
 1818.
   (b) See Barins 5 in Holscher's Annalen, above  cited.
                                  39* 
458      CHEMICAL COMPOSITION OF  MEDULLARY FUNGUS.
   [The following is the analysis of the brain-like substance of medullary fungus
given by Foy (a) .—
Albumen......47,00
White fatty matter  -  - '-    7,50
Red fatty matter  -  -  -  -    5,35
Osmazome    -----    4,00
Fibrin.......6{50
Water.......8,00
Subphosphate of lime    -   -   6,30
              ~) soda  -  -   -   2,75
Carbonates of V lime  -  -   -   4,00
              ) magnesia   -   1,00

Hydrochlorates of j J^88*.   g^
    Oxide of iron  -----   1,35 i Tartrate of soda   -  •   -   -   0,35
  According to Hecht (b), gelatin is found in this substance, though less in quantity
than in scirrhus; but its proportions vary in different stages of medullary fungus,
the gelatin being in greater quantity than the albumen in the first, or stage of crudity ;
whilst it was found considerably less than the albumen in  the second, or stage of
softening.  Maunoir,  however, ascertained that no gelatin existed in the brain-like
mass  ; and  his  statement is confirmed by  Muller, who on this account, places
medullary fungus among tumours which are albuminous and do not contain gelatin:
though he says, "in one case of medullary fungus, he obtained, after boiling it for
eighteen hours, a little gelatin, whilst the principal part showed no disposition to be
changed  or dissolved.  The exceptional appearance  of the  gelatin he  attributed to
the addition of some cellular tissue."—(p. 5.)]
  Krause (c) found in the medullary matter, in addition to an unnaturally loose or
formless whitish substance and branching vessels, a  quantity of round and oval  cor-
puscles,  j^th of a line in diameter, opaque-white, transparent at their edge, uneven,
resembling pus-globules, and  also, smaller, smooth, clear globules, from jj^th to
g^yth of a line in diameter.
  Gluge (d) considers m eduUary: fungus as no peculiar tissue, but merely an infiltra-
tion of a  diseased fluid into the healthy tissue, as into  a  sponge, by which it is
distended, and altered into the most various forms.   The white fluid squeezed out
presents, when magnified two hundred and fifty-five times,numerous corpuscles, with
a small quantity of large, irregular particles, in a transparent fluid.   These corpuscles
are spherical, but their upper surface is streaked, and these dusky  streaks stretch to
the edge.  They have nowhere spots like pus-globules, and are  much  larger, being
■^th of a millimetre  in diameter,  whilst the pus-globules are only yfoth.  About
two-thirds of the medullary substances are  made up of  these corpuscles.  When
the fungus becomes larger, there are still distinguished a quantity of large irregular
particles which  all  have dusky and pale lines; perhaps here, instead of corpuscles,
only irregular bodies  and fibrous matter have been capable of being formed, differing
according to the organ affected.  The  greater the quantity of medullary corpuscles
and medullary  substance deposited in the fungus, the greater is its softness, even to
fluidity;  and then  occurs  the illusive feel  of fluctuation, which  can  only be  dis-
tinguished from that of pus, in that the collections of the latter are isolated, whilst
the medullary  corpuscles are infiltrated between the several primitive fibres.   If,
however, but  little medullary fluid be deposited,  the tissue retains its ordinary
hardness and consistence.  A very remarkable circumstance is  the presence of
medullary corpuscles in the  entire substance of an  organ, where only some small
fungi, or even  none at all, exist, whilst they are present in  other  parts of the same
individual.  The medullary  substance operates destructively, just like gangrene,
upon  the tissue in which  it is collected, if it have affected it long enough.   The
fibres of the organ retain their usual direction, but in small fungi are separated by
 close-lying particles, and when more advanced, fibres can no longer be traced.  In
 all these forms of fungus, there are numerous  rhomboidal crystals of Vofyhs  of a
 millimetre, mean diameter, commonly  in groups, but in quite fresh fungus they are
 scattered, on which account they must be sought for.
    In  the development of inflammation, the whole swelling, or part of it, distended
 with  blood, presents newly-developed thick  nets of capillary vessels, and the me-
 dullary corpuscles are mixed with compound corpuscles.  Fibrous matter may also
 be closely deposited in  the fungus, and so give it the  appearance  of a scirrhous

    (a) Archives  Generales de Medecine, vol.    (c)  Above cited.
 xvii. p. 185. 1828.                         (d; Anatomiseh - mikroscopische  Unter.
    (b) Lobstein, Traite d'AnatomiePatholo-  suchungen zur  allgem. und speciell Patholo-
  gique, vol. i. p. 456.  Pari*, 1829.  8vo.     gie.pait i.-ix. Leipzg, 1839. 
CHARACTERS OF MEDULLARY FUNGUS.            459
degeneration.  Concentrated sulphuric acid dissolves the medullary corpuscles in
part, and there remain  only little dusky bodies; in like manner hydrochloric acid
exhibits a flocky, granular substance.   Alcohol coagulates the medullary fluid, and
the medullary corpuscles, like those  of pus,  become still more distinct, without
changing  their shape.  Acetic acid dissolves the  medullary corpuscles but  very
slowly, which is done much more quickly in pus-corpuscles.  The crystala dissolve
in sulphuric so completely as to leave a sediment; whilst in nitric and hydrochloric
acid on the contrary, they do not dissolve at all.
   The  medullary substance exists also in the fluids of the human body.  Gluge
observed in one case, in the blood-clot of the right  iliac vein, an undoubted  me-
dullary mass; the walls of the vein were healthy,°and led to no diseased organ.
   2298. The tumour presses the neighbouring parts together, the muscles
are often completely enclosed in the substance, and  as it were marbled
with it.   The whole mass  is  surrounded  with  a cellular investment,
more or less distinct, according as it is developed in an organ, of which
the cellular tissue is of a tougher or more yielding nature.  The external
form is in these cases generally round, sometimes flattened, egg-shaped,
sometimes quite irregular, and its external surface divided into lobes, which
are separated by  more or less deep furrows.   Laennec, as also Cruvel-
hier,  found the brain-like  substance contained  in cysts, of which the
walls were pretty even, scarcely more than half a line thick, of a grayish
white, silvery or milk-white colour, and semi-transparent, in their struc-
ture resembling  cartilage,  and so firmly connected with  the brain-like
mass,  that they could not be  easily separated.
   2299. In medullary Fungus of the Testicle, the brain-like substance has
generally a pale-brownish or reddish  colour ;  oftentimes the whole testicle
is converted into a mass of this kind.   Often this mass consists of many
parts,  very  different from  each other in reference to  their  tissue, and
separated by thin membranous partitions from each other:  some portions
are soft, others hard, and some actually bony.   If this substance be rinced
in water,  a soft cellular tissue  remains.  The partitions are  generally
united to the tunica albuginea; but sometimes they are separate,  and
the interspace is filled with water.   In the bones, the swelling most com-
monly has a white brain-like nature ;  all the above-mentioned varieties,
however,  occur.   Bone  and periosteum are as above mentioned, (par.
2296.)
    2300.  The  following  are  the  characters of medullary fungus.   The
 swelling is  soft, elastic, and both during life  and after death, yields a
 delusive fluctuation to the  touch ;  destruction at one part of the skin
 covering it, through which  sprouts a  fungus, but little  painful when
 touched, and bleeding readily ; the edges of the skin encircling the neck
 of the swelling often remain a long while in their natural condition, with-
 out thinning, or undergoing any other change; neither do the considera-
ble discharge of ichor nor the throwing off of portions  of  the fungous
growth produce  any diminution ;  on the contrary, the swelling continues
increasing,  and  thrusts the surrounding parts asunder, without infecting
them  with  its own peculiar diseased  metamorphosis;  they  are  only
altered by the continued pressing  together which the swelling effects
 upon  them.  This disease especially occurs in the earlier periods of life.
    2301.  The diseased substance contained in   the tumour  differs  so
 much at  different periods of the disease,  that a definition which  shall
 include all  stages of its development is impossible.  It may be whitish, 
460             CHARACTERS OF  MEDULLARY FUNGUS.
reddish,  brownish, and  even black; its consistence  may vary  equally,
which depends on more or less of the cruoric or albuminous elements of
the  blood being deposited.   On these different relations of the diseased
substance rest the  conditions, which have been put forward as different
degenerations, and bear different designations, though alone  depending
on the different stages  of its  development, or on the  peculiarity of the
organ in wdiich it  has its seat.
   Of the  many designations  applied to this disease, all of which are taken from
different  stages of its development, I  have preferred Medullary Fungus (Mark-
schwamm) as  most appropriate, and  specially as thereby  all confusion  with  the
blood-fungus,  produced  by unnatural distention of the capillary-vascular system,
(par. 1507,) is avoided.
   Allan  Burns (a) makes a difference  between fungus haematodes and  sarcoma
medullare, in that, in the former, the  substance of the swelling is penetrated by a
quantity of membranous  bands, whilst in the latter it is of an homogeneous medullary
consistence, and similar  to the cortical substance of the brain.  In the former, if the
soft brain-like  mass be washed away, the membranous partitions still remain;  but if
the latter be treated in  like  manner, its capsule only, and  a number of fiocculi
hanging  from  its inner surface, are left.  I  have never found  these distinctions in
my examinations.
   von Walther has also founded a difference between fungus haematodes and sar-
coma medullare, on the  difference of the  substances composing the swelling, from
which he assumes, that though in other  respects the nature of both tumours is alike,
and  the substance of both alike  consists of  cellular tissue and  vessels, some  of
which are lengthened, and some  newly produced, yet that the blood is deposited
rather in  its cruoric  elements in fungus  haematodes, and in its white, albuminous
elements, in sarcoma medullare.   I  have really found  such  different  relations  of
these substances to each other, that in the otherwise like progress of both diseases,
it is difficult to determine such distinction.
   According to Samuel Cooper  (b) Abernethy did not assume  the identity  of
sarcoma medullare and fungus haematodes, as has been done by Wardrop and others.
   [Abernethy certainly does not assert  the identity of medullary sarcoma and fungus
haematodes; for, in considering the former, he does not make  the least allusion  to
the latter, although the two cases he gives in illustration are both medullary fungus.
one  of which  had burst and  bled before death, and in the other the patient died
before the skin  ulcerated.   But he  does not  incidentally refer to  Hey's fungus
haematodes in  relating the case of a girl who had a cyst on her arm which he
punctured, and discharged  a little  serum, but on introducing the finger, some strata
of coagulated  blood  came away, and severe bleeding ensued, which could not be
stopped,  and the arm was  obliged to be amputated;  in doing which, however, part
of the cyst was left behind, which thrust forth a fungus and the girl died.  Aber-
nethy remarks :—" An unrestrainable hemorrhagic tendency seems to be  the
essential character of that disease, which Mr. Hey has denominated  Haematodes.
That it takes place from diseased structure is manifest; yet I have known  it happen
without any morbid growth  having  preceded it."  He then observes, that "the
term fungus haematodes seems to be a name  commonly now applied to every bleed-
ing fungus, whjlst  that haematodal  disposition, which Mr.  Hey has  described, is
very rare;" and concludes by giving a  case  exemplifying Hf.v's views, which is
evidently a case of medullary/u^gus, in which, according to  Walther's opinion,
the  cruoric part of  the blood was  that deposited forming fungus haematodes. (p.
 125-27.)   Abernethy had either a very confused notion of these two forms of the
same disease,  or, like many other authors, did not like to disturb or intercalate the
classification of tumours which he had  made.—j. f. s.]
   The most decided difference  between the two diseases  is, that in  sarcoma me-
dullare after the part has broken, the place heals till another similar tumour bursts
through  the skin; whilst  on the contrary in fungus  haematodes, the fungus grows
larger and larger, never diminishes by  being thrown off,  nor is  there  ever any

               (a) Surgical Anatomy of the Head and Neck, p. 220.
               (6) Fi.st  Lines of Surgery, p. 353.  Sjventh Edition. 
CHARACTERS OF MEDULLARY FUNGUS.            461
attempt at a curative process.  I have frequently noticed this distinction in the pro-
gress of the disease, but have not been able to determine how far it has been actual
or only accidental, according to the difference of the organ affected;  as for example,
in the testicle there is scarcely ever protrusion of the fungous growth.
   John  Muller (a),  who views  medullary fungus  as  merely a modification of
Cancer, (soft Cancer,) considers it most correct to employ the name medullary fungus,
as a collective designation of the different forms of soft cancer which run into each
other, and  hence from  his own  observation he enumerates  the  following:—First,
Carcinoma medullare, with formation of medullary substance composed of roundish
formative corpuscles in greater quantity than the delicate fibrous tissue, which runs
through the tumour.  These are the corpuscles seen  by Gluge (par. 2297); they
are those  of common cancer, and very like  the gray basal substance of  Carcinoma
reticulatum.   Second,  Carcinoma medullare, consisting of oval, tailless  corpuscles,
in addition to an extremely soft, brain-like substance.  Under the microscope these
corpuscles are one and a half  as large as  the blood corpuscles, and  of like breadth.
Third, Carcinoma medullare, with tailed or spindle-shaped  corpuscles.   Such me-
dullary fungi have sometimes,  when broken, a-sort of fibrous appearance, if the
tailed corpuscles be regularly  disposed.  They are sometimes scattered  among
other formative  corpuscles, sometimes exceed them in number.  According to the
direction in which the corpuscles are disposed in reference to each other is there,
sometimes  the  appearance of  a radiated  formation,  sometimes  of  a clustered
arrangement; but at other times  their direction is so various, that the swelling when
broken exhibits  no fibres.  In other respects there is no criterion of the malignity
of a tumour in the tailed corpuscles, as there are many  benignant,  albuminous
sarcomata with tailed corpuscles, and  many fibrous tissues  in the  embryon consist
of tailed corpuscles.
   According to Vogel, the essential element of medullary fungus in the different
parts of the body is a cell, doubtless developed from  a formless blastema, which
escapes observation.  The cells have very different forms and  size, oval, roundish
tailed, sometimes very largely branching, like the pigment-cells of the lamina fusca.
Almost all these cells  present a nucleus with  or without a nuclear body.   Many
cells contain very numerous cell nuclei; not unfrequently large cells are observed
which contain one or more little  ones (mother cells with daughter cells.)  The cell-
nuclei seem first to arise  from the  cells.  Very frequently there are nuclei without
investing cells,  some single, some collected in packets; but very rarely are the cells
devoid of nuclei.  The cells of one and the same medullary fungus ordinarily pre-
sent the same or a  similar character.  Sometimes the cells, free from all foreign
parts, without any visible connecting medium, are closely locked together and form
the whole tumour.   In other cases, there is a fibrous basal  tissue (stroma) between
the cells, and when this is in excess, the niedullary/ung-us runs into scirrhus.  When
complicated with  melanosis, the cells  filled with black pigment plunge among the
medullary fungus cells.  Tf they be fewer in number and  equally distributed, the
medullary/u7ig«s appears gray throughout: if only disposed in certain  parts, it is
marbled and veined.   When melanosis is  prevalent, the swelling is black.
   In regard to the  so-called blood-fungus, the opinions of Bradley and Jaeger re-
main to be mentioned.
   Bradley (b)  supposes that  fungus medullaris is nothing but the distention of a
vein (aneurysme veneux.)  At first, whilst the blood in the aneurysmal sac is still
fluid, opening the tumour and obliteration of the vessel suffice for the cure ;  in this
case, the aneurysmal sac is still healthy.  But if the blood be clotted, the sac be-
comes diseased  and liable to form a fungus haematodes.   Else observed a fungus
communicating  with a vein.   Pott's Aneurysm 1
   Jaeger (c) holds  that blooi-fungus consists of larger or smaller, thin and thick
skinned cells, penetrated  with delicate streams of blood or actual vessels, and pos-
sessing a  more or  less  distinct  mucous  membrane.   In these cells is contained
blood, some of which is clotted, some thinly fluid, and some decomposed.  Several
cells are  generally torn, and the whole swelling often consists of an homogeneous
mass of blood.  This tumour either lies loose in the cellular tissue, or is surrounded

   (a) Above cited, p. 21.                    (c) Schaffner, F. A., Ueber den wahren
   (b) Diet, des Sciences  Medicales, Article  Blutschwamm,  cine  inaugural  Abhandl.
Hematode, vol. xx. p. 133.                 Wiirzb., 1834. 
462               CHARACTERS OF MELANOSIS.
with a tough, fibrous, very vascular cyst, in the covering of which, the cellular
tissue is also very vascular.   No trace of lard-like or  brain-like substance is dis-
coverable.  Between some of the cells, fibrous ridges are sometimes found.  Single
vessels and their openings into the cells, are not to be discovered.
  Vogel considers blood-fungus as merely a complication of medullary fungus with
teleangiectasy.
  2302. As in scirrhus,  the  tissue forming the  swelling  exhibits great
variety, depending on the different  proportions  of the fibrous and lard-
like substance, so that in this respect, two extremes maybe pointed out,
of  which, the one presents a fibrous centre,  whence proceed numerous
fibrous rays, between which but little lard-like  substance is scattered,
whilst the other exhibits an  homogeneous lard-like substance, without a
trace of any such fibrous rays; so a like relation is also noticed in me-
dullary fungus.   A pure white, brain  and marrow-like substance here and
there mixed with a brownish or  blackish substance and clotted blood,
and at the other extreme, only a brownish or blackish mass  of blood,
and that condition which Jaeger has pointed out as blood-fungus.
  2303. Meckel holds, that the swellings called by Laennec, and others
Melanosis are completely the same as  medullary fungus;  and in one re-
spect, he  is certainly right,  because the  substance forming medullary
fungus in many cases is, for the  most part, blackish, and  seems  to re-
semble a black pap.  But melanosis occurs  in other ways, and is to be
considered merely as a diseased secretion of  a  colouring matter, a pig-
ment, the analogue  of which is also found in  a healthy state of the body,
and deposited  in the parenchyma of the organ on different surfaces, even
on  mucous membranes, as I  myself have observed in the nose.  If then
melanosis be no degeneration, no product of a new structure, but merely
an  altered secretion, therefore  also does the black substance present no
trace of organization, and  may be observed alone, or in tumours of dif-
ferent kinds.   This unnatural  secretion depends on difference of tem-
perament and  constitution, on peculiar changes  of the blood in diseases
of the kidneys, lungs, skin, and the like, whereby the throwing off of the
phlogiston is prevented, and an  increased production of carbon caused.
The symptoms noticed in  melanosis, seem rather to arise from other cir-
cumstances which exist with that disease, than  from the disease  itself;
for instance, from chronic  inflammation, from the simultaneous presence
of  unnatural formations, as medullary fungus, cancer, tubercles, or from
the mechanical irritation and pressure of the deposited substance.
   According to this variety in the occurrence  of melanosis are its different
course, and influence upon the constitution, as also the different results
which are apparent from microscopic observation.   It sometimes  exists
for a longtime without any effect upon the health; sometimes the powers
soon sink;  sometimes it  continues till the  melanosis runs  on to an open
ulcer;  then from the clefts and fissures of the broken-up swelling,
escapes  a black fluid, and mixed with pus when the neighbouring parts
have been destroyed.   These openings sometimes heal, sometimes break
out again, and run on to destructive sloughing  and the like.
   Upon the subject of  Melanosis,  the following writers may be con-
 sulted :
  Bayle, Recherches sur la Phthisie pulmonaire, Obs. xx. xxi.   Paris, 1810.
  Laennec ; in  Journal de Medecine, par Corvisart, &c, vol. ix. p. 368.
  Merat; in Diet, des Sciences Medicates, Article  Melanose, vol. xxxii. p. 183.
1819. 
         DIAGNOSIS BETWEEN MEDULLARY FUNGUS, &C.     463

  Cazenave ; in Diet, de Medec, Article Melanose, vol. xix. p. 324.   1839.
  Breschet,  Considerations sur une alteration organique  appelee  Degeneration
noire, Melanose, Cancer melane, etc.  Paris, 1821.
  Heusinger, C. F., Untersuchungen iiber die anomalen Kohlen-und Pigment-
Bildung.  Eisenach, 1823.
  von Walther, above cited, p. 567.
  Noack, C. A., De Melanose cum  in hominibus turn in equis obveniente.   Lips.;
with three copper plates.
  Cullen, Will, and  Carswell, R., M.D., On Melanosis; in Medico-Chirurg.
Trans, of Edinburgh, vol. i. p. 264.   1821.
  Fawdington,  Thomas, A Case of Melanosis, with general Observations on the
Pathology of this interesting disease.  London,  1826; with a plate.
  Schilling,  E., Dissert, de Melanosi.  fol.  Francof., 1831.
'  Carswell, Robert, M.D., Illustrations of the  Elementary Forms of Disease,
fasc. iv. Melanoma.  London, 1834.
  Vogel, above  cited.
   2304. If  the above-mentioned appearances of medullary fungus be
compared  with the internal  condition  of  scirrhus, the following  distin-
guishing characters  may be  observed.   The tissue of scirrhus,  which
must not be confounded with  induration, equally at  its onset forms  a
hard, firm, imcompressible substance, which  when  cut  into  thin  layers,
is-semi-transparent, has the  consistence of cartilage  and fibro-cartilage,
even to that of lard, with which  it agrees in appearance, and is composed
of two different substances ;  the one hard  and fibrous, the other soft, and
of  an inorganic appearance.   The fibrous part  forms various partitions
and cavities without arrangement, in which is contained the softer sub-
stance, ordinarily of a pale brownish, sometimes  bluish, greenish, whitish
or,reddish colour, similar to hardened albumen:  the fibrous  part has
sometimes  a cartilaginous hardness.  But especially are the proportions
of  these substances very different.   Sometimes  the fibrous  substance
forms  the nucleus, from which  the  partitions  spread in every direction,
and, when cut through, presents a radiated appearance.   Oftentimes the
swelling has a uniform hardness, in  which no  distinct tissue can be
traced.  Sometimes  encysted tumours form in  the  scirrhus, filled with
differently coloured fluids.   Ulceration always begins in these swellings
with excessively  severe stabbing, lancinating, burning  pain, extending
either from without inwards, or  from within outwards, and accompanied
with secretion of acrid, very stinking ichor.   Sometimes a bleeding hard
fungus  springs  from the surface of the  ulcer.   This,  however,  is  not
always the case, and in the further  progress of the disease, this fungus,
together with  every thing that surrounds it, without distinction of tissue,
is  destroyed,  after  having  previously passed  into  a  scirrhous  state.
 Cancer  is the especial peculiarity of advanced age, and most commonly
occurs at  the  critical periods of life, when  the  capability  of production
 declines.   It  may otherwise be  primarily developed from any scirrhus,
or from any ulcer, if its bottom have passed into a scirrhous  condition.
   A resemblance between medullary fungus and cancer can alone be drawn from the
 following circumstances : in both diseases, when ulceration has taken place,a thin,
filthy-smelling ichor is secreted; in'cancer there are often fungous growths; both
are in a high  degree destructive, spread in all directions, are frequently accompanied
with bleeding, commonly appear in  different organs  in the  same individual, at the
same time,  and rarely heal.  But in medullary fungus it is always  characteristic
that it spread only by growth, and compress the parts, but not as cancer, which, by
its extension, draws  the parts into  the same degeneration.  I cannot therefore, in 
 464   DIAGNOSIS BETWEEN MEDULLARY FUNGUS AND SCIRRHUS.

 this respect agree with John  Muller (a), when he states that medullary fungut
 with tailed corpuscles can be distinguished from the benignant corresponding sar-
 coma, for this only admits the distinction of the tissue formation in  the affected
 organs or their neighbourhood.
   Breschet (b), who, like most French writers, applies the term Carcinoma to a
 different degeneration from scirrhus and cancer, points out four different kinds; first,
 Carcinome encephaloide ou cerebriforme; second, Carcinome melane~; third, Carcinome
fungoide ; and fourth, Carcinome hematode.  If the description be compared with the
 results which  I have given from examination of medullary fungus in its several
 stages, it cannot be otherwise considered that these  kinds of carcinoma are merely
 different degrees of development of medullary fungus ,• nor to think that it is contrary
 to the usual mode of expression, to point out with carcinoma another state of disease,
 than the passage of scirrhus by ulceration into open cancer.
   Meckel (c) hold's that Abernethy's sarcoma tuberculatum  probably agrees entirely
 with medullary fungus.  As this opinion is not  supported by any positive grounds
 drawn from  sarcoma tuberculatum, so I think  I  can the less agree with  it, as the
 symptoms which set in with that disease do not accord with those given to medullary
fungus.  Sarcoma tuberculatum, according to Abernethy {d), consists of an agglo-
 meration of firm roundish tumours of different size and colour, connected together
 by cellular substance.  Their size varies from that of a pea to that of  a horse bean
 and above;  their colour is brownish red, and in many yellowish.  Abernethy had
 seen the disease only in the lymphatic glands of the neck.  It runs on to ulceration,
 malignant, phagedenic sores, and thus causes death.   From this description sarcoma
 tuberculatum does not in the least agree with medullary fungus, and it  seems rather
 that it must be taken for a cancerous  degeneration, at least when it has passed  into
 ulceration and incurable sores.
   2305. In regard to the cetiology of medullary fungus, nothing decisive
 is known.   In most cases the disease is developed without any percepti-
 ble remote cause, and it  is usually found not confined to one spot,  but
 present at the same time in several organs.   Under such circumstances
 the whole constitution ordinarily  exhibits general disease ; the  skin is of a
 greenish-yellow colour, frequently covered with a clammy sweat,  there is
 constant troublesome cough, difficulty of breathing, and the like.  If no
vdecided  general affection   can  be  perceived, still  there  is  a peculiar
 diathesis not to be mistaken, which  is best distinguished as the diathesis
fungosa.  Sometimes an  external mechanical influence is the cause of
 this disease,  and although  it be  quickly developed under, these circum-
 stances, yet is its influence upon the  constitution less.   It is quite unde-
 cided what general affections, scrofula, rheumatism, gout, syphilis, and
 the like, contribute to the origin  of this disease.
   According to my observations medullary fungus may be developed in
every organ.   Its seat is in the cellular tissue, in  which the capillary
vessels and vegetative  nerves are spread.  In the cellular tissue, where
the vessels  are numerous, new vessels are formed, the tissue itself loosens
up, effusion takes place, which, according  as  the albuminous or  cruoric
part of the blood prevails, exhibits, in  various proportions, the white,
brain-like,  gray,  or reddish, brownish, even blackish colour, or all these
together.
   2306.  Art  can do  little  against medullary fungus.  The  strongest
escharotics are  unable to restrict its growth.  The only remedy which
discovers the possibility of cure is the early, complete  removal of the part,
or the amputation of the limb on which it is seated, and the employment
of such remedies as may improve the  constitution.   This practice, how-

        (a.) Above cited, p. 27.                      (c) Above cited, p. 297.
        (6) Above cited.                           (d) Above cited, p. 51. 
SOFT AND HARD POLYPS.
465
ever, is but in the rarest cases crowned with success, as the disease either
recurs in its original seat or in some other organ, and makes quick pro-
gress.   The time when it reappears is various;  sometimes the fungous
mass quickly shoots forth from the operation wound; sometimes during
the first stage of scarring; at other times after the wound has been some
time healed.
                          XVI.—OF POLYPS.

                (Polypi, Lat.; Polypen, Germ.; Polypes, Fr.)

    2307. Polyps are unnatural growths arising from the surface of mucous
 membranes, and in  reference to their nature, form, size, and mode of
 prpduction, very different from each other.   They are commonly divided
 into Soft Polyps {Schleim-Blasen-Polypen, Germ.; Polypes mous,  vesicu-
 leux ou muqueuses, Fr.) and Hard Polyps{Fleisch-Polypen, fibrose Polypen,
 Germ.; Polypes durs, charnus oufibreux, Fr.)
    2308. The Soft Polyp consists of an homogeneous soft tissue, contain-
 ing in its cells a mucous fluid which escapes when squeezed, and thus
 may be very much diminished in size, leaving only a slimy skin remain-
 ing.  Its surface is covered with a very thin process of the mucous mem-
 brane lining the  cavity in which it is developed, and so intimately con-
 nected with the polyp itself as not to be separable from it; some minute
 vessels and nerves are  spread upon its surface, but very few of either are
 found in its interior:  its colour is grayish white, or yellowish; it is com-
 monly attached by a  stem; its form varies and depends on  that  of the
 cavity in which it is developed;  it in general grows quickly, enlarges in
 a moist, and diminishes in a dry atmosphere.   Usually several of them
 exist at the same time,  but cause no other  inconvenience  than blocking
 up the canal in  which they have been formed.
   2309. The Hard Polyps have a more or  less red or bluish appearance
 according to the quantity of blood-vessels branching in them, and are
 covered with a shining skin, which is tolerably firm.  The arteries always
 run in the middle of the stem and of the polyp itself, whilst the veins are
 superficial.  Their surface is either smooth  or furrowed, and cleft, which
 doubtless depends on the rending of the enclosing skin.  Their interior
 consists sometimes of an homogeneous, flesh-like, very vascular substance,
 in which case it is called a Fleshy Polyp {Fleisch-Polyp, Germ.;)  some-
 times of a very thick  cellular tissue divided into lobes by fibrous bands,
 and hence it is named a Fibrous Polyp (fibrose Polyp, Germ.)   The
 base of the polyp is usually narrow, and its form bean-shaped;  sometimes
 it is attached at a single point, and sometimes  has several roots, and these
 are not always superficially connected with  the mucous membrane, but
 often penetrate deeply into its substance.  These polyps  grow slowly,
 their form depends little on that of the cavity in which they are contained,
the bony walls of which they often burst asunder by their pressure, in
consequence of which, the polyp itself is often torn, ulcerates and adheres
at different points.   In consequence of the strangulation which the polyp
undergoes, the blood collects in it, and it becomes bluish ; by the tearing
of the vessels considerable bleeding ensues;  it sometimes inflames, ulcer-
  Vol, in.—40 
466
HARD POLYPS.
ates, becomes gangrenous, and throws off its lobes; sometimes it is pain-
ful, at other times not so.
   2310. This division of polyps  does  not indicate  all the differences
which they present.   Oftentimes the  polyp remains in  the same state a
long  while,  and  is restricted  to the  same  size ; sometimes it  grows
quickly; but at other times this only happens in consequence  of some
accidental  irritation.   In consequence of such irritation, various changes
are set up  in its tissue, and may  run  on  to  scirrhous degeneration.
There is then considerable hardness, the tissue  becomes lard-like; se-
vere  lancinating  pains  occur  ;  a  stinking  ichorous  fluid  continually
flows from it; it bleeds on the slightest touch, and grows excessively
quick.  The  degeneration of a  polyp into cartilage, has  been, although
rarely, observed.  In  other  respects, the tissue of one  and the same
polyp is every where the same.
   2311. The symptoms specially produced by polyps  are  different ac-
cording to their nature, size, and  seat.   At first the  polyp is painless,
and the annoyances from it depend on  the  pressure which  the walls of
the cavity and the neighbouring parts suffer  from  it;  as  it  enlarges
both the hard and soft parts by which it is surrounded  are burst asun-
der, the bones thin, become fragile, and at  some parts are,  as well as
the soft parts, completely destroyed.   If the polyp be painful, it  ap-
pears to  be the result of incipient degeneration.  The then always in-
creasing, continual pain, the frequent bleedings, and the  destruction of
the neighbouring parts, lead  on to death from exhaustion, or it results
from the pressure made upon important parts.  The harder  the polyp,
the more is cancerous degeneration to  be  feared.  Soft are much less
dangerous than  hard polyps,  and so long  as they retain  their  cellu-
lar structure,  no inflammation or degeneration  readily takes place in
them.
  I have frequently noticed  medullary fungus of mucous membranes, in form of
grayish-white, or reddish excrescences, without any symptom indicating the great
danger of that disease.  After removal, the  excrescences soon came again,  and
caused death, by the  destruction of the neighbouring parts, in consequence of their
unrestrainable enlargement.
   2312. The proximate cause of polyps is an  alteration of the vegetative
processes depending on  continued irritation of  the mucous  membrane,
producing these new and peculiar formations,  which are either developed
from  the parenchyma, or from  the   deeper tissues which  the  mucous
membrane  overspreads,  and are thereby distinguished from the mere
swelling up of the mucous membrane, which  has the same tissue  as the
membrane, whilst in polyps there  is  nothing resembling it.   In mucous
polyps,  the unnatural formation  is confined  simply to the mucous paren-
chyma of the mucous  membrane, from which  any participation  of the
vessels  is wholly cut off'; they are therefore without  any vascular appa-
ratus, and are to be  considered  merely  as processes and dependencies of
the  unnaturally vegetating  parenchyma, overspread with epidermis, the
tissue of which, when there is  also irregular  enlargement of the vessels
of the  mucous membrane, (angiectasic  complication,)  are drenched
with  transuding blood,  or in  addition to this, with mucous  juices,
which,  however, are only inorganically changed.
   But in fleshy polyps, .with the unnatural growth of the  parenchyma, 
OPERATIONS ON POLYPS.
467
there is  also an  arterial vascular system, they live as  self-reproducing
substances, in which an organic circulation  can be  observed, and the
cellular substance is converted rather into a fibrous texture (a).   From
this circumstance the blood-vessels in polyps are sometimes found very
numerous, often in very small quantity, and at other times entirely want-
ing.   Therefore, the opinion held by some may be correct, to wit, that
polyps have no vessels, but  merely possess blood canals in their tissue,
which are not like blood-vessels ordinarily separated from the surround-
ing parts (6).
   Polyps are formed in  all  ages, in either sex, in  every constitution  ;
they are most frequent in adults, but rarer in very old persons.
   The occasional causes are dyscrasies, especially scrofula, syphilis, and
continued  irritation  of the mucous membrane by external influences,
producing a condition which is kept  up by irritation,  and give another
tone to the vegetative process of the mucous membrane.  In this latter
circumstance, is  probably the  reason that polyps are  most commonly
seated at a little distance from the passage of the skin into mucous mem"
brane, and that they frequently  occur in  the womb.
   In many instances the setiology of polyps is quite obscure.
   2313. The prognosis is guided  by the nature, form, and seat of the
polyp.   Mucous polyps  are in general more easily  cured than  those
which are hard ; the harder a polyp is, the more is cancerous degenera-
tion  to  be dreaded, which when once set in, no cure can be  effected.
The broader the base of the polyp, the more  difficult;  and the  more  it
is necked, the easier is its  removal.   Such  is also the case when the
polyp is developed near the outlet of  a cavity, and  when the propor-
tionate size of the latter to  the  former  does not  interfere with the em-
ployment of the  necessary  instruments.  The  more completely a polyp
is removed, the more certain is the cure;  if bits\ of it remain, it is de-
veloped afresh ;  nevertheless, even  after its  complete removal, a recur-
 rence is not infrequent.
   2314. The cure of polyps is effected by tearing, or by cutting them
 off, by tying them, and  by destroying  them with the  actual cautery, or
 other escharotics.  The choice of these several  remedies must be di-
 rected by the individual case.
   The drying used in former times, the tearing to pieces, (Paulus jEgineta, Al-
 bucasis,) torsion, (Brodon,) the squeezing to pieces-, and pulling  away piecemeal
 of polyps are now but matters of history.
   2315.  Tearing out polyps is performed with  the polyp-foreeps,  which,
 when the seat of the  polyp is  wrell ascertained, are carried  to  its root,
 the polyp grasped with them, and separated by a twisting rather than  a
 drawing motion.  This method is  simple and quick; it  is usually fol-
 lowed only by slight reaction  from the injury done, the neighbouring
parts are neither  damaged, nor disturbed in their functions ; recurrence
 of the disease is less frequent  after this than after other methods.  But
tearing out is not applicable if the polyp have a broad base, if it  be at-
tached  to yielding parts, if it  be very deep  seated, and if difficulty in
 stopping bleeding be feared.
   (a) Schreger, Annalen des Chirurgischen   (b) Meissner, Ueber die Polypen  in den
Clinicums auft'er Univcrsitat zu Erlangen, verschiedenen  Hohlun des  menschlicliea
p. 47.  Erlangen, 1817.                 KOrpers, p.  13.  Leipsig, 1820. 
468
POLYPS IN  THE NOSTRILS.
   2316. Cutting off the polyp, which some of the moderns endeavour to
bring into  general practice, is only applicable where the  disease is not
deep-seated, and the introduction of the instruments necessary for the
operation can be, effected without injury of the neighbouring parts ; also
when the seat of the polyp  admits the use  of  remedies  to  stanch  the
bleeding, which is always  to be feare'd in cutting it off".  This practice
is also objectionable, inasmuch,  as the disease almost  always recurs, its
roots still remaining.  Otherwise, a  partial  cutting off may be requisite
in those cases where the cavity in which the polyp is  seated is  quite
filled by it, for the purpose of introducing the  instruments necessary to
tear it away or cut it off.
  The extensive  experience of  Dupuytren, however, proves that  considerable
bleeding, after cutting off a polyp, and its  recurrence, are not more frequent than
after the other modes of treatment; at least such  is  the case with polyps of the
womb, rectum, and pharynx  (Pigne.)
   2317. Tying  a polyp is specially indicated where it is situated deeply,
and on an  organ which, on account of its yielding, will not allow tearing
away; further, when the polyp  has  a broad firm base, and  also, when
severe  bleeding is feared,  if any other practice  be followed.   As the
polyp, after being tied, swells and enlarges,  because,  on account of the
situation of the  arteries  in  the middle of its root, the circulation is not
completely arrested, except  in the  superficial veins, tying must not be
had recourse to when the polyp is so situated, that the functions of more
important organs are disturbed or destroyed by its swelling; and even
considerable bleeding may be caused by this mode of treatment.   It must
also be observed, that in  many cases tying is extremely difficult, and the
repeated introduction of  the instrument rendered  necessary.  By a gen-
tle graduated drawing together  of the  ligature severe pain may indeed
be prevented ; but in many instances it requires  tightly  tying, by which
violent pain is produced;  and in very inflammatory subjects, this is caused
even by very slightly tightened ligature.  When,  after a polyp has been
tied, it begins to be  destroyed, a flow of extremely stinking ichor ensues,
w7hich affects the neighbouring parts,  and   is  very troublesome to  the
patient.
   2318. Destroying a polyp  with the  actual cautery, is only applicable
when the polyp bleeds on the slightest touch, and the patient has become
greatly exhausted by the  previous bleedings; when the polyp cannot be
satisfactorily managed in  any  other way; and  lastly, when it is malignant
or cancerous,  and its  speedy removal  is requisite.  In some cases of
polyps in the antrum Highmorianum, other escharotics may also be em-
ployed (a).
                A.—OF POLYPS IN THE NOSTRILS.

  De Jussieu, B. et J., Dissert, ergo ex ligatura Polypi Narium tutior curatio.
Paris, 1734.
  Leviet, Observations sur la Cure Radicale des  plusieurs Polyps de la matrice,
de la gorge et du nez, operes par de nouveaux moyens inventes.  Paris, 1749.
  Palluci, Ratio facilis atque tuta narium curandi Polypos.   Vienna?, 1768.
  (a': Schmidt, R., Comment, chirurg. de Polyporum congestiune.  Berol., 1829,4to.; cum
tab. xv. 
POLYPS IN  THE  NOSTRILS.               409
   Pott, P., Remarks on Polypus of the Nose ; in his Chirurgical Works, vol. iii.
 p. 209.  Edition of 1783.
   Desault, De la Ligature des Polypes des Narines;  in his QEuvres Chirurgi-
 cales, vol. ii. p. 501.  Edition of 1812.
   Klug, Dissert.  Historia instrumentorum ad Polyporum extirpationera, eorumque
 usus chirurgicus.   Balae, 1797.                          p
   Kreysig, Dissert, de Polypis Narium.  Vitembergae,  1802.
   Deschamps, Traite des Maladies  des Fosses Nasales et de Ieur  sinus,  Paris*.
 1804.
   Petit Radel, Considerationes sur les Polypesdes Fosses Nasales, et les moy~
 ens auxquels jusqu'ici on a eu recours pour leur guerison.  Paris, 1815.
   Meissner, above cited, p.  144.
   Gruner, Dissert, de Polypes in cavo Narium obviis. Lipsiae, 1825; cum. tab. iv.
   [Watson, Jno., On the Pathology and Treatment of Polypous Tumours
 of the Nasal Fossae in the American Journ. of the Med. Sciences, vol. 3.
 N. S. 1842.—g. w. n.J
   2319.  Polyps occur more frequently in the nostrils than  in any other
 cavity.   They  arise either from the  walls  of the  nostrils  or from  the
 frontal sinuses; they  may even have their root in-the-antrum Highmoria-
 num, and as they grow,  may branch  into- the nostrils'.  They are most
 commonly situated on1 the upper outer wall of the cavity of the nose, and
 in their further development assume its form.  They, therefore, enlarge
 usually at first vertically, and having  reached- the floor of the nostril,
 increase  more  horizontally; not unfrequently- they  grow towards  the
 throat; oftentimes even in both directions, in consequence of which, the
 polyp rs;divided into two processes.   There  is commonly  but a single
 polyp'; yet not unfrequently several are produoed at the same time, and
 even1 in both nostrils.
   2320.'  The following are the symptoms caused by  nasal polyps:—At
 first the patient  complains of a long-continued snuffling, loses the power
 of smelling, has his nose  stopped up, and a great  discharge of fluid front-
 it.   These symptoms often vary, according to the state of the weather,
 and are more violent in damp, and less so in dry warm weather.   In pro--
 portion-as the polyp enlarges-, the passage of the air through the nostril
 becomes  more  difficult, and at last the nose is completely filled ;  it pro*
 jects through the  external  opening of the nose, or enlarges towards the
 throat, in,which  case'it  may considerably interfere with breathing and
 swallowing:   When the increase of the polyp has become very great, the
 walls of the nostrils  enlarge in every  direction, the passage of the tears
 through their duct is stopped up, the nasal partition is thrust to the  op-*
 posite side, inconsequence of which the healthy nostril is narrowed, and
 at last all the bones are pressed out of their place.  The discharge, which
 had hitherto been  raucous, is sometimes streaked-with blood, becomes
 ichorous  and  stinking;  the polyp ulcerates, suppuration attacks  the
 bones, and the  disease, by wearing out the patient's powers,, may cause
 death.  The growth of the polyp is frequently accompanied  with intense
 headach',  which spreads  over half the-face:  Many  polyps bleed very
 easily andviolently, and  thereby cause great weakening.
   2321. Nasal polyps are either the so-called  hard polyps, red soft, and
 sensible, although not causing any great- pain; or  they ase soft or mucous
polyps, of a  leathery nature, of pale colour, accompanied with copious
 mucous secretion, an J varying according to the state-of the  weather; or
                                 40*" 
470
KINDS  OF  POLYPS IN  THE NOSTRILS.
 they are  of a firmer  character, of cartilaginous  hardness, very painful,
 bleed on the slightest touch, and easily run into cancerous degeneration.
 Upon these differences rests their division into malignant and benignant.
   The malignant polyps are those which from their beginning are accom-
 panied with severe pain in the head or the upper part of the nostril, and
 when they appear  externally have a  pale red or livid colour, are very
 painful to the touch, bleeds readily, are  not moveable, but firmly fixed,
 and attached at many parts  to  the mucous  membrane; coughing  and
 sniffing produce a painful sensation in the nose or in the fore part of the
 head: and there is a discharge of stinking ichor.
   The polyp is benignant, when it has a grayish-white, pale, or brownish
 colour, is of  a soft  nature, is accompanied with little pain in its growth,
 and is not painful when touched ; when occasionally it increases and then
 diminishes in size ; when, excepting at its root, it  does not adhere to any
 other part of the nostril; and when it is moveable in sniffing, and secretes
 mucus.
   2322.  The causes  of nasal polyps are  in many  instances  doubtful.
 They may sometimes  be produced by mechanical  injury, poking the nose
 with the fingers, and other things; but, for the most part, the nasal polyps
 are so situated that these causes can have no influence.  In general, a ca-
 tarrhal affection of the mucous membrane of the nostril, a continued blen-
 norrhcea  is the  origin  of  these polyps.   In many  cases, the polyp is
 causally connected  with  a  general dyscrasic affection, as syphilis, sup-
 pressed natural discharges, and  the like, which seems to be proved by
 the frequent production, at the same time and in the  same nostril, of se-
 veral polyps, by their  frequent recurrence after removal, and by the  ac-
 compan) ing symptoms of general ailment.  The disposition to form polyps
 often seems connected with the natural development  of the body,  as they
 frequently occur at the period of puberty, or this unnatural formative ac-
 tivity is at least favoured by the loosening up of the  mucous membrane;
 ^tnd  truly the healthiest persons, who  about puberty are subject  to fre-
 quent bleeding  from the  nostrils  are  commonly affected  with nasal
polyps,
   The bursting asunder and diseased changes of  the nose-bones are not
 always simply the result of their mechanical separation by the polyp, but
 oftentimes the disease of the soft parts and of the  bones, is co-existent,
 and  both depend on one and the same cause; which is especially the case
 when the disease is produced and kept up by a dyscrasy (a).
  Scherger notices a complication of polyp with unnatural enlargement of the ves-
 sels (teleangiectasy) of the mucous membrane, which seems specially proper to those
 cases in which the beginning of the polyp is long preceded by a phlogistic loosening
 up of the mucous membrane, together with blennorrhcea; yet  they do not occur in
 polyps whieh form without them and quickly.   It does, not, however, in all cases
 come to teleangiectasy, at least not to a great degree of it.   The symptoms of this
 teleangiectasy are, a discharge of mucus, mixed with  blood, during the primary
 blennorrhea, diminution of the narrowing, and pressure in the nostrils, by spontane-
 ous bleeding from  the nose; and  when the polyp is visible, it is redder, thence
 towards its root, frequently of a b!uish-red colour;  the uneasiness is greater, the
 bleeding violent on touching, and the growth rapid.
  According to Richerard (6), the benignant polyps spring from the mucous mem-
brane, and the malignant  from the bony walls of the nostril; except in those cases
in which a vesicular or fibrous polyp runs into cancerous degeneration.
       (a) Schreger, above cited, pp. 42,  43.
       (b) Nosographic Chirurgicale,  vol.  iv. p. 304.  1821.   Fifth Edition. 
OPERATION FOR NASAL POLYPS.
471
  2323.  The  prognosis of nasal polyps depends on their nature, seat,
origin, and complication  with other diseases.   The mucous  polyps  are
least dangerous, and most easily managed ; the harder, firmer, and more
painful the polyp is, so much the more is its degeneration into cancer to
be dreaded.   As, however, polyps seem to assume the cancerous charac-
ter during their growth, their removal as early as possible, seems the only
means of preventing this  degeneration.   The more accessible is the seat
of the polyp, the more moveable it is, and the less its connexion with  the
walls of  the nostril, the more easily may it be removed ;  and the more
completely this is done, the less is its recurrence to be feared.  When  the
polyp is connected with general disease, the latter must be first met  by
proper treatment, or otherwise, after the performance of the  operation,
the polyp will more certainly recur.
  2324.  Nasal polyps  always require operation; but if early discovered,
especially when  of the mucous  kind, the unnatural vegetative process of
the mucous membrane may be  checked, and the incipient formation of
the polyp prevented, by the application  of cold astringent fluids, by snif-
fing up powders of calomel, or  oxysulphuret of antimony with sugar, by
touching with tincture  of opium, by  purging, and corresponding general
treatment.
  The removal  of nasal polyps  may be effected by tearing away, by
tying, by cutting off, and by destroying  them with the actual cautery.
  2325.  Tearing away a nasal polyp is the most common and  indeed  the
most suitable mode of cure, when the polyp, be it fleshy or mucous, is not
deep seated, has not a  very broad base,  and is not very hard.   For this
purpose  polyp-forceps  are used, of  different size, and either  straight  or
curved.  The blades of good polyp-forceps must be a little hollowed  in
front  and rough, so that the polyp may be more firmly grasped; their
edges must be neither  very thin nor sharp, or the polyp will be easily
snipped asunder  ; they  must be  broad and strong, and their handles suffi-
ciently long (a).
  Schreger (b) uses also forceps with disjointed parallel arms.
  2326.  Previous to tearing away the polyp, its  extent and the place  of
its attachment must be carefully examined with a whalebone probe, which
must  be carried  around  it; the  light made to  fall  properly  into the
nostril, and the finger passed upwards behind the soft palate; but the
frequent  irregular surface of the polyp, and the various projections  of
the walls of the nostril, render, in most cases, a certain knowledge of  the
sea(; °f ^e polyp impossible.   On the whole, however, this is not of so
great consequence as generally  supposed ; since less depends  on the seat
of the polyp, than on its  form and  size, whether the polyp-forceps can
be properly carried to its root.
  2327.  The operation is performed in the following way :—The patient
being seated on  a chair of corresponding height to that of the operator,
and opposite the light, so that it may fall into the nostril, his head is held
by an  assistant standing  behind him, who placing his hand upon the
patient's forehead, presses and  fixes  the  head against his own chest.   If
the polyp do not hang  quite loosely in the nostril, attempts must be made

              (a) Richter*9 Anfangsgriinde,  vol. i. p]. v. fig. 1.
              (b) Neucr Chiron, vo!. i. part ii. p. 197, figs. 1, 2. 
472            OPERATION FOR NASAL POLYPS BY
to loosen it with the whalebone- probe, which should be carried round,
and the patient, closing the healthy nostril, should blow forward the polyp
as much as he can;   Theoperator holds the forceps with the thumb and'
fore-finger of the right hand by the rings of their handle, and passes them
closed into the nostril up to the polyp, then opens them, and by twisting
and turning'themabout endeavours to get the  polyp between their blades.
The patient must strive to force the polyp still  further between the blades,
■whilst the operator, at the same time, tries to  carry them up highertothe
root of the-polyp;  The forceps are now closed,, and  being kept tight
with the screw or the  fingers, are twisted on  their axis, and^at the same
time pulled till the polyp'be completely separated;
   2328. The polyp is frequently removed'from its root at one  pullj and
on sniffing the nose  is quite pervious;  but if such  be not the  case, if
a portion of the polyp remain; if, perhaps, there be several polyps, the
forceps must be again introduced; the remnant grasped' and pulled out,
as already directed.  If there be not much bleeding, this must be repeated
till the whol^ polyp is removed.   The entire  removal of the polyp is-the
most certain means of checking the bleeding; but if this be dangerous,
the operation^ must be suspended for a moment, and recourse had to the
means already advised for arresting  bleeding.
   2329; When the- polyp has  acquired great  size, when it  protwides
through and stops up the nostril, the introduction of the forceps can then
only be effected by seizing the- front of the  polyp with a pair of forceps
held in the left hand; and'drawing  it forwards, and thus enlarging the
space in the nostril.  If, in such case, the commonly employed forceps
cannot be  introduced; a pair must be-used1 with a  separable joint, with
their blades curved before the joint and* meeting at their tip (a).  Both
blades must be separately introduced to the necessaryheight, then closed,
and the polyp torn away according to the rules already given.
  In Charriere's cleverly arranged polyp*forceps, the handles cross, so that when
they rest upon each other the blades are open.
  When the size of the polyp is such that it completely prevents the  introduction of
the forceps, it has been recommended to destroy with caustic, or to slice  off the part
filling up» the nostril.
   2330. When the forceps cannot be passed  up to the root of  the polyp
on  account of its size,^the result of tearing it off"is always very  doubtful,
as the polyp.may be either torn away at its root, or only that  part grasped
by the forceps be pulled off'  In the latter  case there is generally great
bleeding, which is best stanched by the complete removal of the polyp.
  2331. If the polyp be  rooted far  back in the nostril,  and hang down
behind the soft palate into the throat, it  is thought best by some  practi-
tioners to draw it through the mouth; for this purpose a pair of curved
forceps  are introduced through the mouth, behind the,soft palate  to the
polyp, which is to be grasped as high as  is fitting, and'pulled away; ani
if any portions remain they can  usually be removed  through the  nostril.
It is, .however, more convenient to pass the forceps*-through the nose into
the throat, and guide them by the finger introduced'behind the soft palate,
with, which at  the same  time  the polyp may be pressed  between the
forceps..  Tn general, tying the polyp is indicated in these cases;
(a) RicHTBR, Anfangsgriinde,.voli upl. v. fig. 2.—SciiREG€Rr above cited. 
TEARING AWAY.                         473
   Tearing away the polyp with a noose, in preference to using the forceps,
 is in every case to be avoided.
   2332.  Bleeding always follows tearing off" a polyp;  this is  often very
 great, and as it cannot be known  before the operation, to what  extent this
 may be, the  necessary means for arresting it should be in readiness. The
 danger of bleeding is always less when the whole polyp and its root are
 pulled off;  but  if only part be torn  away the  bleeding is considerable,
 and the surest mode of stopping  it is the complete removal of the rem-
 nant.   The  means used for  arresting bleeding are, sniffing  up or inject-
 ing cold water,  vinegar and water.   Theden's arquebusade, solution  of
 alum, and the like ; or a bit  of linen or lint soaked in  an instringent fluid
 and rolled up, must be passed with the forceps, or a screw probe up to the
 bleeding part.   If the nostril be  very wide, pressure  may be made with
 the finger.   If these means be ineffectual  to arrest the bleeding, the hind
 and front openings of the nostril  must be plugged with Bellocq's tube,
 which is to be introduced through the nose into  the throat, and  the spring
 it contains thrust forward, so that it may project  from behind  the palate
 into the  mouth, and to  the  knob at  its  end a double thread must  be
 attached, with a sufficiently thick plug at its extremity.  To  the pad a
 second  thread  must be  added for the  purpose of pulling  it  out after-
 wards (1).   The spring is now to be drawn back into  the tube, the in-
 strument removed from the  nose, and the pad, by means of the thread,
 brought into the hind opening of the  nostril so  as to close it.  The two
 threads  hanging out of the nostril, are to be separated  and between them
 as much torn lint passed  into the front opening of the nostril  as will stop
 it up, and then the two threads are to  be tied  on the  lint.  An elastic
 catheter may be  used instead of Bellocq's tube.
   [(1) Bellocq's canula is one of the most clever and handy instruments ever in-
 vented, and admirably fitted for plugging the nostril, or for introducing a thread any
 where, in which, without it, great difficulty,  waste of time and annoyance, if not
 indeed great pain to the patient, are experienced. I brought it five and twenty years
 since from Paris, and have  frequently used it with  the  greatest facility.   It is an
 instrument which every practitioner should always have about him, and ought to be
 found in every pocket-case.  It is not necessary to have any additional thread pass-
 ing through the arch of the fauces and mouth  for the purpose of pulling the plug
 back, which is always best withdrawn  by drawing it gently through the  front open-
 ing of the nostril, pulling the thread by which it has been introduced so soon as a
 purulent discharge begins from the nostril,  which  generally occurs about  the third
 or fourth day;  but the plug must not be meddled with till then, as if it be the clot
 in the bleeding vessel is disturbed, and the bleeding returns, and requires  the plug
 to be again introduced.  I prefer a piece of very soft dry sponge, as nearly as possi-
 ble corresponding to the size of the nostril, or even a  little larger, which  must be
 carried quickly through the mouth and throat to the hind opening of the nostril,
 otherwise it will soon be filled with moisture, and  cannot be introduced till it has
 been clipped so small that it is useless.  When the sponge has entered the nostril
 it  must be gently drawn forwards till the bleeding cease, when  it is to be left, and
 as it expands with  the blood it soon fills up, and adapts itself to the whole  cavity of
 the nostril.  Stuffing the front opening of the nose is quite unnecessary, if sponge
 be used;  and if the bleeding do not stop, the practitioner may be  sure the sponge
 does not reach  the bleeding vessel, and must arrange it  properly by introducing a
 probe through the front opening of the nostril, and varying the position of the sponge
 till the bleeding be arrested, which is done easily, although in general drawing the
 sponge forward with the thread is sufficient.  Sometimes there is a little difficulty
 in  getting the sponge through the arch of the fauces, as it catches the soft palate,
 and pulls it either directly against the spine, or up against the back of the nostril; it is
therefore best always to keep the sponge close to the knob of the spring, as it is then
most manageable.   The thread by which it is attached should, therefore, be merely 
474
OPERATION FOR  NASAL POLYPS, &C
threaded in the eye of the knob, one long end left out at the mouth, and the other
carried with the spring into the nose, and having been brought out first at the front
of the nostril, there left.  The canula is then, with its knob drawn close up, to be
drawn back along the thread through the throat, and then by pulling the end hang-
ing from the nostril, the other end of the thread with the sponge is easily pulled into
the  throat.  If  the sponge  catch upon the soft palate, it may be quickly freed by
passing the finger into the  arch of the fauces, and gently slipping the palate down
over the sponge, when all difficulty immediately ceases.  The explanation of this
proceeding requires many  words, and may seem  tedious, but the whole operation
from the first introduction of the canula  till the proper placing of  the sponge, ought
not  to occupy at furthest a couple of minutes, but often not half that time if the
rules just given be attended to.  If Bellocq's canula  be not at hand, a common
bougie serves the purpose as well as an  elastic catheter; it must be bent to the curve
of a common catheter, and carried along the floor of the nostril, into the throat.  The
patient opens his  mouth widely, and the end of the bougie  being seen, is grasped
with dressing forceps, and dVawn forwards till it protrude from the mouth.  A strong
thread is now tied to the end of the bougie, having a piece of sponge attached to its
loose extremity; after which  the bougie is gently pulled back through the mouth,
throat, and nose, bringing with it the thread and the sponge,  which is brought into
the nose as directed already.   This is much more tedious, and, compared with the
former, a more  clumsy proceeding, but is a good make-shift.
  Any bleeding from the interior of the nose may be managed readily in the same
way.—j. f. s.]

  2333. If, after the operation, inflammation ensue, it must be managed
by  suitable treatment, but  generally it soon subsides.   When the bleed-
ing has  been stopped by the plug, the  lint may be withdrawn from the
front of the nose on the third day, and the hinder plag pulled out by the
thread hanging from the mouth.   If there  be suppuration in the nostril
some mild decoction may  be thrown up.
  To prevent the recurrence of the polyp astringent  injections are gene-
rally used.   Perhaps a  seton in the neck might do good service.  If the
polyp grow again the operation must be repeated.
   2334.  Tying a nasal polyp avoids indeed the  danger of bleeding, but
leads to other  results, and in my opinion  has not the  preference over
tearing it off, which is given  by some practitioners.   The application of
a ligature is indeed, in  most eases) accompanied with considerable diffi-
culty, and to the patient  with  no trifling inconvenience.  K  the polyp
largely fill the cavity of the nostril, the ligature  can very seldom be ap-
plied  sufficiently  close  to its root; its  earlier return after having been
tied is therefore to be feared, although indeed, in some instances, when
the ligature has not been  applied  directly on  the root, the whole polyp
has been thrown  off by subsequent inflammation and suppuration.   The
inflammation which occurs after  a  polyp has  been  tied, often spreads
over the whole Schneiderian membrane and the neighbouring parts, and
may  produce serious symptoms.   The  swelling of the polyp after tying,
as  well  as the subsequent discharge of stinking ichor, may give  rise to
great  inconvenience.   The peculiar  states of the   disease, which may
specially indicate tying, are, therefore,  when the polyp has a broad firm
base, when the application of the forceps is impossible,-or when the pa-
tient will not submit to its being term off;
  A pouch-like protrusion of the inner fold of the mucous membrane, if it cannot
be  removed by the use of astringents, or by repeated  scarifications, is favourable for
tying, but not for tearing off.  Internal disease in connexion with this complaint
must have suitable treatment.  When this protrusion of the mucous membrane is
very extensive, it is only got  rid of with great difficulty, or not at all.
   2335. Of the numerous modes  of proceeding which have been recom- 
DESAULT'S MODE OF TYING NASAL POLYPS.
475
mended for tying nasal polyps, I consider the introduction of the ligature
with Bellocq's canula and Desault's method to be the most preferable.
The former specially applies to polyps at the back of the nostril, and the
latter to those in front.  The best material  for a ligature is a silken or
hempen thread.
  2336. The application of a ligature with Bellocq's canula is managed
in the following  way:—The patient having been put in the  same posi-
tion as in  that for tearing off  the  polyp, Bellocq's tube  is  passed be-
tween the foot of the polyp and the neighbouring wall of the nostril into
the  throat.  On the protruded knob or in its  eye, a long hempen or
silken thread is  fastened, and  with the instrument  drawn back into the
nose.   After the thread has  been  loosened from the knob, Bellocq's
tube is again passed between the  wall of the  nostril on  the other side
and the foot of the polyp, and the  end of the thread hanging in the mouth
is attached to the knob  of the protruded spring, and  drawn back through
the nose.   In this way  a loop is formed with the thread, the two ends of
which encircle the sides of the polyp.   The two ends of the thread hang-
ing from the nose are brought  into the end  of a loop-tier, which is  intro-
duced to the foot of the polyp, and  the loop is in  a  degree tied together
by drawing its ends, according to circumstances.  The loop-tier is to be
wrapped in  lint, so that it may not irritate the nostril;  and its projecting
end supported in the usual manner.
   As the loop when  moist does not remain open, and in drawing it  together the
polyp is not always grasped, it is necessary to guide it with the fingers  of the left
hand behind the soft palate.  To the loop catching the polyp, another of a single
thread is attached, with which, when  the former being drawn does  not catch the
polyp, it may be pulled back through  the mouth, and  so the necessity of reintro-
 ducing it with Bellocq's canula be avoided.   The loop may be kept open by draw-
ing the thread in a  piece of elastic tube, which  when  the  thread has caught the
 polyp, may be so removed that one end of the thread may be drawn till the tube ap-
pears (a).  The tie is made as already directed.   For  polyps which are developed
towards the upper hinder part of the nostril towards the throat, I make use of a pe-
 culiar pair of forceps for the more certain introduction of the thread (b).  Hatin has
 also proposed a similar instrument.  It is further advantageous in these cases to pass
 the ends of the thread before drawing them, into a loop-tier  or a Levret's tube, and
 to introduce it as far as possible into  the nostril, for the purpose of thereby giving
 the loop a more vertical direction (c).
    2337.  In tying a polyp situated in the front of the nostril, according to
 Desault's  method, a silver canula slightly curved upwards,  and a loop-
 drawer are introduced up to  the root, of the polyp, with one ligature
 through the cavity of the former and the hole of  the latter.   The loop-
 drawer is given to an assistant, who holds it steady, and the surgeon then
 carries the canula round  between the  polyp and  the wall of the nostril,
 and back to the loop-drawer.   The drawer is now to be taken with one,
 and the canula  with  the other hand, so that both instruments cross, and
 the thread at  the upper end of the canula  lies above that of  the loop-
 drawer.  The drawer is  now  held steady, and  the  canula brought back,
 both ends of the ligature introduced into the whole  of a loop-tier, which
   (a)  Dubois, Propositions sur diverses par- ausserst grossen Rashen polypen, durch die
 tiesde l'Artde Guerir.  Paris, 1818.       Abbhidung  ausgerottet, nebst allgemeinen
   (6) Ueber die Einrichtung  der chirurg. Bemerkungen iiber die Ausrottung der Ra-
 Klinik zu Heidelberg, 1820. PI. i. figs. 2, 3. chenpolypen uberhaupt;  in  von Siebold's
   (c) Sabatier, Medecine  Operatoire, vol. Chiron, vol.  iii. p. 315, pi. v.—Zang, Opera-
 ii. p. 218.—A. vo.n Winter, Geschichte eines tionen, vol. i. p. 483. 
476    TREATMENT OF POLYPS BY THE ACTUAL CAUTERY.
 is passed up to the root of the polyp, and the loop-drawer removed after
 it has been  freed  from the ligature by pushing forwards its  stem.   The'
 tying is managed as before  (a).
    In cases where, on account of the large size of the polyp, the introduction of in-
 struments is impossible, the soft palate has been cut through, which, however, is
 rarely necessary.
    The following works maybe  consulted upon the different modes  of proceeding,
 and the different instruments requisite for carrying a loop around the  polyp, instead
 of tying  or cutting it off:—
    Glandorp's Tractatus de Polypo Narium.  Bremen, 1828,  describes an eyed
 hook.
    Dionis, Cours de Operations de Chirurgie, p. 464.  Eighth Edition.  Paris, 1777,
 gives his crow-beak forceps.
    Junker et Gorter, Conspectus Chirurgiae, p. 221.  Halae, 1731.   Chirurgiae re-
 purgata, p. 202.  Viennae, 1762; in which are mentioned the flexible needles.
    Heister, Instructiones Chirurgicae, vol. ii. pi. xix. fig. 12, gives his eyed probe.
    Levret, above cited, pi. v. fig. 9, in which Lecat's forceps are shown.
    ------; in Memoires de l'Academie de Chirurgie, vol. iii. p.  598, pi. vii. fig. 3.
 Journal de Medecine, vol. xxxv. p. 235, gives his single and double cylinder.
    Bell, Benjamin, System of Surgery, vol. iv. p. 132.   1787.  Second Edition—
 describes Evckholdt's mode of treatment.                       ^
   Theden; in neue Bemerkungen, und  Erfahrungen zur Bereicherung der Wun-
 darzneikunst, vol. ii. p. 195, pi.  iii. figs. 1, 2.  His forceps.
    Hatin, A. F., Memoire sur de nouveauxinstrumens propres k  faciliter la ligature
 des Polypes qui naissentde la base du Crane.  Paris, 1829.
   Hatin, A. F., Supplement au Memoire sur de nouveaux Instrumens propres a.
 faciliter la Ligature  des Polypes  du  Nez et de la Gorge.  Paris, 1830.
   Sach's, A., Beschreibung des elastichen Ligaturwerkzeuges  and  birnformigen
 Brenneisen.  Berlin, 1830.

    2338. As soon as the  polyp is tied  it  begins to swell and become
 painful;  in a few  days it crumples up and mortifies,  and  a stinking ichor
 flows from the  nostril.   The pain is often very  severe,  and  the inflam-
 mation spreads ;  under these circumstances the  loop must be slackened
 a little.  If  the polyp swell  up so much as to  produce symptoms, the
 loop must be so tightened, that  all influx of blood into the polyp be pre-
 vented, and  the polyp may also be scarified at  the same time.   When
 there is  bleeding the loop must  also be well tightened.  To lessen the
 nasty smell from the discharged ichor, injections of aromatic  herbs or of
 diluted acids are often  made.  The loop must be tightened every day till
 the polyp fall off,  and when  it has been loosened by the  ligature cutting
 in, it may be seized with the  forceps and torn off; and after  its separa-
 tion, astringent injections must be used for some time.  When the polyp
 is  expected  to fall off, the patient should be carefully watched, lest it
 drop into the throat and cause symptoms of suffocation.
   2339.  Cutting  off a nasal polyp is alone indicated when  it is rooted
 near the front of the nostril,  has a tendinous stem  and no broad  base;
 also if the front of the polyp so block up the orifice of the nose, that it is
 impossible to introduce the forceps or tying-instruments.  Bleeding and
 recurrence after cutting off a  polyp are specially to be feared.
   2340.  The  polyp may be cut off with  either scissors  or a curved

  (a) Desault, above cited, vol. ii. p. 227.—  und Harless, Annalen der Englischen und
Bichat; in Memoires de la Societe d'Enn-  Franz'teischen Literatur,  vol, i. p. 378, figs.
Iation, an n. p. 333, gives a modification of  1, 6.—Zanq, above cited, vol. i. p. 487, pi. i.
 Desault's method; but, according  to  my  figs. 2-7.
experience, not more practicable.—Schreger 
POLYPS IN THE THROAT.
477
 bistoury.  It must be seized with a pair of hook-forceps, and drawn a
 little forwards; the scissors are then to be passed into the nostril, where
 most convenient, up to the foot of the polyp, which  is then  cut through
 and withdrawn.   If a bistoury be used, Pott's, with its blade covered
 with sticking plaster to within half an inch of its button, may be carried
 up to the stem of the polyp,  which it cuts off whilst drawn forward.   If
 the bleeding after the operation  be not much, it may be  stanched by a
 wad of lint moistened with some styptic.   In severe bleeding the means
 recommended {par. 2332) may be used.  If the bleeding part  can be
 readily got at, the actual cautery may be also employed.  If the polyp
 be disposed to grow again, it may perhaps be prevented by the cautious
 application of escharotics.
   Besides the cutting forceps of Fabricius ab Aqtjapendente,  Severinus, and
 others, special instruments for cutting off polyps  have been recommended by the
 following writers:—
   Levret, above cited, pi. iv. figs. 11-14.
   Perret, L'Art du Coutelier, pi. cxii. fig. 3.
   Whately's Cases of two extraordinary Polypes removed from the Nose; the one
 by excision with a new instrument, the other by improved forceps.  London, 1805.
   Booth, Thomas; in London Medical Depository, vol. xiii. p. 283.  1820.
   Schreger, above cited.
   2341. The Application of the Actual Cautery  should  only be  had
 recourse to when the polyp bleeds on the slightest touch, when the patient
 has been much weakened by repeated bleedings, and when the polyp so
 blocks up the entrance into the nostril, that it Cannot  be removed in  any
other way.  A trocar-tube wrapped round with moistened linen is passed
up to the polyp, and the space between the tube and walls of the nose
stuffed with wet lint.  A white-hot trocar is then thrust through the tube
so deeply, and so directed into the polyp as is believed will hit  the polyp
in its greatest  diameter.   The polyp is not in this way at once destroyed,
but a violent degree of inflammation is produced, and it is got  rid of by
suppuration.   The inflammation, severe headach, and fever, which fol-
low  the  use  of  the  actual cautery, must be diminished  by mild fluids
injected into the nostril, by due quietude  and proper antiphlogistic treat-
ment.   If suppuration ensue, soothing injections must be employed; but
it  continues a long time,  till the whole polyp has been destroyed by sup-
puration.   When  it has once lessened, the polyp  may perhaps be torn
off, or any  small remnant got rid  of by cautiously touching it with lunar
caustic.
                 B.—OF POLYPS IN THE  THROAT.

   2342. Throat-Polyps may be rooted in  the  hind part of the  nostrils,
 and grow towards the cavity of the throat;  or they may grow from the
 back of the palate, or even from the walls of the pharynx itself.  These
 polyps  are  in  general of a more  firm and fleshy nature, and usually
 attached by a short thick stem.   In proportion to their size, they cause
pressure and irritation of  the tissues of the throat, cough, choking, and
difficulty of breathing and swallowing.   The rubbing  to  which such
polyps are subjected by the touch of the food in swallowing, very com-
monly produces a continued irritation of their surface, and even ulcera-
  Vol.  in.^-41 
478
POLYPS IN THE MAXILLARY SINUS.
tion.   The discovery of a throat-polyp is very easy, so soon as it  has
acquired any size.
  2343. The structure of these polyps, and the nature of  the parts with
which they are connected, render it impossible, or at least very dangerous,
to tear them off*;  only in  those cases where they are  attached by a thin
loose stem, can this be undertaken with the forceps.   The best mode of
treatment is tying them, which in general is most conveniently done in
the same way as recommended {par.  2336) for nasal polyps passing into
the pharynx.   If  the polyp more  conveniently permit tying through  the
mouth, Desault's apparatus is best suited for that purpose.
  Special instruments for tying throat-polyps are recommended by Dallas (a), by
Theden (b), and Roderick (c) ; and an improvement of the latter by  Braun (d).
  2344. The symptoms, after tying a throat-polyp, are generally violent*
as, by its swelling, the breathing isconsideiably interfered with, and even
danger of suffocation may ensue.  Tightening the ligature and scarifica-
tion of the  polyp are the only means of lessening the symptoms.   If there
be bleeding, the ligature must be tightened till all circulation in the polyp
be stopped.   When the  polyp begins to be loose, it  may be pulled off
with the forceps; which must be also  done when, from the putrescence
of the polyp, the stench  is  unbearable, and the neighbouring parts are
affected by the ichor which escapes.
  2345. The just-mentioned method of rotting off polyps  is applicable
only to those which are above the narrow passage of the oesophagus.   But
if the  polyp arise from  the wall of  the oesophagus itself, it  can  only be
brought into the throat  in choking,  and as it  cannot  remain there for a
moment without suffocation, it is impossible to  tie it.  For such  cases
Zang proposes laryngotomy, which having been performed, and the polyp
brought into the throat, it may be tied (e).
  According to Benjamin Bell (/), for  those polyps situated in the cesophagus, a
slip-loop should be passed down, which by frequent retractions, may catch the polyp,
and then the curved double cylinder should be passed down to it.
           C—OF POLYPS IN THE MAXILLARY SINUS.

  Bordenave, Precis d'Observations sur les Maladies du Sinus Maxillaire; in Mem.
de l'Acad. de Chirurg., vol. iv. p. 3-29.
  Becker, (praesid. C. Siebold,) Dissert, de insolito Maxillae superioris tumore
aliisque ejusdem morbis.  Wirceb., 1776.                              .  .
  Ri'nge, Dissert, de Morbis praecipue Sinuum ossis frontis et Maxillae superioris.
Rintel, 1750;  in Haller, Disput. Select., vol. i.
  Jocrdin, Traite des  Maladies et des Operations de la Bouche.   Paris, 1778.
  Desault, GSuvres Chirurgicales, vol. ii. p. 165.
  Descamps, Traite des Maladies des Fosses Nasales et de leur Sinus.  Pans, 1804.
  Eichhorn, Dissert, de Polypis, speciatim de Polypis in Antro Highmori.  Got-
ting., 1804.
  von Siebold, B.,  Sammlung seltener und auserlesener chirurgischer Beobachtun-
gen, vol.  i. ii.

  («) Edinburgh Physical and Literary Es-    (d) Salzb. Med.-Chir. Zeitung,  vol. iii. P-
says, vol. iii. p. 525.                     429, figs. 1—3.  1811.
  (6) Above cited.                         (e) Operationen, vol. i. p. 502.—Bt njamin
  (c) Richter's Chirurg.  Biblioth., vol. ii.  Bell's System of Surgery, vol. iv. p. 108.
part i. fig. 8.                             (/) Above cited. 
POLYPS IN THE MAXILLARY SINUS.
479
  Leinicker, Dissert, de Sinu maxillari, ejusdem morbis iisque medendi ratione.
Wirceb., 1809.
  W'einhold, Ueber die abnormen Metamorphosen der Highmorshohle.  Leipzig,
1810; with a plate.
  ■---------, Ueber die Krankheiten der Gesichtsknocken und ihrer Schleimhaiite,
u. s. w.  Hall, 1818.
  Adelmann, Untersuchungen iiber krankhafte Zustande der Oberkiefer-Hohle.
Dorpat, 1844; with three plates.
  [Harris, C. A., On the Diseases of the Maxillary Sinus.   8vo.  Phi-~
ladelphia, 1843.—g. w. n.]
  2346. I shall now treat, not merely of polyps, but also of all the other
diseases which may be produced in the Highmorian  cavity,  and set out
with inflammation of its mucous lining, as the first step of these  various
diseases, which, according to their different  course, and the  causal rela-
tions of the inflammation, may produce a blennorrhagic state, ulceration,
loosening  up of the mucous  membrane, polypous degeneration, sarcoma,
caries, exostosis, osteosteatoma, and osteosarcoma.
  2347. Inflammation of the mucous membrane of the Highmorian cavity
has either  an acute or an insidious course;  most commonly the latter,
and therefore, in  general, it is not at first noticed.  The symptoms of this
inflammation are at the  onset a burning, throbbing pain, which  extends
from the edge of the teeth into the orbit, not externally, but  in the max-
illary cavity itself, and  not increased  by external pressure.   According
to the  kind of inflammation, this pain is either very severe and constant,
with increased heat, headach, and febrile symptoms; or it is slight, and
then only supposed  to be a slight catarrhal affection, and not attended to.
  2348. If the inflammation do not  disperse,  it may, if acute, and in
healthy, robust persons, run  on  to suppuration ; but generally it acquires
a blennorrhagic character, with a feel of constant dull pain, not increased
by  pressure, but  it soon attacks the teeth, and  becomes severe  and ob-
stinate.  The patient blows  from his  nose puriform fluid, streaked with
blood; or it  escapes into the nose when the head is laid on the other
side.  By the  continuance of this blennorrhagic affection, the  mucous
 membrane  of the Highmorian cavity gradually become swollen, and its
 opening of communication with the nostril  is  narrowed, or  completely
 stopped up.  The unnaturally secreted  fluid, which  is  either puriform,
 lymph-like, actual pus, or even a solid cheese-like substance collects in
 the cavity, which it expands; at the same time  the cheek is  reddened to
 a certain extent, the nostril of the  affected side becomes drier, the pain
becomes more severe, loss of sleep, and the like, ensue.  As the max-
 illary cavity continues  enlarging, its walls expand, in general, most  to-
 wards  the  front, but also towards the orbit, towards  the  nostril, and
 towards the palate ;  in consequence of which great disfigurement of  the
 face, closure of the nostril of the affected side, pressure on  the  eyeball,
 and the like,  are  produced.  The bony walls, by their expansion,  be-
 come  thinned, and  sometimes so soft that they yield on pressure of  the
 finger; at last they are  destroyed  at  some one  spot, fistulous openings
 are produced in the cheek, in the orbit, in the palate, and most commonly
at  the edge of the  tooth-sockets, from which  pus escapes,  and a probe
 can be passed into the maxillary sinus.
   2349.  The  above-mentioned inflammatory symptoms, more or less 
480          POLYPS IN THE MAXILLARY  SINUS;
 decidedly pronounced, always precede the formation of polyps, osteostea-
 toma, osteosarcoma, and exostosis, in the maxillary cavity.
   Polyps grow quickly, expand  the cavity in all directions, destroy the
 front wall or the edge of the tooth-socket, and burst through these open-
 ings ; the walls of the cavity being at the same time softened.  Frequently
 the polyp passes through the aperture of the cavity into the nostril;
 sometimes it rises more especially towards  the inner angle of the orbit;
 at other times leaves the front wall untouched, drives up into the cavity
 of the skull, and may cause death by pressure on the brain.
   In osteosteatoma  and osteosarcoma, the bones forming  the maxillary
 cavity are converted into a  mass, consisting in  part of a viscid,  pappy
 substance, in part of a fat or tallow-like substance, and in part of a car-
 tilaginous and  bony substance.   The enlargement of the tumour caused
 by a  polyp always  runs on more quickly than in that from osteosteatoma
 and osteosarcoma.
  2350. Inflammation being considered as the general groundwork of the
 diseases of  the maxillary sinus, the following may  be mentioned  as its
 causes.   External violence,  catching  cold, rheumatic, gouty, scrofulous
 and  syphilitic  diseases: suppressed eruptions of. the skin, caries at the
 roots of the teeth  corresponding to the maxillary cavity, injury of the
 tooth-sockets  in drawing teeth,  foreign  bodies, insects,  and  the  like.
 The different terminations of inflammation of the maxillary cavity, seem
 in part to depend on the variety of its causes, as for example; in catar-
 rhal and rheumatic affections of the mucous membrane of the bones of
 the face, its upper layer especially, is attacked, and  the inflammation
 passes on to blennorrhcea, loosening up, and polypous degeneration of the
 mucous membrane, whilst gouty and syphilitic inflammation rather attack
 the under layer of the mucous membrane, which blends with the perios-
 teum, and more quickly runs  into ulceration  and degeneration  of the
 bones.
  2351. The prognosis of the various diseases of the maxillary cavity is
 guided by their cause and degree.  In the acute course of the inflamma-
 tion,  if not caused by internal disease, its dispersion may be effected by
 proper  and early treatment,  but it is generally more difficult in dyscrasic
 affections.  When the disease has proceeded to a closure of the aperture
 of the maxillary sinus, and to organic changes, the cure is always tedious,
 and impossible without operation.   In the blennorrhagic state, in collec-
 tion of  mucus,  or lymph-like fluid in the cavity, the prognosis is  more
 favourable than in polyps, and the above-mentioned degeneration of the
 bony  walls.  In the further  progress of polyps, osteosteatoma and osteo-
 sarcoma, cancerous  degeneration  not  unfrequently ensues, a condition
 which is beyond aid.
  2352. In considering the  treatment  of the  different  conditions of
 disease in the  maxillary sinus, that  of  its inflammation must be  first
 taken up.
  Acute  inflammation  must be  treated strictly  antiphlogistically, free
 blood-letting, leeching, and cold  applications to  the cheek.   If it have
 been  caused by external violence, and any separation of the walls of the
sinus  be supposed to exist, moderate pressure must also be made.   If the
 inflammatory tension be thereby relieved, then, in catarrhal or rheumatic 
TREATMENT.
481
affection, recourse must be had to diaphoretic treatment and to purgatives.
If there be restlessness and loss  of sleep, to these  remedies must  be
added opium in moderate  doses, rubbing  in  opium  powder and spittle
on the cheek, and  at night a strong  camphorated  belladonna  plaster
applied.
   2353. When  the inflammation  is chronic  or becomes so, which   is
generally the  case in  any causal relation with dyscrasic  affections, the
treatment must be specially regulated by the disease on which it depends.
If there be a blennorrhagic condition, loosening up of the mucous mem-
brane, which is  to  be feared when there  is a discharge streaked with
blood, injections of astringent decoctions must be made into the nose,
purgatives, and according to Weinhold's  experience, specially,  a snuff
composed often grains of calomel, and two drachms of  sugar, or  from
two to three grains of  sulphuric oxide of mercury, and a drachm of sugar,
and tincture of  digitalis, in connexion  with remedies which counteract
the  existing dyscrasy, and1 in such doses  as< will  depress the vascular
 action.
   2354. When the disease has proceeded to closure of the aperture of the
maxillary sinus, and there is any collection  in it, or a  blennorrhagic con-
dition, or the ulceration which-has taken-place in the  cavity,  even whilst
its aperture is still open,  cannot  be cured, or if polyps or other kinds of
degeneration have formed, opening the maxillary sin us 'remains the only
remedy;  by means of this,  the unnatural collection is emptied, the
diseased secretion got rid of, and' the  diseased production removed  or
destroyed.
   In estimating this operation, the diseased conditions requiring it  must
be considered, whether the general affection on which they-depend,  is,
or can be removed.    Blennorrhoea and  ulceration are more easdy cured
than  polyps, osteosarcoma,  osteosteatoma, and.  exostosis.   In  these cases
the after-treatment is  always- extremely difficult,  the  after-products are
easily reproduced, and not unfrequently run  into cancerous degeneration*.
When these after-products are very largely formed, the neighbouring
bones are involved  in the diseased change, or manifestly assume a can-
cerous condition, and^ the patient's powers  being already  much sunken,
the operation will only hasten his death.
   2355. The  various  spots  at which opening the maxillary sinus has
been proposed are, first, the alveolar socket of the second, third,  or
fourth molar tooth (a); second, the fossa canina (Desault); third, the
under part of the  zygomatic process  between  the  second and third
molar tooth (b); fourth, the bony palate; fifh, where- any one part of the
cavity is very thin or  perforated;  sixth,  boring through the cheek,  or at
the same time,  also through the palate (Weinhold.)   If there be a fistu-
lous aperture, it may,  especially if  corresponding with the bottom of the
sinus, be  sufficiently enlarged.
  The re-opening of the closed aperture of the sinus by injection, by the use of probes,
and the like, according to Jourdain (c),  as well as the perforation of the wall of the
sinus in the nose, after Richter's plan (4), when the cavity protrudes much towards
the nose, are objectionable.
  (a) Cowper, Anatomia.  Oxford, 1637.—Drake, Anthopologia.  London, 1707.
  (6) Lamoiuer.; in  Mem. dc l'Acad." de'   (c)~ Above Gited, p. 50.
Chirurg. vol. iv. p. 351, pi. iii. b. c.           {d) Anfangsgriindp, vol.ii. p. 360.

                                41* 
482
TREATMENT OF POLYPS
  2356. Opening the maxillary sinus through the tooth-socket is then only
to be undertaken, first, when it  contains  fluids, pus or mucus;  second,
when the tooth-soeket itself is specially diseased, when there are also
carious teeth, or they are very painful when touched, when there is.caries
of the socket, or fistulas have formed between the molar teeth or in  their
sockets.  The second, third, or fourth molar tooth is then to be  pulled
out, and whilst an assistant properly fixes the  patient's head and draws
down the corner of the mouth with a blunt hook, a trocar, without its
canula, is to be passed into  the tooth-socket and  thrust into the sinus;
or the  alveolar process is  to be  penetrated  with a  perforator, and the
opening enlarged to  such degree  that the  collected fluid  may  escape
freely, and the state of the cavity  be properly examined.
  [Opening the maxillary sinus through the tooth-socket, is the most preferable
mode of performing this operation; and although  thrusting in a trocar is usually
recommended, it is far more convenient to use the instrument formerly employed
for introducing a canula into an obstructed nasal  duct, as the extremity of its stem
being bent at right angle, can be more handily introduced after the tooth has been
drawn.  Not unfrequently, the sharp end of a tent probe bent at right angle readily
thrusts through the little shell of bone separating the tooth-socket from  the sinus.
And it is not even an uncommon circumstance to find that either this plate has been
absorbed, or one fang of the tooth has penetrated the sinus, so that immediately, the
tooth.is pulled out the puseseapes.—j. f. s.}.
  2357. The escape of the matter is furthered by soothing fluids or luke-
warm, water, with which the patient should  frequently wash his mouth,
and  at the same time, force it into the  aperture.  If  there be any  pieces
of exfoliated bone on the alveolar process,  they must be picked off with
the forceps.  Any contrivance for plugging  up the aperture is unneces<-
sary,'and* also hurtful, by  shutting up the fluid in  the  cavity.   If the
patient  every day push the'tip of his little finger into the opening, that
will  be  sufficient to prevent it closing too quickly.   Whilst taking food,
however, the aperture should be plugged with a little-bit of sponge, and
afterwards the mouth again washed out.
  When, these are ulceration and  caries,  which are discovered by the
character of the discharge  and by the  probe,  means for supporting the
general health must  also be  employed  besides the local treatment; and
any loose pieces of bone removed with the forceps.
  In a  blennorrhagic  condition and loosening up of the mucous mem-
brane, a solution of bichloride of mercury, of sulphate of zinc with tincture
of opium, or the like  must be used.  The introduction of a small portion
of red precipitate ointment on a probe is of good effect.   With this local
treatment must be connected  general remedies corresponding to the
state of the health.
  When by these  proceedings the secretion of  the  mucous membrane
h»s  become healthy,  attempts should,, be made  by sternutatives to  render
the natural opening again  pervious, after which the opening in the tooth-
socket will close.   If, however, the aperture cannot  be restored, it must
be sought to get rid  of the secretive activity of the  mucous membrane.
According to  Weinholb {a) this should always be the object of the treat-
ment,  asthe cure is only effected when secretion ceases, and the^whole
cavity  filled with  granulations.  For  this purpose  Weinhold  recom->

              (a) Von. den Krankheltpn der Gesichtsknochen,,p. 23. 
IN THE MEDULLARY SINUS.                 283
mends  as  especially advantageous, diluted tincture of capsicum, and
solution of nitrate of silver.
  [The  restoration of the original  aperture between the maxillary cavity and the
nostril, is not of the slightest consequence; at least, so far as the cases I have seen,
prove.   Weinhold's notion, I do not think, is any thing worth, or at all likely to be
correct, for as soon as the pus  has escaped by the hole in the tooth-socket, the in-
flammation subsides, and the  lining of the  maxillary cavity resumes  its  natural
function. But if the pus have  been very long pent up, and  the mucous membrane
destroyed, it is more probable there will be exfoliation of the bony walls, than that
the whole cavity will be filled with granulation.  I  have not, however, seen any
case where either one or other such result has occurred.  Weinhold's recommenda-
tion of injecting stimulating solutions cannot  be too  strongly deprecated, as being
fraught with mischief, and should never be followed.   It is not, however, objection-
able to inject warm water for two or three days after the tooth has been drawn, and
the cavity tapped, as thereby it is more quickly cleansed, and the healthy processes
are encouraged.—j. f. s.]
  2358. Boring into the maxillary cavity in the fossa canina is indicated
when the teeth and alveolar process are healthy, in  collections  of fluid,
and polypous and  other degenerations.  The patient  sitting on a stool,
his head is fixed by an assistant against his breast, and  the corner of the
mouth on the affected side drawn down with a blunt hook.   The cheek
is to be separated at  the  front edge of the base of the zygomatic process,
in the direction of the second or third molar tooth, by a cut through the
gum ; the periosteum  is to be  cut through cross-wise,  and the flaps  cut off
with scissors.   Upon the bared bone a perforating trephine is then ap-
plied and made to penetrate rather obliquely from below upwards through
the wall of the maxillary cavity.   An examination is made with a probe
to ascertain whether  there  be  any after-production,  and if  there  be, to
what extent this  hole should  be enlarged.   If necessary, it must be
widened first with the pointed and afterwards  with the  blunt perforator;
and if the wall be soft, this may be done with a strong curved knife; and
the opening should always be  made sufficiently large to introduce the
finger.   A small-crowned trephine may also be useful in perforating the
cavity  at this part (a).
  2359. The further treatment is guided by the state of disease.  In
blennorrhoea and ulceration the  same proceeding is adopted, as after per-
forating the tooth-socket.  Any after-products existing in the  maxillary
sinus must be removed according  to their nature, by cutting away, tear-
ing off, tying, or by  destroying them with caustic.
  2360. Cutting away cannot  be employed if the  polyp have a  broad
base, as there is always then danger of severe bleeding, and recurrence
of the  disease.   The polyp is to be drawn well forward, and cut off with
the bistoury, or with Cooper's  scissors: the bleeding must be stanched
with wadding moistened or strewed with styptics and pressure, or  by the
application of the actual cautery.                                     ,
   Tying is rarely possible, and tearing off the polyp  with straight or
curved forceps, having grasped it as near as possible  to its root, is always
to be preferred.
  Destruction with caustic is only proper when  the disease cannot be got
at in any other way.   For this purpose, butyr of antimony, caustic potash,
or best of all, lunar caustic, are employed ; a strong solution of the  latter,
on lint, being introduced into the  cavity.
             (fy Desault, above citedj  vol. ii. p. I66,>pl. ii figs. 1, 2, 3. 
484                 TREATMENT OF POLYPS
   The actual cautery is only to be employed when the other remedies are
 fruitless, and even then with great caution.   For this purpose, a metallic
 tube, wrapped in wetted linen, is passed into the opening up to the midst
 of the after-product, and  a  trocar, at white  heat, thrust  through  it.   If
 the unnatural vegetation he by these means  stopped, and'if hard  granu-
 lations sprout up, they may be treated with  astringents till1 the scarring
 is completed.
   2361. The object of boring into the maxillary cavity below the eminen-
 tia molaris, and above the third or fourth molar tooth, is the same  as that
 for boring in the fossa canina; and the indications are  also the  same.
 The patient having been placed as  already described, and  the corner of
 the mouth drawn down, the gum  and periosteum are divided at the part
 determined, and the bony wall is bored obliquely from below upwards,
 and from without inwards, with the perforator.  The further proceeding
 is the  same as in boring in the fossa canina.
   2362. Boring into  the maxillary sinus through the palate, when the
 palate is much altered by disease, and another situation  cannot be con^-
 veniently chosen, or  at  any one part, where the  cavity is  very thin  or
 burst through, is easily managed from  what has been already said  on the
 different modes of boring; the after-treatment is also guided'by the same
 rule.
   2363. For boring into  the maxillary sinus upon the cheek, Weixhold
 proposes several' modes of proceeding.  If the disease be  bt'ennorrhcea,
 and loosening up of the mucous membrane, with narrowing and closing
 of the aperture, in which the object is  to do away with the  secretive ac-
 tivity of the mucous  membrane, the needle-trephine (a) must be applied
 on  the bone, and an  aperture made, rather  obliquely upwards, through
 the distended cheek  into the maxillary sinus, four lines  from the  zygo-
 matic  process towards the nose, and  the same distance  from the  lower
 edge  of the orbit, and then as it is rotated, the front wall  of the cavity is
 pierced.   The perforator may also be appliedwitb the same  purpose, but
 instead of  the needle-trephine after having cut into  the cheek.  A plug
 is then introduced  into  the opening, and1 fastened  to the  temple by a
 thread; it may  also  afterwards be  smeared with red precipitate oint-
 ment,  and a  solution of nitrate  of silver,  or properly diluted tincture
 of capsicum  may be  injected, till the-mucous  membrane  is destroyed
 {par. 2357.)
  2364.  If the after-products, polyps, steatomes, fatty growths and the
 like, or the secretion  of the mucous membrane are  to be destroyed, the
needle-trephine armed with a  thread in its eye should be introduced  at
the appointed'place, and whilst the handle is a little raised,  the point is
 carried so downwards through the maxillary sinus,  that it penetrate the
palate  some lines distant from the third molar tooth.  In doing this, the
tongue is to be protected1 from the  injury by the  forefinger of the left
hand, and  the point of the trephine thrust so far out, that the thread in
its eye can be reached with a hook.   The trephine  is now  withdrawn;
and the thread left behind, by which either a firm cord or a  plug of tape
is introduced,  and these are to be  smeared with remedies proper for de^
stroying the after-products.   In fatty swellings the string should be fre-

      (a)  Ideeruuber die. krankhaften Metamorp'iosen der Highmorshohle, fig. 1. 
IN THE  MAXILLARY SINUS.
485
quently drawn backwards  and forwards, and  moistened with oil of tur-
pentine, and as much as  possible of the mass  removed with Daviel's
spoon.   For the destruction of polyps or sarcomatous degenerations, the
plug should be smeared with a solution of lunar caustic, of bichloride of
mercury, with red  precipitate  ointment, and  the like.   To prevent the
acrid fluid escaping into the mouth, to that part of the string hanging in
it a thread should be attached, and whilst the upper part of the string is
pulled up, the thread must be  drawn through the upper opening of the
cavity,  and separated from the  string.  To the lower part of the  thread
a piece of  sponge or a wad of lint is attached, which  must  be pressed
firmly against the opening in the palate, whilst the upper end  of  the
thread is pulled up.   The upper part of the string is then smeared with
some of the just-mentioned escharotics, and replaced in the sinus.   If
the string be gradually made thicker, it favours the cure.
  According to Hedenus, the seton, after the lip has been separated from the upper
jaw, should  be drawn within the mouth through the front wall of the maxillary sinus
and the palate, by means of a curved needle (a).
  2365. In deciding on the different modes of proceeding for opening
the maxillary sinus,  it  must be remembered that in collections of  mucus
and pus, when there are also caries and necrosis of the alveolar process,
and of  the walls  of the sinus,  the principal object  must always  be to
form  a sufficiently  large opening, so that the collected fluid may freely
escape, and the loose pieces of  bone be removed.  For such cases,  under
the circumstances above  mentioned, {par. 2356,)  boring through  the
tooth-socket or in the fossa canina is best.  The introduction of a seton
according to  Weinhold's method is very advantageous for  destroying
many after-growths.   There are, however, degenerations of the  maxil-
lary sinus,  in which not merely  the mucous membrane, but even  the
bones  are  completely changed in their tissue, to which neither  of the
above-mentioned modes of treatment are applicable ; and the removal
of the after-products is alone possible by taking away the greater part of
the bony wall so  as  to get  at them ;  or the bone may be divided to the
whole extent of the after-product, as will be directed for the  removal of
the upper jaw.  As to the special performance of this operation, nothing
decided can  be laid down; it must depend on the peculiarity  of  the
case, the  circumstances allied to which will be hereafter noticed, in
treating of removal  of the upper  jaw.   In  the  former  case it must be
attempted to penetrate the  front wall of the sinus by a  semicircular  cut
above the  alveolar process with a sickle-shaped knife, and by a like cut
through the palate also, so as to cut out an elliptical portion of the bony
wall.   The after-product  must now be  removed with polyp-forceps, or
if its adhesions be  firm, it must be taken away  with the knife.   The
bleeding during this operation  is  always severe,  and requires, if pressure
with wads of lint  be insufficient, the actual cautery; this is best ma-
naged with a bent trocar, of which the canula is wrapped  in wet  linen.
The  actual cautery should not be  applied very smartly to destroy  the
after-product, because it  may produce severe and  dangerous reaction.
At first, after  the operation, the  treatment must be antiphlogistic and
soothing according  to  circumstances.  When suppuration is set up, it
must be sustained by smearing  the lint with  digestive, and strewing it
  (a) Graefe und Walther's Journal, vol. ii. part. iii. p. 387.—Weinhold, in same, vol.
iii. part i. 
486         POLYPS OF THE WOMB AND OF THE VAGINA.
with irritating powders.   If all the after-product be not  removed, or if
it  be not  destroyed  by the  actual cautery, and a  new growth ensue, it
must be destroyed by escharofics, of which nitrate  of  silver is best.   It
is  self-evident that in this local treatment, the state of the powers and any
causal dyscrasy must not be forgotten, but met with corresponding treat-
ment.
  In consequence of a diseased tooth, its root may expand the surrounding socket,
and form a pretty spacious cavity, unconnected, however, with the maxillary sinus.
Drawing the tooth, and removal of the front wall of the socket, are sufficient for the
cure.  After the removal of teeth, the roots of which extend  into the maxillary sinus,
fistulous  openings often remain between  them, through which occasionally some
saltish fluid escapes into the mouth ; if left alone, these fistulas  are of no conse-
quence.
   2366.  The same  diseased conditions which render the  opening of  the
maxillary  sinus necessary, may also require  the frontal  sinuses to  be
opened, as their mucous membrane is subject  to the  same changes as
that of the maxillary sinus.  In boring into the  frontal sinus, the  bone is
to be laid bare at that part where it  is  most expanded, and the external
plate penetrated  with  a trephine.  The after-treatment must be con-
ducted according to  the  nature of the disease, just  as  after opening the
maxillary sinus.

  A peculiar affection  of the maxillary sinus  must be here mentioned, which has
been specially noticed  by Dupuytren, consisting of a development of a  cellulo-
fibrous swelling, enclosed in a proper cyst, besides the  mucous lining of the cavity.
This tumour, of which  the consistence varies according to its age, if  examined,
presents in its  structure an approach, to that of a fibrous polyp,  but does not  seem, to
have any great disposition to cancerous degeneration.   At first it  is little inconve-
nient; as it grows it distends the walls of the sinus, especially in front, and thins
them so that they form merely a thin plate which is yielding, gives way  to pressure,
and by its elasticity rises again with a sort  of crackling, like that produced  by
pressing a bladder half filled with air.  This symptom, which is pathognomic, fades
away after  repeated examination.  A cut from the infra-orbitary hole to the corner
of the mouth lays bare the distended wall of the bone, and with a  common  bistoury
a sufficiently large opening, or even a crucial cut, may be made into  it.  The swell-
ing may be seized with a hook, or with Museux's forceps, and  easily pulled out.
It is, however, very difficult to get out the cyst at the  same time, and therefore, in
most cases, it is necessary to stuff the cavity with lint, and to destroy it by inflame
mation and  suppuration.  A  moderate degree of pressure  will assist the return of
the bony walls to their  place (Pigne.)
      D.—OF  POLYPS OF THE WOMB AND OF THE VAGINA.

  Levret, above cited.
  -------, Sur  les Polypes  de la  Matrice et du Vagin; in Mem. de l'Acad. de
Chirurg., vol. iii. p. 518.
  Herbiniaux,  Parallele de Differens instrumens  et methode de s'en servir, et de
pratiquer la ligature des Polypes dans la Matrice.   A la Haye,  1771.
  Goertz, Dissert, sistens novum  ad ligaturam Polyporum Uteri instrumentum.
1783.
  Walther, De Polypis  Uteri; in  Ann. Academ. Berol., vol. i. p. 20. 1786.
  Nissen, Dissert, de  Polypis Uteri, novoque ad eorum ligaturam  instrumento.
Gotting., 1789.
  Stark, Ueber Mutterpolypen und Umkehrung der Gebarmutter; in Stark's Neue
Archiv. fur Geburtshiilfe,  u. s. w., vol. i. part iii.
  Heinze, Dissert, de Ortu et Discrimine  Polyporum, praecipue Polyporum Uteri.
Len., 1790.
  Zeitmann, Dissert, de Signis et Curatione Polyporum Uteri.  Jenae, 1790. 
SYMPTOMS OF POLYPS OF THE WOMB.          487
  Rothbarta, Dissert, de Polypis Uteri.   Erfurt, 1795.
  Segarf, Dissertation sur les Polypes Uterins.  Paris, an xii.
  Lefaugheux, Sur les Tumeurs circonscrites et indolents duTissu cellulaire dela
Matrice et du Vagin.  Paris, 1802.
  Roux, Memoire sur les Polypes Uterins; in his Melanges de Chirurgie et de
Physiologie.
  Hauk,  Ueber Gebarmutter Polypen; in Rust's Magazin, vol. iii. p. 263.
  Mayer, De Polypis Uteri.   Berol., 1821.
  Boivin  et Duges, Traite pratique des Maladies de l'Uterus et de ses annexes,
vol. i. p. 333.   Paris, 183:3.
  Besides which many observations may be' collected from writers on nasal polyps.
  2367.   Polyps of the womb are formed either in its fundus, its body, or
its neck.   In general  they resemble  each other in having a long pear-
shaped form with a thin neck, in  being of a fleshy or fibrous structure,
and in being covered  with a  smooth shining skin.  Various differences
are however observed, as they are sometimes  round with a broad base,
have  an uneven, cleft surface, and their internal structure is sometimes
more soft and spongy; at other times more tough, and sometimes having
cavities which contain different  kinds of substances.   Sometimes  they
are very vascular, and at  other  times contain  few vessels.   Their size
differs,  and is sometimes very  great.  Mucous polyps  are rarely  pro-
duced.
  I have seen a polyp, which though rooted in the cavity of the womb itself,  hung
out two inches below the fissura magna, in structure resembled a mucous polyp, and
at its lower edge it had fringed lobes, and an aperture through which a thick probe
might be  passed to its root.
  Upon mucous polyps in the womb, in old women, accompanied with leucorrhoea,
but without bleeding, (hypertrophic mucous sacs,) Nivet and Blatin (a) may be
consulted.
  2368.   The symptoms characterizing  a polyp of the womb are, at  first,
very doubtful; whilst small it causes no  remarkable inconvenience to the
womb.   As  it increases, it often  excites  squeamishriess, disposition to
vomit, weight and dragging in the loins and region of the sacrum, shoot-
ing and  itching in the breasts.   The walls  of the womb are gradually
distended by the  polyp; its  vaginal  portion becomes shorter,  thicker,
and harder, and the lower portion of the womb is larger than usual.   By
the continued  growth of the  polyp,  the mouth of the womb is at last
opened,  when an escape of bloody fluid, and often violent bleeding, takes
place, and the polyp  protrudes  through the mouth, either  gradually or
suddenly, on every exertion, in jumping and falling, going to stool, and
the like, with pains like labour pains,  and dragging of the generative
organs.   If the polyp protrude into the vagina, it enlarges quickly, causes
pressure  on the  bladder and rectum, and consequent difficulty in voiding
the urine and stools;  the pain in the  lumbar and sacral regions  becomes
greater,  and there is  often considerable  bleeding, occurring either  of
itself, or  from  any exertion,  shaking of the body, or  the like.   These
bleedings depend on  the  constriction which the polyp suffers from the
mouth of the womb, in consequence  of which the blood collects and the
vessels burst.   The discharged blood is sometimes very  red, sometimes
black, sometimes  brownish or watery, mingled with  flocks and fibres,
and excessively  stinking; sometimes whole pieces of clotted and very
filthy-smelling blood are discharged.   Sometimes no blood escapes, but
           (a) Archives Generales de M6decine, vol. iii. p. 195.  1838. 
488        SYMPTOMS  OF  POLYPS  OF THE WOMB.
 only a  quantity of rawcMs-like  serous fluid, which greatly weakens the
 patient.  The growing polyp at last protrudes from the vagina, and ap-
 pears externally.  By the weight of the polyp, the womb is constantly
 dragged and pulled down, and there is, consequently, a sensation of con-
 tinual dragging and tension in the belly; eversion of the  womb may
 ensue, the discharge of urine be greatly interfered with, the belly blown
 up and painful, repeated  bleedings, the general health considerably
 affected; the breathing becomes difficult, dry cough, loss of appetite and
 hectic fever may ensue, and death follows, either from continued pull
 upon the  constitutional  powers, or  suddenly from  bleeding.   As the
 polyp protruding from the vaginais  exposed to the air and to  the contact
 of the urine, constant irritation is kept up on it,  and hence often ulceration
 is produced.         <
   2369. If a polyp  form on the neck, or in  the  neighbourhood of the
 mouth of the womb, it is noticed earlier, as  it soon protrudes into the
 vagina, and does not distend the womb as when rooted in its fundus; it
 causes pressure on the bladder and  rectum, and rarely bleedings,  as it is
 not constricted by the mouth of the womb ; by its weight  the womb is
 pulled and  dragged down;  the neck and  mouth  of the womb often so
 swells,  that the bound between it and the polyp is completely lost.  In
 consequence of the irritation of the womb kept  up by the polyp, scirrhous
 or steatomatous degenerations may be produced.
  A polyp arising from the fundus of the  womb, when sinking downwards, may be-
 come  adherent to the wall of the vagina, and so have two roots; it may, therefore,
 when quickly protruding through the external generative organs, evert the womb
 and the vagina, in consequence of which, according to its seat on the latter, there
 may be produced a hollow in the rectum, where it corresponds with or on the^m-
 tonaeum,  where it is attached to the vagina.  If the protruded part of the vagina do
 not differ from the stem of the polyp, it may be tied with it in the operation (a).
   2370. The symptoms produced by the development and further pro-
 gress of polyps, may give rise  to their being mistaken for pregnancy,
eversion, and prolapse of the  womb,  fungous growths, and scirrhous dege-
 nerations.
  2371. As long as the polyp remains in the cavity of the womb it may
 be mistaken for pregnancy; the diagnosis, however, rests on the following
 circumstances.  In pregnancy the vaginal portion of  the womb is only
 gradually distended;  it is elastic and feels soft, the mouth of the womb
remains closed, and opens only during labour.    With polyp the internal
mouth of the womb  opens without  true  pains, and remains  oftentimes
long open, without the vaginal portion being so  regularly expanded, with-
out being soft and thin, and without the lips of the womb-mouth so com-
pletely disappearing.  The mouth of the womb w7ith the polyp is harder,
in pregnancy softer.   The menstrual discharge is rarely suppressed with
polyp, but irregular, more frequent,  and not rarely painful;  the blood is
paler, watery, mingled with fibrous parts ; and  there is, in addition to the
discharge, a mucous ill-smelling fluid, like water in which flesh has been
washed.  In pregnancy menstruation occurs  only in  rare cases, but is
regular, as concerns its coming on and character.  The general symptoms
occurring at the beginning of pregnancy diminish and entirely disappear

  (a)  Berard, (These,) Observations relative aux Polypes de l'Uterus et a quelques-une»
des Maladies des Organes Genito-TJrinaires.  Paris. 
DIAGNOSIS AND CAUSES.
489
in its progress;  but with polyp,  on the contrary, they increase.  The
enlargement of the belly in pregnancy is greater and more regular; but
with polyp is more unequal, does  not attain the size of pregnancy, and
depends on the growth of the polyp.   The enlargement of the breasts is
not so gradual with polyp of the womb as in pregnancy; they are some-
times full, sometimes flabby, and never so large.   To  conclude, the
continuance of pregnancy is definite, and, at a certain time, the move-
ments of the child are perceptible.  In mole-pregnancy, the distention of
the belly  and the  alteration of the  vaginal part of  the  womb,  which
shortens and softens, takes place more quickly; the mouth of the womb
remains closed till  the mole is protruded, which happens suddenly and
not gradually; there, also, is not the discharge as with polyp.
  2372. As to the mode of distinguishing a polyp which  has protruded
through the mouth  of the womb from eversion of that organ, it must be
observed that in  incomplete eversion, the swelling passing through the
mouth is broad above and  narrow below ; hence also the mouth of the
womb is always  more open  than with polyp, as that has a directly con-
trary form, being broad below and narrow above.  In eversion, which is
not of long standing, the replacement of the  womb is in general possible,
in consequence of which the pains are lessened, whilst' after such attempts
the polyp  always protrudes again.   The polyp is less  sensitive than the
everted womb.  Eversion usually occurs after a very recent labour; the
polyp is more  moveable than the  everted womb, its surface is smooth,
and the bending in  of the fundus  of the womb may be  felt through the
walls of the belly, if the eversion be anywise great.  Complete eversion
resembles polyp  in the form of the swelling, as it is narrow above  and
broad below, but it is surrounded  by the mouth of the womb like a fold.
With polyp the finger, or a probe, may be passed deeply between it and
the vagina, but it cannot be by the side of the everted womb.   The slem
of a polyp is hard, the upper part of the everted womb is yielding, be-
cause it is hollow.   Eversion occurs  after a birth.
  Notwithstanding  these different signs, the distinction of polyp from
everted womb, especially if  partial and of  long  duration, is  very diffi-
cult, so that the  most able practitioner cannot be certain without exami-
ning by the touch.  As, however, as  has  been  already  noticed, {par.
1287,) the form as  well as the  sensibility and mobility  of  the polyp
varies ; both swellings may have  a smooth or an irregular surface ; the
polyp may appear soon after delivery;  examination of the belly affords,
in stout persons, no definite  result, and with a polyp rooted at  the fun-
dus of the womb, the fundus may be, in its further protrusion, dragged
down, and a  certain degree of eversion produced (a).   Careful obser-
vation seems to  prove the fact that a polyp, when it has once passed
through the mouth of the womb, grows quickly.
  2373. The mistaking  a polyp which  has descended into the, vagina
for an imperfect prolapse of the womb is not very possible, as the polyp
is softer  and less sensitive than  the protruded womb, has generally a
bean-shaped form, without any opening at its lower part; and when at this
part there is even  a  pit resembling the mouth of the womb,  no probe
can  be introduced  into  it;  replacement is impossible  with a polyp,

                    (a) Chelius ; in Heidelb. klin. Annal.
  Vol. iii.—42 
490        TREATMENT OF  POLYPS  OF  THE WOMB
 though it may be effected with prolapsed womb and  the  pain  thereby
 relieved.   If the finger or a probe be  introduced  between  the  polyp
 and the vagina, it may pass deeply, whilst, on the contrary, in prolapse
 it is soon stopped.   In prolapse there is  no repeated bleeding.   In com-
 plete prolapse  of the womb the distinction is still more easy.
   2374. Fungous growths are  distinguished from polyps  of  the womb
 in that  they are the consequences of a scirrhous state of that organ, the
 mouth  of which is  hard, painful to  the touch ; is  even more  or less
 irregularly shaped, and bleeds  on the slightest  touch.   Scirrhous swell-
 ings of the mouth of the womb  are characterized by the feel of gnaw-
 ing  and burning, by stabbing, boring pain, which  at first remits, but
 afterwards is continual; by a  copious white discharge which corrodes
 the parts; by  the discharge of pieces  of black blood, by very  great
 hardness of the swelling, irregularity, and pain when touched.
   2375. The causes  of polyps of  the womb   are in many cases un-
 known.  Irritation of the womb, repeated  difficult  deliveries, frequent
 connexion, onanism, venereal discharges, and  the like, may frequently
 produce them ;  but more commonly they  arise without any such previous
 ailment; and they have been noticed  eyen in young girls.  Most  com-
 monly they occur  about the period of the cessation  of the menstrual
 discharge, when the altered vital condition  of the womb favours  unna-
 tural productions.  They are very rarely seen in old women.
  2376. The treatment alone consists  in the removal  of the  polyp by
 operation.  Only in rare cases  has it been noticed that the constriction
 of the polyp by the mouth of the womb has caused its complete sepa-
 ration and cure.  The result of the operation is the  more favourable in
proportion to the ease with which the  stem of the polyp can be got at,
and the less thick  and firm  it be.  When there has been for a long time
great loss of blood, other  symptoms  quickly arise  after the  operation
which require particular treatment.  So long as the polyp is still not
large, it is covered with a membrane connecting it with the womb, and
which tears as  the polyp grows.  Hence the reason why the  operation
on large polyps is commonly attended with  slighter  symptoms  than the
 smaller: hence after  the operation the recurrence of the disease is gene-
 rally less to be  dreaded than after nasal polyps.
  When there are other organic changes  of the  womb, scirrhous harden-
 ing and the like, the  prognosis  is extremely unfavourable, as  after the
 removal of the  polyp it more quickly terminates fatally.  Polyps of the
 womb do not  hinder conception, but generally abortion takes  place ;
 pregnancy, however, may reach its  natural  termination.
  2377. Of the generally proposed  methods  for the  removal of polyps,
 tying and cutting off are the most proper for those of  the womb;  pull-
 ing  or  twisting off,  and destruction by  escharotics, are inapplicable,
 partly oji account of the yielding nature  of the  parts  in which the polyp
 is rooted,  and partly on account of the condition of the space (1).  The
 operation can only be undertaken in polyps of the womb when they  have
 protruded through  its mouth into the vagina.   Before  undertaking it a
 review must be taken of the cause of the disease, and of the patient's con-
 stitution.  Hence a preparatory treatment is sometimes  necessary; for
 instance, in  syphilitic disease  by using mercury; and in those persons 
BY TYING  AND  BY CUTTING INSTRUMENTS.       491
  who have been  very much weakened by bleeding, by  strengthening
  remedies,  and the like.                                             >
    (I) Mayor (a) has vindicated twisting off.

    2378. The  number of instruments  which have  been  proposed for
  tying polyps of the womb is very great; they may be arranged compre-
  hensively under the three following heads :—
    First. The ligature, which is carried round the root  of  the polyp  by
  means of a double tube, or two  separate tubes, or  stems,  connectable
  together, and  tightened   by means  of these tubes.  To  these  belong
  Levret's double  cylinder (6), and forceps  (c), with the modifications of
,  Keck {d),  Laugier (e),  Buttet  (f), Contigli (g), and  Clarke {h);
  also the instrument of David {i), Klett  (j), Loeffler (k) Cullerier
  (I),  Goertz (m),  and Nissen  (n); with  the  alterations, of Joerg (o),
  Meissner  {p), and Gooch {q).
    Second.  The loop  is  applied  with the  assistance of a  loop-drawer
  around the polyp, and its tying  managed  with a single tube, or with a
  loop-tier.  Here  belong  the apparatus of Herbiniaux (r), Stark {s),
  Desault {t),  with Bichat's modification  {u), John Hunter  {v), and
  Ricou {w).
    Third. The loop applied around  the root of the  polyp, with a loop-
  drawer, and tied together by the use of little rings, through which the two
  ends of the ligature are passed.   Such  are the rosecrown instrument of
  Boucher (x), Loeffler's alteration (y), Sauter's {z) combination  of  it
  with Ribke's instrument {aa).
 *  2379. Of these several instruments for tying polypsof the  womb those
  only will be  here mentioned, as  being most suitable, which were em-
  ployed by  Desault, and  the tier of Nissen and Ribke.   Previous to the
  operation the  rectum must be emptied With a clyster.   The patient  is to

    (a) Note sur  l'Extirpition  des Polypes   Weibes,  fig. iii.-vii.  Lipz.  1821.  Second
  uterins par torsion ; in Gazette Medicale de   Edition.
  Paris, vol. xii. p. 529.  1844.                (p) Above cited, fig. i.-vi.
    (6) Mem. de l'Acad. de Chirurg., above    (q) An Account  of  the most important
  cited, pi. xiii.                          Diseases peculiar to Women.  London, 1829.
    (c) Journal de Medecine, vol.  xxxii.  p.    (r) Above cited, pi. i.—iii.
  531, fig. I—6.   1770.                    (s) Stark's Archiv.C. I., p.I52, figs, i.-iv.
    (d) Ibid., vol. xxix.  p. 529.        .       (i) Above cited, pi. iv.—HASsELBERG,Com-
    (e) Journal de Medecine, vol.  xxxiii.  p.   merit, chirurg. in qua novum humeri  ex
  363.  1770;  vol. xxxv. p. 173.   1771.       articulo exstirpandi methodum,  novumque
    (/) Ibid., p. 66.                       ad ligaturam Polyp >rum instrumentum pro-
    (g) Raccolta di Opu-cuolo Medico-practi-   ponit.  Gryph., 1788.
  ci, vol.  iii  p. 139.                        {u) Memoires de la Saciete d'Emulation,
    (h) Observations on those Diseases^of Fe-   an n. p. 33.*
  males which are attended  by Discharge.    (v) In B. Bell, above cited.
  London, 1814; with ten plates.             (10) Ms moire et  Observations  sur les
    (i) Loder's Chirurgische Bemerkungen,  Polypes Uterins, avec un nouvel instrument
  vol. i. pi. ii. fi,r. 4 and  5.                   pour en faire la  Ligature; in Museum der
    (j) Stark's Archiv.  fur   die  Geburt-   Heilkunde von der helveti^chen <*esellschaft
  shulte, vol. iii. p. 548, fig. i. iii. a. c.         cprrespondirender Aerzte und Wundaertze,
    Ik) Ibid., vol. iv. p. 301                 vol. ii. pi. v.  Zurich, 1794.
    (l) In  Lecfaucheux, above cited.—Hufe-    (x) Beinstein; in Loder's Journal, vol. ii.
  land and  Aarless, Noues Journal, vol. ii.   p. 626, pi. x.
  p. 196, pi. 2.                             (y) Hufeland's Journal.   1813;  part iv.
    (m) Above  cited, fig. 1,2.               p. 65.
    (n) Above cited.                        (z) von Siebold's Chiron, vol. ii. p. 420, pi.
    to) Handbuch  der Krankheiten  des  vii. figs. 1-8.
                        (aa) Rust's Magazin, vol. iii. p. 153, 
492          TREATMENT OF POLYPS OF THE WOMB
be placed on a bed or table, so as to be in a half lying, half sitting pos-r
ture, and the perineum  and region of the coccyx exposed.  The thighs
must be separated by an  assistant, and a careful examination made to
ascertain the nature and seat of the polyp.
  2380. Desault's apparatus is  to be  employed  as above mentioned
{par. 2337.)  A pretty strong ligature must be passed through  the  eye
of a loop-drawer, and to a silver tube somewhat curved forwards, and the
end of the ligature fastened on one ring of the silver tube.  This and the
loop-tier are now carried parallel to each other  between the swelling and
the wall of the womb on that side  where there  is least resistance, and by
slightly moving it laterally, carried to the upper part  of the stem of the
polyp.  That end of the ligature  attached to the ring of the tube  being
loosened, the loop^drawer is  held fixed with  the left hand, whilst with
the right  the tube is carried round the whole swelling and back to the
loop-drawer.  The hands are  now to be used instead  of the instruments,
and so  crossed over each other that the part of the loop which the tube
draws with  it may pass over that held by the loop-drawer.   The tube is
now drawn  back, whilst the drawer is kept steady, the two ends of the
thread passed into the opening of a loop-tier, and this pushed up to the
root of the polyp, whilst the ends  of the. thread are held fast, the stem of
the loop-draw'er is then pressed forwards, the ligature removed from its
aperture,  and the  drawer  removed.   The twro ends  of the ligature are
now drawn  sufficiently tight, and fastened to the notch of the loop-tier.
  This mode of treatment is very worthy of recommendation  on account of its ease
and certainty,  The objecUop that the ends of the ligature, not being contained in a*
tube, may be softened and loosened by the continual  moisture, is, according to my
experience, groundless. If it be desirable to measure each time the degree of
tightening, that may be easily done by means of a stop-wheel placed at the .end of
the loop-tier.
   2381. Nissen's polyp-tier  is used in the  following manner:—The
instrument well oiled, and having a thread unlooped  attached  to  it, is
passed  with the forefinger of  the left hand up  to the  root of  the polyp.
The handle by which the two tubes are connected is  now removed, and
one tube being held steadily, the other, w7ith  its concavity towards the
polyp,  is  carried round it to its fellow, and the two are then  connected
by slipping  on and pushing forwards the rings, and attachingthe handle.
The ligature is how drawn closely together and fastened ; or it is tightened
with the screw as recommended by Joerg.
   2382.  In using Ribke's instrument, the two loop-drawers are  intro-
duced, like  the  single  blades of delivery-forceps, up to the  root of the
polyp, the stem which holds the two cylinders  together is drawn out, and
then  each of the latter is carried round in a half circle  till they meet
again,  and  are then fastened together with the stem.   The assistant, who
has hitherto held the stop-wheel,  now presses the knobs to the upper end
of the connected cylinders, after which the stilettes in  the latter are drawn
go far out at the  lower opening that the loop is set free, and the cylinders
 can be withdrawn-   The  root  of the polyp  is now  tied and  properly
fastened by  the stop-wheel, which is laid on a pad upon the mons Veneris,
 and confined there by a broad cloth around the loins.
   2383.  The symptoms which may occur after the tie has been made are,
 violent inflammation and fever, pain, spasm, bleedings, and other symp- 
BY CUTTING.
493
toms from pressure of the swelling polyp.  In the first case suitable anti-
phlogistic treatment must be employed; in spasm, narcotic remedies used,
and  if the symptoms be  not  diniinished by these, the loop must be
slackened a little; the bleeding must be stopped by more  tightly tying
the ligature, and with astringent injections.  On account of the increasing
bulk of the polyp it is generally necessary for the first few days to empty
the bladder with the catheter, and the rectum by clysters.
   2384.  The patient must after the operation keep perfectly quiet in bed;
and have a proper diet.  Every two days the ligature must be tightened ;
and to prevent  the effect  of the  stinking ichor, repeated  injections of
decoctions of aromatic herbs must be  employed..  When the polyp has
dropped  off,  which depends  on the thickness  and toughness of its root,
and occurs at different periods, either by the continued tightening of the
ligature,  or on some movement of the patient, the injections  must-be con-
tinued for  some time.  Strengthening  remedies must  also  be given  to
support the patient's diminished powers.
   When the polyp, after  having separated, is  still  retained, in  conse-
quence of its size, it must be withdrawn with forceps, for which purpose
deli very-forceps and much force are often requisite ;  as happened to me
in one case.  If bleeding occur on the  dropping off the polyp, astringent
injections must be used, which are  not, however, to be very irritating, or
great irritation of the  womb will ensue.   If, notwithstanding the repeated
tightening of the ligature,  the  polyp will not separate, which, however,
is very rarely the case, it  is advisable, to save the patient the  incon-
venience of the continued stench, to cut it off below the ligature.
  In  large, long-continued and far extending polyps, it is possible that the fundus
of the womb may be dragged down, the ligature must therefore not be tied too high
up.  1 have related a fatal case of this kind (a).
   2385.  Cutting off polyps of the womb, the oldest method, is, on account
of the  danger following,  and  the difficulty of stanching the blood, only to
be employed in  particular cases, for instance '.first, when the polyp, after
having been  tied fast during  several days, has not dropped off, in which
case, generally, considerable pain  follows every tightening  of the liga-
ture  ; second, when the polyp hangs down, or can easily be drawn out, if
its neck  can be got at, is thin, and there have been no previous bleeding;
third, when the  polyp has produced eversion of the womb, accompanied
with dangerous symptoms, which can  only be  got rid of by the quick
removal  of the  polyp.  Siebold (o), however, not only in this, but in all
other cases, prefers cutting off to tying a polyp cff the womb, when it has
a neck and can  be  reached, whether it  be. at the fundus, in  the body, or
at the  neck of that  organ.  If  in consequence of the breadth of the base
by which it is attached to the fundus or body of the womb, cutting off'
the polyp be not possible, he ties it, for the purpose of contracting the
stem, and then cuts it off'below the ligature.  This mode of proceeding
is less painful, more  speedy, unattended with any particular symptoms,
without fear of bleeding,  and  even should that happen, it is easily stanched

  (a) Heidelb. klin. Annalen, above cited.   tomique des  Polypes de la Matrice, sur
  (b) Ilandbuch zur Erkenntniss und Heil- Temploi de la Ligature et sur les avantages
ung der Frauenzimmerkrankheiten, vol. i. p. de la resection de ces tumeurs ; in Journal
710.  Second Edition.  1821.—Hervez  de General de Medecine. 1827; vol. ci. p. 1.
Chegoion,  Remarques sur la disposition ana-
                                42* 
494   TREATMENT OF POLYPS OF THE WOMB BY CUTTING.

by plugging;  the patient is not inconvenienced by a hateful smell and
discharge,  may  leave  her bed in a few days,  and has little fear of a
relapse.  Dupuytren's repeated  operations in this way entirely confirm
Siebold's statements (Pigne); and although practice shows that the result
after cutting off the polyp may be fatal (a), so on the other hand it shows
that after tying, there may be severe, and even  fatal bleeding (b).
  2386.  Cutting off a  polyp of the womb is to be performed in the fol-
lowing manner:—The patient being placed in the same position as for the
operation for the stone, an assistant presses on the belly to force down the
womb, whilst  another keeps the labia asunder.  The polyp being found
in the vagina,  a speculum with moveable branches is introduced, and the
walls of that passage are expanded with  it, so as to isolate the polyp,
which is then seized with Museux's forceps and the speculum withdrawn.
Whilst the polyp is gradually drawn down, another  pair of Museux's
forceps are to be  applied higher up  and at  another  diameter, and the
drawing down is to be continued, whilst the patient holds her breath and
forces, till the neck of the womb and stem of the polyp are seen, when
it is to be cut  off'with scissors or with a kinfo.   The accompanying pain
is only very little, there escape only a few drops or a teaspoonful of blood,
the womb rises again, and a few days are sufficient for the  cure.  When
the neck of the polyp is still engulfed  in the  womb, the neck of the
latter must be  cut into to reach the stem of the polyp (Dupuytren.)  If
the polyp protrude at the external generative parts, it is only taken  hold
of with the fingers or forceps and  drawn a little  out.  The scissors for
the performance of this operation should be curved on their flat surface,
have their end rounded, and be provided with long handles (Siebold) (c).
The  previous  application of a ligature around the neck of the polyp, after
drawing it down, and before  cutting it off, which is  recommended by
some practitioners, Dupuytren  and  others  consider  unnecessary.  If
there be bleeding, cold injections should be thrown up, cold applications
made to the belly, and  plugs of lint, strewed with or steeped in astrin-
gents, introduced.                                                ,
   2387. Polyps of the vagina, as regards the  symptoms they produce,
and the treatment they require, are  of less consequence than those of the
womb.   They are soon  discovered by examination, and only when very
large, cause pressure on the bladder and rectum.  Their causes are in-
flammation, and.injury of the vagina, venereal poison, and the like.
   Their removal is either effected by tying, which is little difficult, and
often done merely with'the hand, or by  cutting off; and the same  rules
are to be followed as in the operation for polyps of the womb.
   [Occasionally a vaginal polyp will, from s*ome accidental cause, separate  of its
own accord, without any surgical aid; an instance of this kind occurred  to me a
few years since.^-^. f. s..]

  (a)  Mayer, above cited.                chern des fistr. Staates. Neuste Folge, vol.
  (b)  Amming, Einige  praktische Bemerk-  vii. part ii. p. 285.
 ungen ueber die Gebarmutterpolypen und    (c) Mayer, above citedt figs. i. ii. iii.
 ihre  Entfernungsarten;  in  Med. Jahrbii- 
OF  CANCER.
495
                 F.—OF POLYPS OF THE RECTUM.

  Desault, above cited, vol. ii. p. 498.
  2388.  Polyps of the rectum are situated either near the verge of the
anus, and are then  external, or they are deeper seated, and can only be
protruded in going to stool, or even remain concealed in the gut.   They
are generally round, not large, necked, and of a pale-red colour.   Some-
times there is only  one, but at other times several.
  2389.  Those polyps which constantly lie out  of the rectum, may be
grasped with forceps,   drawn^down,  and  taken off at  their root with a
stroke of the bistoury, or with the scissors; and this applies also to such
as are situated  higher, but can be forced out.  If, however, the polyp be
seated so high, that it will not be forced out of the rectum, the ligature
is the only remedy, and is best applied according to Desault's method.
                         XVII.—QF CANCER.

                  (Cancer, Carcinoma, Lat.; Krebs, Germ.)
  Peyrilhe, Dissert, de Cancro.  Paris, 1774.
  Le Dran, Memoire avec un Precis de plusieurs Observations sur le Cancer; Mem.
de l'Acad. de Chir., vol. iii. p.'l.
  Jaenisch, Vom Krebse und dessen Heilart.  Petersburg, 1793.
  Pearson, John, Practical Observations on Cancerous Complaints.  London, 1793.
8vo.
  Whistling, Aeltere  und  neuere Kurmethoden des offenen  Krebses.  Altemb.,
1796.
  Legaux, Dissert, sur le Cancer.  Paris, an xi.
  Roux, P. S., Memoire sur le Cancer; in his Melanges de Chirurgie et Physo-
logie, p. 149.  Paris, 1809.  8vo.
  Home, Everard, Observations on Cancer connected with Histories of the Dis-
ease.  London, 1805.   8vo.
  Ferrier, Dissert. Observations et Considerations sur le Cancer.  Paris, 1806.
  Bayle, Vues theoretiques et pratiques sur le Cancer; in Biblioth^que Medicale,
vol. xxxv.  Paris, 1812.
  Wenzel, C, Ueber die  Induration und  das  Geschwiir in indurirten Theilen.
Mainz, 1815.
  Abernethy, John, A Classification of Tumours; in his Surgical Works, vol. ii.
p. 68.   Edition of 1815.
  Bayle et Cayal, 'Article Cancer; in Diet, des Seiences Medicales, vol. iii. p.
537.                                 1
  Scarpa, Antonio, Sullo Scirrho e sul Cancro.   Milano, 1821; and Opuscuoli di
Chirurgia, vol. i.  Pavia, 1825.
  von Walther, Ueber Verhaxtung, Scirrhus, harten und weichen Krebs, Medul-
larsarkom, Blutschwamm, Teleangiecktasie, und Aneurysma per anastomosin; in
his  Journal fur Chirurgie und Augenheilkunde, vol. v. p. 194, p. 567.
  Recamier, J. C. A., Recherches sur le Traitement du  Cancer.  Paris, 1829.
2 vols.  8vo.
  Cruvelhier, Anatomie Pathologique, livr. iv.  and viii.   Paris, 1829.
  Muller, Johan, above cited, p. 10.
  Canquoin, Traitement du Cancer.   Paris, 1836.  8vo.
  Carmichael, Richard, M. D., An Essay on the Effects of Carbonate of Iron upon
Cancer; with an Inquiry into the Nature of that Disease.  London, 1806.  8vo.
  Travers, Benjamin, Observations on the Local Diseases termed Malignant; in
Med.-Chir. Trans., vol. xv.  1829.
  Hodgkin, Thomas,  M. D., On the Anatomical Character of some Adventitious
Growths;  in Med.-Chir. Trans., vol. xv.   1829. 
496           ORIGIN AND SYMPTOMS OF CANCER.
  2390. That degeneration is called Cancer which is the consequence of
ulceration of a Scirrhus, has a decided disposition  to destroy all parts
without distinction of their nature, which never heals,  and which having
arrived at a certain height, produces peculiar general disturbance.
  2391. Two distinctions are  established in reference to the origin  of
cancer;  it is either  developed from a previously formed scirrhus, or it
arises from some other swelling, or some other ulcer in which  the scir-
rhous degeneration has been set up.
  2392. In the first case different periods may be distinguished in the
development of the  cancer.  There arises generally  without any known
case, sometimes in consequence of  external violence, a defined  tumour,
or a swelling of some one organ which is generally quite free from pain,
though rarely very sensitive; from  the  first it is very hard, irregularly
knobby,  and heavy,  though sometimes regularly  elastic on the  surface,
and soft  at some parts.   The skin covering the tumour is in  its natural
state;  the  substance of the organ in which  it is formed, is  usually in-
creased ; though sometimes it crumples  together,  and  is then firmer.
These  symptoms designate the first stage of cancer {Scirrhus).   The con-
tinuance of this stage is indefinite, though mostly long, and especially the
harder the swelling,  the older the individual, the less vascular the organ',
and  the  more all dynamic and mechanical -irritation  be wanting, and
the secretions and  excretions  remain natural.   The general health is
commonly undisturbed during this period,  and the  countenance un-
changed ; sometimes,  however, various derangements, loss  of power,
wasting, earthy countenance, irregular febrile action arid the like  appear,
by which a more speedy progress of the disease is indicated.
  2393. Of its  own accord, or in consequence of  some evil influence
upon the swelling it becomes  irritable; the patient  feels shooting, and
excessively painful stabbings, or has the feel of constant burning in the
tumour.  The hardness  and the extent of the hardness constantly in-
crease,  it becomes more knotty and knobby; the   skin covering it is
bluish-red, tense, adhering to the surface of the. swelling, and the veins
upon it swell (Concealed cancer, Cancer occultus, Lat.; verborgener Krebs,
Germ.).   The neighbouring lymphatic vessels and glands swell, become
hard and painful, the constitution is more or less disturbed, loss of appe-
tite follows, indigestion, wasting, and cachectic earthy countenance.
  2394. Under  aggravation of the  above symptoms the thinned skin at
last breaks, and an  ichorous, bloody, brownish, or limpid fluid escapes,
without the bulk of the tumour being in the least diminished;  an ulcer is
formed with hard edges and with irregular surface ; very painful fungous
growths spring  up; an  excessively stinking ichor  is  discharged; the
neighbouring glands, even those lying beyond the course of  the lymph,
swell,  and all parts are destroyed by the ulcer spreading in every direc-
tion after they have first assumed a scirrhous state. Bleedings frequently
come on, the body wastes considerably, the skin assumes a peculiar yel-
lowish-gray colour,  the  countenance has  the characteristic  impress of
deep-seated disease; collections of serum are formed in the cellular tissue,
and in the cavities;  peculiar frangibility of the bones;  hectic fever with
nightly sweats, and  colliquative diarrhozay and the powers of the patient
are exhausted. 
SYMPTOMS AND KINDS OF CANCER.            497
  2395. If a scirrhus be examined before any ulceration have taken place,
there is found a hard, firm, incompressible substance which, cut into thin
layers, is semitransparent, has the consistence of cartilage and fibro-carti-
lage to that of lard, with  which appearances it in general agrees, and is
composed of two different substances ; the one hard and fibrous, the other
soft  and seemingly inorganized.  The fibrous part forms without regu-
larity various partitions and  cavities, in which is  contained a soft  sub-
stance, having usually a pale brownish, sometimes bluish, greenish,
whitish, or  reddish  colour,  similar to hardened  albumen.  The fibrous
part has sometimes a cartilaginous hardness.   But specially are  the pro-
portions of  these two  substances  very different; sometimes the fibrous
substance forms as  it were the  nucleus, from which the partitions spread
in every direction, and on the substance being cut, a radiated appearance
is presented.  Sometimes the  whole  swelling forms an homogeneous
hard lard-like substance,  in which no definite tissue  can be discovered.
Between these two  extremes there are various  links, merely distinguished
by the different proportions of the  two substances.  Sometimes encysted
tumours filled with  fluids of different  colours are found in  a scirrhus.
The scirrhus specially exists  either as a tissue  different from the organ in
which it is developed, or from the conversion of the substance of the
organ itself; in the latter  case,  the boundary between health and disease
cannot be accurately determined.
  If the tumour be examined in the state of concealed cancer, the lard-
like  substance is found harder  in  the  centre  than at  the circumference;
here and there it is spotted with red ;  rough  and uneven at some parts,
with cells of different size which are filled with a viscid, ash-gray, bloody
fluid, of a very acrid nature.   The edges of these cells which are found
in the interspaces of the fibrous streaks are pale-red, and their inner walls
covered with a soft and fungous substance; from which last may be here
and  there separated, by scratching with  the finger-nail, little portions of
the hard-white matter lying beneath  (a).
  Microscopic examination presents the following as elements of scirrhus.
First, cells  of very great variety in different cases; simple  cell-nuclei
with nuclear corpuscles, sometimes surrounded with very pale cells, some-
times with completely formed cells, in general rounded, sometimes studded
with granules, or having granular contents.  Tailed cells are rare,  and
when existing, seem rather dependent on the  development of the fibres.
Sometimes  there are very characteristic cells, with  very thick double
walls and granular  contents.   Granules and fat-corpuscles are frequently
mixed together with the cells,  sometimes singly, sometimes collected in
heaps,  and  sometimes as it  appears enclosed in cells.  Second, fibres,
sometimes broad and band-like, sometimes narrow, and not unfrequently
elastic fibres.   The arrangement of the fibres varies considerably.   Third,
together with the cells and fibres there is commonly found as an actual
element of scirrhus, a mucous fluid, which coagulates with acetic acid  and
solution of alum.
  Muller (b) distinguishes four  several kinds of Carcinoma,  according to the
different nature of the  tissue.   First, Carcinoma simplex; second, Carcinoma reticu-
(a) Scarpa, above cited, p. 29.
(b) Above cited, p. 11. 
498
MULLER AND HODGKIN'S
fare; third,  Carcinoma alveolare ,• and, fourth, Carcinoma fasciculatum.  Therewith
he also reckons Carcinoma medullare and melanodes.
  In Carcinoma simplex and fibrosum, the uneven, generally lobeless substance which
resists the knife, presents when cut  through, a gray basal mass, which seems only
remotely  similar to  cartilage,  and  in  which  there  are irregular whitish  bands.
Scirrhus of the breast sometimes exhibits here and  there white threads, in which a
space can be perceived, and in it some  colourless,  whitish, or yellowish contents.
It seems to originate in the thickening of the walls of the milk canals and lymphatic
vessels.   In  scirrhus of  nonglandular  organs,  no  such hollow  white threads are
observed.   The substance consists  of a fibrous and of a granular gray substance.
The former rarely appears distinct when cut through, but is seen on scraping off the
gray  matter, for which it is also the bed and presents a very irregular mesh-like
tissue  of  bundles  of tough fibres.  The gray substance  is composed entirely of
microscopic  formative corpuscles, which have little connexion with each other, are
transparent and hollow cells or  vesicles, with a diameter of  from 0,00045-0,00120
of a Paris inch  in diameter, and are soluble in neither cold nor boiling water nor
acetic acid.   In many of these cells  may be distinguished merely some small spots,
having the appearance of little granules; in others, a large corpuscle, like a nucleus,
or little vesicle contained  in the cell-corpuscle.  Besides the formative corpuscles,
many little knobs of fat are always found scattered  in the scirrhous substance.
  Carcinoma reticulare when cut through is distinguished from Carcinoma simplex
by the white reticulated figures distinguishable with the naked eye, which run through
the gray substance, and by its tendency to form lobes as  well also as by the greater
bulk which it acquires.   In consistence  it sometimes resembles scirrhus, sometimes
is softer and approaches medullary fungus; hut with this variety of consistence the
structure always remains the same.  It  is composed of a gray globular basal sub-
stance,  embedded  in a mesh-like tissue of  bundles of fibres, first  observed by
scraping,  or  by getting rid of the  gray granular  substance by maceration.  The
latter consists of similar transparent  formative corpuscles or cell-corpuscles to those
of Carcinoma simplex, which contain one, two, or  several little vesicles with pale
nuclei.  In other cases, the little nuclear cells cannot be distinguished within the
large formative corpuscles; on  the  contrary,  many little granules are seen in the
interior of the transparent cell-corpuscles, and such also are sometimes observed in
large quantities lpose between the vesicles, the smallest exhibiting molecular move-
ment.   Characteristic are the white  or yellowish-white reticulated figures, more or
less distinct  but  never  deficient, which  have  no expanded little- vessels  with
thickened walls, but are peculiar formations, and consisting of a deposition of white
granules in the gray substance.  They do not  appear to be cellular, but seem for the
most part a, conglomeration of opaque granules of roundish and oblong corpuscles,
which are two, three, or four times as large as the blood corpuscles.   These white
corpuscles collect more and more during the progress of development, and form an
element of the self-destroying tissue, sometimes whole pieces which are enclosed by
the  other substance  or line,  the interior of the existing  cells from whence they
detach themselves like  a  film.  The corpuscles thence pass into the softening and
suppuration  of the broken up surface.   With further development the reticulated
figures  readily flow  into irregular  white  spots; their appearance then has some
resemblance  to the first appearance of white tubercles in the gray basal substance.
   Carcinoma alveolare exhibits an irregular knobby surface, and as the base  of the
substance, a  tissue of endless, crossing, very firm, white fibres and plates, between
which simple cells are found, from the  size of grains  of sand to that of the largest
peas, which are closed, but frequently communicate with the neighbouring cells, and
all  contain a very viscid  pale,  very transparent jelly.   Under the microscope the
little cells are seen to enclose still smaller cells, and these again contain still less.
On the little cells the dusky-yellowish  nucleus of its wall is plainly seen.   Many
cells also contain simple nuclei  loose in their interior.  The large cells are distinctly
fibrous in their walls, and the fibres  pass from one cell to another.
   Carcinoma fasciculatum is distinguished by its throughout fibrous structure, which
may be seen either by breaking or cutting through it.   The  tumour may be  easily
torn in the direction of the fibres, is not  thereby crumbled, and under the microscope
shows neither the cell globules of  other carcinomata, nor the tailed bodies of the
seemingly fibrous medullary fungus.  The  arrangement of the fibres is either tuft- 
DEVELOPMENT AND PROGRESS OF CANCER.         499
like, and then the fibres can be torn into simple radical bundles, of which the points
are directed towards the bottom and their base towards-the irregular surface, or the
bundles form different sets of fibrous expansions.  Whole masses of fibres form one
tuft, others different tufts.  The large bundles of fibre's thrust through each other, as
is seen on tearing them asunder.   In this case the swelling readily  forms large and
Small lobes upon the surface and  even  in the interior.   Between the lobes  mem-
branous partitions pass, to which the  tufts  of the  fibrous substance are attached.
Sometimes  it is seen how the fibrous substance arises on a membranous surface,
protrudes like a sheaf, then forms an arch above and again attaches itself to another
membranous wall.  These lobular throughout  fibrous tumours often acquire con-
siderable  size.   But the  lobular  form  may  be  entirely  wanting,  and  the whole
swelling consist of a single tuft of radically arranged  fibres.   These swellings are
very vascular, and the vessels  have  a straight  course similar to the fibres.   The
substance of the swelling is sometimes  transparent like jelly.   The  fibres are
throughout pale and transparent;  their surface is here and there beset as if tinctured
with nuclei.
   [Dr. Hohgkin (a) considers scirrhous to originate, like other malignant growths,
from cysts, either of a simple or compound character, and has  given the following
excellent account of their  development and progress:—
   "Scirrhous tumours have a more or less rounded form.  On making the section
of them they present various appearances, but are all more or less divided by septa,
which affect sometimes a  radiated form, and at others a cellular character.  Both of
these characters have been insisted on by many writers on this subject; but I believe
the differences which have been observed in  many instances depend on the direction
in which the sections were made.  * * * If we carefully dissect down to the surface
of one of these tumours,  we shall usually find  that it has a capsule or covering,
which has, I believe, generally been supposed  to consist of the altered and con-
densed cellular membrane of the parts which have  given way before  the growth of
the tumour. This  idea is probably  correct with  respect to the  unequally  thick
external  part of the  capsule; but if we dissect carefully, and examine those tumours
in which the progress  of  decay has either not commenced, or has made very little
progress, we shall find that surface which is next to the  mass of the tumour more
or less smooth and  even,  and on raising it we find  that it is reflected over one or
more pyriform bodies, attached by  a base, which is generally  narrow or peduncular,
to some part of the circumference  of the enclosing capsule.  Unless  the tumour is
very small, it is much  more common to  find  several rather than a single body of this
kind, and as there  is often little,  if any, fluid intervening between  them and the
enclosing  capsule,  their form is  somewhat modified by their mutual  pressure.
Sometimes, though more  or less closely applied to each  other, these pedunculated
bodies are perfectly detached at their  sides, and  may,  consequently,  be readily
traced to the point which  forms the common origin of their peduncles.   At other
times these bodies are so adherent amongst themselves, and the membrane covering
them is so tender and delicate, that without very great care the arrangement of their
structure may  be overlooked,  in  consequence  of the pedunculated  bodies  being
broken or  torn through in a different direction  from that to which their  mode of
formation would naturally dispose them.  It  must  be sufficiently  obvious that the
appearance presented by  the section of a  tumour, such  as 1 have just described,
must be very materially affected by the  direction in which the section is made.  If
it pass through or near to  the point at which the  pyriform bodies are attached to the
enclosing  cyst, it must nearly correspond  with  the direction which some of these
bodies take towards the circumference, and these edges will consequently be seen
in the form of radiating lines.   On the other  hand, if the section be made more or
less nearly transversely to the axes  of  these bodies, their section will  convey the
idea of cells of various shapes.   If we continue dissecting and raising the outer cyst,
for mi no-  the reflected membrane which covers the radiating pedunculated  bodies, we
shall generally find that on one  or  more  sides it  dips down deeply into the mass of
the tumour, and forms a part of the  septum which separates  the one  packet  of pe-
dunculated bodies from the others, which generally concur to form  the mass of the
tumour; for it comparatively rarely happens that the tumour is composed  of a  single
cyst filled  with pedunculated bodies.  On examining the different encysted packets
(a) Above cited. 
500           DEVELOPMENT AND PROGRESS OF CANCER.
 of pedunculated bodies which compose the tumour, we shall often find some indica-
 tion of their having taken their origin from nearly the same spot, which is generally
 the most indurated part of the tumour.  We may likewise observe that the different
 secondary tumours, or encysted bundles of pedunculated bodies, are in very different
 stages of progress.  In those in which the internal growth is most active, we shall
 find that a process has taken place perfectly similar to that  which I described as
 occurring in ovarian tumours  when the  development  of  the contained cysts pro-
 duced the hernia  or  rupture of the containing one.   The secondary cyst or cysts,
 which make their way through  the  containing one, rapidly advance when they are
 free  from the  restraint  which  its pressure  afforded,  and  thus constitute  another
 tumour,  which adds to the original mass.   If we examine the structure of this new
 tumour,  we shall find that the subordinate growths of which it is composed, radiate
 from  the point  at which this tumour made its escape from the original one.   At the
 same time that the escaped cyst or cysts acquire their more rapid growth, they often
 acquire a new character with respect to  their consistence, which is  generally much
 more soft and  tender.  *  *   *  Those  parts of the tumours  in which the rapid
 and unrestrained growth is most remarkable, are generally  situated near the circum-
 ference, where  they are at once  both exempt from the restraint of mutual pressure,
 and  receive  more  abundant  supply of nourishment from  the surrounding  natural
 structures.  A  marked difference exists between those  just described, and others in
 which development has been restrained, or vitality lost by pressure, and consequent
 defective supply of nutrient matter.  I have already explained the  mode in which
 these effects are  brought about in those  ovarian tumours  in  which the secondary
 cysts are thickly crowrded and attached by very narrow peduncles.   Precisely the
 same process takes place in the tumours of which I am  now speaking; and when we
 make a  section through  one  of them, which happens to  be composed of  many
 secondary tumours, and which consequently presents many centres of radiation, we
 shall  often find that the pedunculated bodies  connnected with one or  more of these
 centres have lost their vitality by a  natural  strangulation or ligature, and also that
 the immediately adjoining parts which yet retain their vitality,  irritated by that
 which has now acquired the character of a foreign body, are brought into a state of
 inflammation.  The result of this compound action is the formation of a cavity filled
 Avith broken down and softened matter of a peculiar character, intermediate between
 suppuration and gangrene.  This process very frequently takes place before the
 exterior of the  tumours exhibits any symptom of irritation  or inflammation, and to
 my mind, very  satisfactorily accounts for  that disposition  to central softening and
 decay, on which Laennec, Wardrop, and some others, have so  forcibly insisted as
 characterizing the progress of heterologue  deposits.   At the same time, I think I am
 correct in stating,  that for the  production of this form of gangrene or softening, the
 supply of nourishment should be  pretty promptly cut off by the operation  of the
 natural ligature.   When the process proceeds more slowly, the parts which are
 under its influence gradually acquire  an increasingly dense structure, and ultimately
 becoming penetrated by earthy matter, are allowed to remain unproductive of serious
 irritation, notwithstanding their deteriorated organization and diminished supply of
 nourishment.   *   *  *   Such tumours in the course of their development produce,
 by the irritation which  they excite,  a greater or less degree  of thickening of the
surrounding cellular structure, and  sooner or later become visible externally, dilating
the integuments which are stretched over  them.  The  points at  which this disten-
tion is the most considerable are inflamed, the inflammation proceeds to ulceration,
arid the tumour either sprouts luxuriantly at the part from which the pressure is thus
removed, or participates in the ulcerative process.                            ^
  "The  ulcer is universally described as presenting elevated and  everted edges,
 while, its ragged and depressed central portion is bathed by an unhealthy secretion,
to which  the name of pus can scarcely be  applied.   The mechanism by  which this
peculiar ulcer is produced, is well worthy of attention.  I  have  shown  that  at the
external part of the tumour its growth is most luxuriant, both from the want of pres-
 sure,  and from  the increased supply of nourishment.   This will explain why the
 circumference of the tumour is the most elevated.  The central parts, on the  other
 hand, have not  only to encounter the pressure which they sustain  from the surround-
ing parts of the tumour, and to suffer the diminished supply of nourishment which
this pressure occasions, but moreover, ulceration having removed the integuments,
all supply of nourishment from the surrounding natural  structures is necessarily cut 
SECONDARY DEVELOPMENT OF CANCER.           501
 off.  The depth and irregularity of the central part of the ulcer is often further pro-
 moted by a communication being formed between this part of the ulcer and a cavity
 commenced and  produced on the interior of the tumour by the process heretofore
 described." (p. 294-302.)
   "True scirrhous tumours," Hodgkin further remarks, "appear sometimes to de-
 pend on a single primary tumour; at other times, several may be satisfactorily made
 out.  That part of the tumour which appears to have been the common origin of the
 primary cysts, where there are more than  one, or from which the contained pedun-
 culated bodies radiate, when there  is only a single primary tumour, is, in general,
 the most indurated portion, and is, at the same time, the most indistinct in its struc-
 ture.  When examined externally, after  the surrounding natural structures have
 been carefully dissected off, this part of the tumour is found to be the most irregular,
 has a somewhat corrugated appearance, and suggests the idea of its having been the
 sort of root by which the adventitious growth was implanted on the  natural struc-
 tures.  The radiated appearance  so strongly insisted on by most authors who have
 described scirrhous  tumours, and the  rationale of which I trust I have  shown, is
 particularly conspicuous when  the section passes through this point.  The fluid part
 of a true scirrhous tumour bears in general a very small proportion to the rest of the
 structure, it  has a viscous or mucous  character, more especially where softening
 has not taken place; but where this is going on it assumes the character of an offen-
 sive ichorous discharge, and acrid and  highly deleterious  qualities have  by some
 been ascribed to it.  The  process  of  softening sometimes commences  internally
 at one point, at other times in  several  small isolated  points;  in others, again, the
 ulceration through the integuments  is  the  first part of the process of decay." (p.
 323-25.)]
   2396. The secondary development of cancerous ulceration may occur
 from venereal,  herpetic, scrofulous, and other sores, as well also as from
 different kinds  of growths, condylomata, warts, and polyps, wdiich  are
 not  originally carcinomatous, but by irritating treatment  and the like,
 pass into a scirrhous  condition.
   2397.  Cancer does not appear to be primarily developed in  all  tissues;
 at least, the muscles of locomotion, the serous membranes, cartilage, and
 tendon, are not  originally attacked by it.  The skin, the  cellular tissue,
 the secerning and lymphatic glands, the mucous membranes ; the nerves
 and bones appear to  be the only tissues capable of an original develop-
 ment of cancer.   This disease also arises more frequently in some organs
 than others; it is most commonly seen in the gland of the breast, in  the
 testicle, on the womb, on the lips, the tongue, the eye, on the penis, the cli-
 toris, and the like.  The spreading of the disease to the neighbouring parts
 appears also proportional to  their nature; the cellular tissue and  skin
 coveringthe tumour  are first attacked and destroyed, even before the tu-
 mour adheres to the underlying muscles, as for instances, in cancer of the
 breast.   The serous  membranes only become attacked  at a later period.
 The bones for a long while withstand the destruction ;  however, they are
 eaten into and at last destroyed, as well, indeed, as the vessels which are
 attacked  latest,  though, however,  yielding to destruction, as the  often
 occurring bleeding prove.   When the disease has been still  longer pro-
 tracted, the lymphatic glands which are in relation to the original scirrhus
become  affected ;  sometimes  this  happens even at the onset,  sometimes
only in the latter stage of the  disease.
  Walther (a) has disproved by cases, Scarpa's assertion, that true scirrhus never
occurs primarily in a lymphatic  gland.
  2398.  The symptoms which  cancer presents in its origin and course
                        (a) Above cited, p. 202,
Vol. hi.—43 
602    DIAGNOSIS AND PROGNOSIS OF SCIRRHOUS TUMOURS.

are very different, and seem to depend on the difference of constitution,
of the mischief producing it, and of the tissue  attacked by it, as has been
already noticed in the special consideration  of the  subject, although a
definite causal relation in this  respect cannot always be determined.
   Cancer is often excessively destructive, and eating, surrounded with
hard  edges, and sometimes accompanied with fungous  growths.  The
former kind seems to be peculiar rather to old persons, to sanguineous
and choleric temperaments; whilst  the  latter occurs in young persons
and phlegmatic constitutions.   Sometimes the 'course of the cancer is
extremely quick, a large strip  of the skin  is suddenly destroyed, and the
greater part of the  cancerous  swelling bursts  through the turning out of
the edges of the skin.  In other cases the course of the cancer is tedious,
the ulceration seems determined after the  bursting of the swelling; the
edges of the skin turn inwards, the discharge of ichor is slight, and the dis-
ease may have long existed before it spreads.   The mischievous influence
of cancer upon the constitution also varies according to its seat in differ-
ent organs.   The general symptoms of cancerous dyscrasy often set in
early, before softening and ulceration ;  often  it appears when there has
been  already farspreading destruction of the scirrhous part.
  Alibert (a) has  laid down six  different kinds of  cancer; first, Cancerfungoides,
common cancer;  second, Cancer terebrans, cancer of the skin ; third, Cancer eburneus,
hard like  ivory; fourth, Cancer globosus,  presenting a roundish swelling,  usually
painless, of a violet or blackish colour, and generally, not confined to one spot, but
affecting large streaks on the head,  feet, and so on; fifth, Cancer anthracinus, arising
with a black spot in the skin, accompanied with a painful itching, and, as it enlarges,
a mulberry-like excrescence rises out of it; sixth, Cancer melaeneus, tuberosus, taking
its origin from the knobs which are developed more  or less numerously, and of dif-
ferent  size in the -cellular tissue.
  2399.  The diagnosis of scirrhous  tumours  is frequently  accompanied
with  difficulty.  When the skin covering the swelling is puckered, has a
dark-leaden Colour, a knotty and irregular surface ; when sometimes there
is lancinating pain in. the tumour, and it  is firmly  attached to  the neigh-
bouring parts, there  can  indeed be no doubt of the  scirrhous nature of
the swelling.   But the hardness and condition of  the surface  of scirrhus
often  varies, and may be equally present in swellings of other kind.  In
many instances scirrhus is moveable, not connected with  the underlying
parts, painless, and the skin often not at all altered.   The disposition of
scirrhus to  run into  cancer, usually given as  a mark of distinction from
benignant induration, cannot  be  decided  beforehand; this transition is
not even necessary  thereto,  and not unfrequently depends on  acciden-
tal  influences,  to which the tumour is subjected.  Scirrhus does  not,
in  general,  easily  acquire that size which  other  swellings do;  and
the latter do not readily acquire the same heaviness, nor have they the
disposition to draw the neighbouring parts into the same diseased meta-
morphosis.   Examination of the swelling after  removal  gives a distinct
explanation of its nature, as does also the recurrence of a like tumour
after removal, which,  indeed, is then only of importance as to the prog-
nosis.  The cancerous sore itself has no such  decided and characteristic
mark  that a mistake may not sometimes be possible with much neglected
syphilitic or  scrofulous ulcers, as  these, oftentimes, without being actu-
ally cancerous, present the same symptoms as  cancerous sores.  In these
(a) Nosologic Naturelle. 
        DIAGNOSIS OF SCIRRHUS  AND MEDULLARY FUNGUS.    503


cases, the improvement or injury effected  by anti-syphilitic or anti-scro-
fulous  treatment, as well also, as  the circumstance,  that in  cancerous
sores, the pain is alone diminished by softening and soothing remedies,
but increased by all irritants, will direct the practitioner.
  Scarpa («), who commonly applies the term scrofulous or strumous tumour to a
great extent, and also refers to cases which must manifestly be reckoned with medul-
lary fungus, states the following, as distinguishing characters between it and scirrhus.
Scrofula rarely attacks the external conglomerated, but usually the lymphatic glands.
and in general, several of them at the  same time, and in different parts of the body;
there  may be  also an  existing scrofulous  habit.  The  hardness of the scrofulous
tumour is regular and flat, and different  from the peculiar hardness of scirrhus. The
scrofulous tumour, from the first, produces a wearing, numbing, heavy pain.  Scirrhus
only attacks persons  of advanced age, rigid fibre, and sanguineo-choleric tempera-
ment, in whom, if there be suspicion of a dyscrasy, it  is not that of scrofula; scirrhus
appears alone, grows slowly, and scarcely perceptibly  in every direction, is not sensi-
tive, and when long  existent, has in general, knots on the surface, and  is adherent
to the skin in many places.   When stabbing pains come on in scirrhus, it no longer
increases, indeed, even contracts, with a hardness, from which it may be said, it is
disposed to dryness.   In injecting a strumous gland, the fluid at  first passes freely,
but suddenly runs out, because the vessels are torn.   When cut through, such gland
presents a compact very vascular substance, penetrated with albuminous fluid, which
sometimes, though rarely,  is mixed  with a fatty, granular, or  whey-like  matter.
Between the bodies of the strumous glands, and their external covering, some trace
of coagulable lymph is always found, which favours  adhesion; but this is also often
in the interior.  In scirrhus, the injection penetrates  only into  the principal arterial
trunks.   In  maceration, the substance of scirrhus retains the  peculiar hardness of
softened cartilage, whilst strumous glands dissolve into, a soft,, fungous,  fringy
substance.
   [The following are the diagnostic characters  given- by Hodgkin, of scirrhus and
medullary fungus, or fungoid disease, as he calls the latter.
   "One of the most striking features  which distinguishes the fungoid disease from
true scirrhus, is to be found in the extent and rapidity of the development of fungoid
tumours.  Whilst, as has been seen, the true scirrhus often remains for a considera-
ble length of time in a chronic and indolent state, and. after a growth of some years
produces a tumour of only a moderate size, the  fungoid  tumour in the space of a
few weeks is sometimes  seen to attain to a prodigious size, and to pass through all
the stages which  belong to it in common with the other members of the same family
of adventitious structures.   Whilst true scirrhus is almost  exclusively the  disease
of advanced life, the fungoid disease  makes its appearance in individuals of every
age; but its most formidable and extensive ravages are seen in the young.   Whilst
in true scirrhus the fluid  matter forms  a very inconsiderable and  scarcely notable
part of the structure, in the fungoid tumour it is frequently pretty  abundant, presents
a great variety in  its characters, and  is often collected  in cavities of considerable
size.   In the scirrhous tumour, the peculiar mode of formation I have pointed out,
must often be inferred by analogy, guided by faint  and  partial  traces.; but in the
fungoid disease we meet with those unequivocal, manifestations, which almost speak
for themselves.   In true  scirrhus, the  traces of vascularity, are very faint, but in the
fungoid disease, the adventitious membranes possess a higher and preternatural de-
gree of vascularity.   The vessels which we see  ramifying in them, are not only
numerous, but large.   By some they  have been  considered principally arterial;  by
others venous.  I will not attempt to  decide to which class  of vessels they are most
allied.  They appear to consist of capillary vessels of Bichat on a large scale; and as
we sometimes meet with these membranes of a bright and arterial red, and at other
times of a venous or livid hue,  it seems probable that accidental or fortuitous cir-
cumstances have  the principal share in determining to which class of vessels these
capillaries should most incline.  These newly-formed  vessels,  though large  and
numerous, are extremely weak and  tender, and derive little or no support from the
structure through which they ramify,  or by which they are surrounded; hence they
are liable to give  way at numerous points, whence proceed more frequent and exten-
(a) Above cited. 
504   CHEMICAL COMPOSITION OF SCIRRHUS—SKIN CANCER.
 sive haemorrhages which so  often characterize these tumours, and  have led to the
 term of fungus haematodes, which has not inaptly been applied to  many of them.
 Sometimes the haemorrhage from these vessels produces an effusion into the cavity
 of the membrane reflected over an inferior order of pedunculated cysts or bodies,
 and distends it into a cavity filled with blood, the characters of which will vary accord-
 ing to the time which has elapsed between its effusion and the making of the exami-
 nation.   At other times the effused blood infiltrates the more solid parts of the
 tumour, and produces  an appearance which  by Laennec has been  well compared
 to an apoplectic clot.   The more  solid parts  of the tumour  differ  in  a marked
 manner from  that which composes the scirrhous tumour.  In this  disease, the se-
 condary cysts, which are often of large  size, generally become filled with a material
 which at first bears a considerable resemblance to tender or feebly coagulated fibrin
 or plastic lymph.  Into this substance new vessels speedily shoot; but being neither
 susceptible of perfect  organization, nor calculated to remain inert and dormant, it
 speedily, but gradually loses its vitality, and, like other transparent parts in which
 such a change is effected, gradually becomes opaque, and  bears, in consistence and
 appearance, a close resemblance to the  substance of the brain of a child ; hence the
 terms,  cerebriform cancer, encephaloid tumour and medullary sarcoma.   *  *   *
 Although in  fungoid disease, the solid part of the  tumour often bears a striking
 resemblance to cerebral substance, we frequently find it, on the one hand, deviating
 into a much more firm  material, and, on the other hand, into one of a softer and gru-
 mous consistence.  Sometimes it has a minutely foliated structure of a pearly white
 colour.   When the diseased structure has completely lost its vitality, it breaks down
 into a variously discoloured pultaceous  grumous mass, in which the remains of the
 membranes of the secondary  cysts and  their  vessels  may  often  be  detected.
Although in a recently formed tumour, or in the newer parts of an older one, the
traces of  that  mode of formation on which  I  have insisted are sufficiently evident,
they are very much lost or obscured, as the progress of decay advances.   It is also
at times difficult to distinguish it when the tumour has only advanced to the stage of
 opacity, provided, the substance of the tumour be very uniform, and the membranous
parts not  only very thin  and  tender, but adherent amongst  themselves  and to the
contained substance."  (p, 333-57.)
  The following is the analysis of scirrhus  by Fov (a) :—
Albumen   ------  42,00
White fatty matter  -  -. -   5,00
Red.....,  - ,   3,25
Osmazome    -  -  - • -. -   0,00
Fibrin.......5,85
Water.......5,00
Oxide of iron  -----   1,65
Subphosphate of lime    -  - 16,60
             C soda  -  -  -  5,00
Carbonates of < lime  -  -  -  6,60
             (magnesia  -  0,85

Hydrochlorates of j J°*sh "_  *'™

Tartrate of soda   -  •  -  -  0,85
Hence it appears  by reference  to the analysis  of medullary fungus (p. 719) that
scirrhus contains less of  the first  three substances, that it has no osmazome; that
the subphosphate of lime is nearly three times as much ; and that the total amount
of the salts is double that in medullary fungus."]
   2400.  Cancer in the Skin arises from  true scirrhus, which appears as a
round or oblong flattened  firm swelling,  also from  warts and other excre-
scences of the  skin,  sometimes from  dark red, blackish spots, or from
scurfy  excoriations.   It may occur on  all  parts  of the surface  of the
body, but especially in the face, on the nose, on the lips, and  on the
organs of generation, either on account  of the peculiar sensibility of the
skin on these parts,  or because  it is here so much affected by external
influences.  At first  a  superficial ulcer  forms, which enlarges, becomes
painful, and is not improved  by any remedy.   Its progress is'sometimes
slow, sometimes quick, and relative to  the  severity  of the pain and the
violence  of the  suppuration.   These ulcers  are  long confined  to  one
definite spot,  and remain superficial;  the  surrounding skin  is some-
times but little  changed,  its  surface  red  and  even,  sometimes  co-
               («) Archive* Generates de Medecine, vol, xvii.  p.  185. 
CANCER IN NERVES.
505
vered with a'dry grayish  crust, which is reproduced as often as it is re-
moved.   As soon as these ulcers take  effect on the edge of the lip, the
nose, the eyelid, the  anus or the urethra, they  make quick progress, in-
crease in depth, destroy all parts without distinction of structure, and are
characterized  by their  condition,  by the  lancinating pain, and by the
infection of the  neighbouring glands.   Whilst  the  ulcers are still small,
they are  generally only made  worse by common treatment.   They are
frequently found existing at the same  time with external  and  internal
cancerous disease.
  Ulcers, specially on the face, and wings of the nose, and the like, which without
pain, without a  hard base, without everted hard edges, without fungous growths,
without secretion  of ichor, spread  in all directions, and destroy the parts without
distinction of their organization, without our knowing where they will go, have, in
common with cancer, only  the destructive spreading,  and the general circumstance
that they can ordinarily be  brought to heal, only by destroying their surface.  These
are phagedenic ulcers, stinking, eating, tettery sores, and' form-, a Contrast with the
scabby Herpes exedens, which on the face often causes the most frightful destruction,
and in general can only be made to heal by destroying the diseased portion of skin.
   2401.  Cancer in glands always, begins, as scirrhus, and  presents the
symptoms above described ( par. 2392.)
    2402. Cancer in  mucous membranes  is developed either  in form of
polyps, which are hard, uneven, dusky^ red, and painful;  often bleed of
themselves, or, on the  slightest mpvement; ulcerate  quickly;  exhibit
the same symptoms as  a, cancerous ulcer, and on  examination, present
the same condition as scirrhus; or, under the form of hard,  wart-like ex-
crescences,  or as hardening of the mucous membrane, which runs into
 ulceration.
   2403.  Cancer in the bones shows itself as osteosarcoma, or, osteosteatoma;
and these tumours may have primarily a scirrhous condition, or the can-
cerous: nature may be developed in  them at a later periods
    2404'.  Cancer of the nerves  exists as a hard^ firm swelling, which inter-
nally  shows its  scirrhous  nature, and seems to belong  tothe neurilcma
rather than to the medullary substance.  Sometimes the tumour is seated
on a stalk with which the neurilemma is confluent; $oa>etimes it is formed
by the swelling  of the nerve itself.   Their size^varies from that of a pea
to  that of a nut, and"larger.   These swellings,arise sometimes of them-
selves, sometimes after external violence, most commonly on the super-
ficiaf nerves of the upper  limbs.  They  increase slowly,  feel hardish, are
tense, seem often filled with  fluid"; they are very  painful, specially on
motion, and particularly  on. being moved* from above downwards;  a
sudden  movement of  the  swelling in  this direction produces on the
brain  and nervous system  a  sensation  like that of  an electric shock.
The tumouradheres to  the neighbouring parts, and  draws them into*the
same diseased'condition,,
  Not all tumours  of nerves have'  this, cancerous character.  They are often mere
consequences  of previous inflammation, and originate  in increased and* altered nu-
trition; ihey are often formed by unnatural exudation, in which case- examination
shows  a cavity, of which the walls, are-the neurilema, filled with thin, coagulable
fluid, like the serum of the- blood;; or  between the  nervous threads, which are
pressed apart  a softishi, but constancy becoming firmer substance is. formed ;  or in
the  nervous threads themselves oblong vesicles are formed, which at first are soft
and transparent, but afterwards become harder, and by their increasing size, affect
the  whole substance of the  nerve, and the nerve above  penetrates into the swelling,
                                43* 
506
TUMOURS ON NERVES.
and below passes out of it.  Their size varies from that of a pea to that of a  nut,
and bigger.   I have  seen  a  tumour in the lower third of the thigh,  on the ischiatic
nerve, as large as a small  melon, which had proceeded from the nervous mass itself,
and was covered with neurilema.  The characteristics of  these tumours is always
great painfulness on examining and  moving them with the  finger; they however
cause, especially when seated on large nerves, severe pain on moving the part, even
without displacement,  especially on voluntary motion.   The pain is very severe,
radiating in the course of the  nerve, and frequently accompanied with cramp and
convulsions of the part.   Sometimes there is less pain than a sensation of formica-
tion, and going to sleep, or even a palsied  state of the  part to  which the nerve is
distributed.
  The removal of the tumour is the only remedy; destructive remedies of all kinds
are useless,  and eseharotics  act injuriously.   The removal consists  in laying bare
the swelling, and where it protrudes from the  nerve, and is separable from it, in cut-
ting it off.   If this be not  possible, or the tumour spring from the nerve itself, then
the nerve must be cut thro.ugb.y_/irstf above, and then below the tumour, and the inter-
mediate portion,  together with the swelling, removed.  Small swellings on the
nerves of  the  skin may be taken away  with  the  corresponding piece of skin.   In
large tumours of principal nerves, as in the case of the ischiatic nerve which I have
mentioned, amputation is  the only remedy.
   [I  am doubtful whether  the following cases mentioned by Cheselden (a) be
tumours on the small branches of nerves; but the  symptoms  scarcely permit them
to be considered any other:—"Immediately under the skin, upon the shin-bone, I
have  twice  seen," says he, "little tumours,  less  than a pea, round and exceeding
hard, and so painful that both cases were judged to be cancerous; they were cured
by extirpating the tumour.  But what was more extraordinary was a tumour of this
kind  under  the skin of the buttock, small as a pin's head, yet so painful  that  the
least touch was insupportable, and the skin for half an ineh round was emaciated;
this, too, I extirpated, with so much of the skin  as was emaciated, and some  fat.
The patient, who before the operation  could not endure to set his leg to the ground,
nor turn on  his bed without exquisite pain, grew immediately easy, walked to his
bed without any complaint,  and was soon cured."  (p. 136.)
  There is in the Museum at St. Thomas's a fine example of a tumour in the popli-
teal nerve of a man, which caused such severe pain and  tenderness, with occasional
spasm, in the limb, that amputation was performed  by Astley Cooper.  The tumour
is about the  size of a walnut, whitish and hard, and of a somewhat scirrhous charac-
ter; it seemed to have formed amid the  cords of the nerve, which do not appear to
enter it, but are expanded  over its surface.
   Liston (b) observes, that "these tumours (of  nerves) vary in structure; they
consist of a cheesy or albuminous  deposit in the neurilema; sometimes they are
hard, fibrinous, or earthy, or again, their seetion  presents a brainlike and  bloody
mixture."   And  he  mentions a case in which the tumour,  soft and bloody, was
situated "in the popliteal space,  grew rapidly to  the size of a cricket-ball, and  im-
peded the motions of the limb.   On  pursuing  the dissection, the tibial nerve was
found intimately connected with the growth, tbe fibril'Ise stretched upon its  sheath,
and entering into its substance.   The nerve was  cut across above and below, and
the whole mass extirpated unbroken and entire. *  * *  The removal of the tumour
from the ham, with  at least three inches of the tibial nerve, was not for an instant
followed by the slightest deprivation  of either sensation or power of motion in the
limb and foot."  Whilst  in the  hospital, a tumour was found  on the front of the
same thigh ; an inflammatory swelling took place there and suppurated, but the lump
remained.   "Within six  months after the wound in the ham had healed, the patient
returned  with an enormously swollen limb, and a large elastic morbid mass in the
back part of it;  from this a bleeding fungus was protruded, and  he soon died.
The original tumour was  soft and bloody; the one from the  fore part of the thigh
ovoid and larger than a hen's egg, involved the anterior  crural nerve, and was appa-
rently fibrinous; the diseased  structure, which  was reproduced in the popliteal
space, had all the characters of fungus haematodes." (pp. 350, 351.)  Tumours not
malignant have been occasionally removed from nerves  with success.
   It will be here convenient to notice the formation of Tumours on the extremities of

   (a) The Anatomy of the Human Body.    (6) Practical Surgery.  Fourth  Edition,
8vo,  Eleventh Edition, 1778.              1846. 
TUMOURS ON NERVES.
507
the nerves of stumps, which occasionally, though rarely, occur, and I do not recollect
to have seen more than two or three such cases.  At an indefinite period after am-
putation, either before or after it has healed, the stump begins, without any apparent
cause, to become painful, and though  it had previously been well shaped, it now
begins to assume a conical form, the soft parts  retract, the bone sticks out covered
only by the scar,  which is  generally a little  inflamed, and the skin above  it is
extremely tender and painful, when touched.  Langstaff (a),in noticing this con-
dition, says:—"Sometimes,  a spiculum  of bone  projects  horizontally, generally
taking the direction of the artery, vein, and nerves  of the limb, which thus become
implicated with  the bony deposit;  and  sometimes I have found a large spiculum of
bone, with  a very sharp point, taking an  oblique  direction, and connected with a
muscle, occasioning morbid changes in its fibres, and being a source of great suffer-
ing to the patient.   In all such stumps I have found the nerves greatly enlarged at
their extremities, giving them a ganglionic  appearance, and generally firmly adherent
to the surface of the stump, and frequently in union  with  spicula of bone."  (p. 131.)
In the two cases which I have had the opportunity of dissecting, there was certainly
no bony spiculum .irritating  the  nerve, and  there did not appear any satisfactory
reason why  its  enlargement should have taken place.  The tumours  seemed to be
caused by interstitial deposit  of  fibrinous  matter among the fibrils of the nerves,
which  were  principally spread out on their surface.   Astley Cooper amputated his
case at the shoulder-joint, and there was no  recurrence of the symptoms.  Henry
Cline thought that  the retraction of the  stump depended on the irritation of the
diseased ends of the nerves, and  that if these were  removed, amputation would not
be needed.   He, therefore, cut through the skin over the  swellings, also through
the nervous  trunks above them, and left the bone and other parts undisturbed.   The
result proved the justness of his opinion.  There was no recurrence of swelling of
the nerves, nor  pain, and  the stump gradually filled out, ceased to be conical, and
resumed the  ordinary appearance.  From comparison of these two modes of practice,
I should not think it warrantable to perform a second amputation at any distance
above the,stump;  I  should  be  inclined to follow Henry Cline's method;  and if
there were reason to think this could not be sa'isfatorily  managed, I should merely
amputate sovhigh above  the nervous tumours as would appear necessary to ensure
cutting through the healthy nerve.   I have an indistinct remembrance that Tyrrell
pursued the  latter practice in one instance  successfully, but I have  not any note of
it, so that I  mention it with doubt.
  Sometimes, however, neither of these methods are of any permanent service, as
the painful affection of the  nerves is not confined to their extremities.  A remarkable
case of this kind is mentioned by Mayo (b), in which, on account of this condition,
amputation was  performed a second  time.  "On examination, the seiatic nerve and
the saphenous nerve were  found to terminate in large callous bulbs.  In the second
operation, care was taken to draw out and remove a considerable portion of the sciatic
nerve, which, retracting, lay well eovered among the muscles.   Nevertheless, when
the stump had nearly healed, the old pain again commenced." (p. 140.)  He  after-
wards cut down on  the  sciatic nerve, where covered  by the  lower edge of the
m. gluiaeus maximus, divided  and removed a portion of it, but with  only temporary
benefit.  He thought that amputation  at  the  hip-joint  might possibly have cured
this, as amputation at the shoulder-joint had put an end to a similar neuralgia in the
fore-arm, which had been  unsuccessfully amputated  a seeond time.  I must confess
I should feel little disposed to perform a third amputation in a ease of this kind.—
J. F. S.]
  The following writers may be  consulted  on tumours of the nerves :—
  Viel-Hautmernil, Considerations ge'nerales sur  le Cancer.  Paris, 1807.
  Alexander, Dissert, de Tumoribus Nervorum.   Ludg. Bat.,  1810.
  Spangenberg, Ueber Nervenanschwellungen; in  Horn's Archiv., vol. v. p. 306.
   Neumann, Geschichte einer Nervenanschwellung; in von Siebold's Sammlung
seltener chirurg. Beobacht., vol.  i. p. 54.
  Weinhold, Ideen iiber die abnorme Metamorphosen der Highmorshohle, p.  184.
  Aronsohn, J. L., Observations sup les Tumeurs developpees dansle Nerfs; avec
fig. col. Strasbourg, 1822.  4to.

              (a) Med.-Chir. Trans., vol. xvi.
              (b) Outlines of Human Pathology.  London, 1827.  8vo.
f 
508
CAUSES AND
  Chelius; in Heidlb. klinisch. Annalen, vol. ii.
  Wood, William, Observations on Neuroma, with cases, &c.; in Transact, of the
Med.-Chir. of Edinburgh, vol. iii. p. 367.
  Baumeister, Dissert, de Tumoribus Nervorum.  Bonnae,  1833.
  Hasler, Dissert, de Neuromate.   Turici, 1835.
  Struck, Dissert, sistens observationem Fungi medullaris  Nervi mediani.  Gry-
phiae, 1836.
  Knoblauch, A., Dissert, de Neuromate, et gangliis accessoriisverisadjecto cujus-
vis casu novo atque insigni.  Francof. ad M., 1843.
  2405.  Cancer is a disease of specific character, depending on a peculiar
disposition, the nature of which is entirely unknown; it may be asserted
to be hereditary, in different degrees, in  one and the same person, and at
different  periods.   This disposition  is  the cause  why the treatment of
cancer is ordinarily without  benefit, why the disease appears in several
parts at once, and  why even the early removal of scirrhous swelling is
usually unsuccessful.   In the progress of the disease a peculiar dyscrasy
{par.  2394) is  set  up by the  absorption of the  matter produced  in the
diseased organ.
  Opinions upon the causal nature of cancer aie different.  Some denying a peculiar
disposition, consides cancer to be a local complaint, which, only produces a decided
dyscrasy from its spreading.  Others allow no  specific nature in cancer, some hold
it infectious, others not.  Even the assumption  of a specific dyscrasy arising out of
cancerous parts, is. denied, because  the neighbouring glands  often swell, before the
scirrhus is disposed; to ulcerate;  because, further, the glands often even when the
disease has long  existed., are not attacked, and. the experiments of the capability of
the poison of cancer to infect contradict this assumption  (a).   Many deny  the
absorption  of the cancerous ichor, and a  dyscrasy  depending  on it (b),  whilst
Langenbeck  (c)  showed microscopically the presence of cancerous matter  in  the
veins, and after injecting into the veins of a dog found tumours in the lungs, the
cancerous nature  of which was shown by m-iscroscopic examination.
  The swelling  of the neighbouring glands may indeed  be also  produced by
pressure, and by the propagated irritation.   Relapses of the disease after removal
commonly depend on what has been left behind.  In those  cases, however,  where
the scar has been for  many years, till the disease again breaks out, it is more pro-
bable that the cause of its recurrence is a decided predisposition (1).
   [(1) Upon this point John Hunter (d) observes:—"Some suppose cancers to be
hereditary; but this lean only admit according to my  principles of hereditary right;
that is, supposing a person to possess  a  strong disposition  or susceptibility for a
particular disease, the  children may  also; but I have  not  yet ascertained  the
generality of  this fact.   In many persons  it would seem that  some of the predis-
posing causes are sufficient to become the immediate ones; as when the diseased
action takes place at a Gertain stated time, without any immediate cause." (p. 623.)]
   2406. The occasional causes of scirrhus and cancer are, all mischief
which produces a  constant but  not intense irritation, blows, continual
pressure, bruises,;  irritating treatment,  or any injury  of an ulcer, a hard-
ness or an excrescence ; internal diseases, especially scrofula and syphilis,
as the consequent swellings and affections may assume a scirrhous charac-
ter.   Cancer  is- most frequent at the  critical  periods of life, when  the
capability of production declines,  and especially in organs destined for
production and propagation, as the womb, testicle, and breast.  Women
are more subject to it than  men ;  in  like  manner,  also, persons who are
very sensitive  or melancholic, lead  a  sedentary life, atnd have  suffered
much care and trouble {!}.

  (a) Alibert, above cited; p. 558.            (c) Schmidt's Jahrbucber, vol. xxv.parti.
  (6) Steffani; in Revue Medicale.  1844;    (d)  Lectures; in his  Works by Palmer,
vol. ii. p. 351.                            vol.i. 
PROGNOSIS OF SCIRRHUS AND CANCER.           509
   [(1)  "The cancerous age," says John Hunter, "is from forty to sixty in both
sexes, though  it may  occur  sooner  or later  in  certain  cases.  The testicle for
instance often become cancerous  at twenty or thirty,  but then not from the dis-
position of the part alone, but from accident.  *  *  *  We  often see tumours in
 the breast at thirty, and probably  some of them are cancerous, although scrofula is
more  to be suspected." (p. 622.)  He further observes:—"The parts most disposed
to cancer are those peculiar to  the  sexes, as the breasts and uterus in women, and
the testicles in  men.  Cancers are more frequent in women than in men, in the pro-
portion of three to two;  owing, perhaps, to the  more frequent changes taking place
in these parts in the former.  It is that change which renders them unfit for concep-
tion, and changes the whole system, which is particularly obnoxious.  Thus the
three  disposing causes are: first, a peculiar part; second, the age of the patient; and
third,  the peculiarities of the part of this age." (p. 623.)]
   2407.  The prognosis  in scirrhus  and  cancer is always unfavourable,
and proportionally so according to the importance of the organ affected,
the bad constitution of the patient, when there is  hereditary disposition,
when the symptoms accompanying cancer are very  painful and destruc-
tive,  and  when general dyscrasy has set in.   The  more superficially the
scirrhus or cancer is  seated, the less hereditary the disposition or general
disease accompanying it, the more it is the consequence of local disease,
the better  the constitution, and the more recent  the disease, the  more
favourable is  the  prognosis.   When several  cancerous ulcers or scirrhi
exist at the same time, and the cancerous dyscracy has already affected
the whole body,  the disease  is,  according  to  my present  experience,
incurable.
   Scarpa assumes that scirrhus in its first period is merely a deposited, malignant
kind of germ, which is produced in the constitution, but is developed by the  living
powers, and is most  intimately connected with any one of the conglomerate glands,
or upon any one part of either the external or internal skin, where  it  is concealed
and  remains latent; but that in cancer, the hitherto harmless and latent deposit
is converted into a cancerous ichor, and  produces general dyscrasy.  He supposes
also that the removal of the scirrhus whilst in its  painless state can aldne have a
successful result.
   [Travers has most justly observed, that "not unfrequently the scirrhous tumour
is perfectly inert from the period of its formation to the close of life, undergoing very
slight, if any,  increase, and  giving, when mental apprehension is appeased, no
trouble to the subject of it.  A lady under his observation had  been many years so
situated, enjoying uninterrupted health,  though considerably above seventy years of
age." (p. 214.)  Brodie (a) mentions one case in which the patient had scirrhous
disease of the breast for  several years, he believes ten or fifteen; and another, " who
had a scirrhous tumour of the breast twenty-five years, and she died at last, not from
the disease of the breast, but from  effusion into the cavity of the chest." (p.  211.)
Such  cases, I suspect, are more frequent than generally  believed.  I have known a
few instances, one of which  indeed was in a relative, who suffered  only occasional
slight shooting  in the breast, for at least twenty years, during which the tumour did
not increase in size  after its early growth to the size of a walnut.  So long,  there-
fore, as the disease remains in  this quiet condition, I am disposed to believe that it
is best left alone; for scarcely any, if indeed any, treatment has other effect than
exciting an increase of the diseased action, and  hurrying on the fatal result.  Very
few surgeons have any reliance in  the employment of internal and external remedies
for the cure of cancer, even when in the scirrhous state; and the large experience of
those who, in the course of operating practice, have extirpated cancerous tumours in
their several stages, has  been most lamentably unsatisfactory, the disease speedily
recurring in the 6car of the operation-wound, and the patient often quickly cut  off.—
j. f. s.]
   2408.  The  cure of scirrhus and cancer requires either the dispersion

  (a) Lectures illustrative of various  subjects in Pathology and Surgery.  London, 1846. 
510          RECURRENCE OF SCIRRHUS AND CANCER.
of the  tumour by internal and  external remedies, or its removal by the
knife or escharotics.
  [Leroy  d'Etiolles (a)  has  given the following interesting facts relative to the
treatment of cancer:—"The mean duration of the life of persons not operated on is
five years for men, and five years and  six months for women; whilst, on the con-
trary, with those who have undergone the operation, the mean is five years and two
months for men, and six years for women.   It  must, however, be borne in mind,
that the class of those not  operated on includes cancer of the  viscera, which is so
certainly and promptly, for the most part, fatal.   By  withdrawing these, the  mean
duration of men not operated on is six years, or  one  year more than in those upon
whom  the  operation has been  performed.  If, however, it be inquired, what time
elapses between the appearance ,of the disease on the one hand, and on  the other,
between the operation and death,  on taking the mean of the results of three hundred
operations  on men, the duration of  life will  be found to have been three years and
nine months before, and one year  and five months after the operation.  For women,
the result  of four hundred  and twelve operations, gives, before the operation, three
years and  six months; after the operation two years  and  six months.  Extirpation
does not, therefore, prolong life.  (pp. 454, 55.)   Of eight hundred and  one cases
operated on, one hundred and seventeen were performed in less than a year after the
appearance of the disease;  of these one  hundred and  seventeen there are sixty-one
which have returned; but as of the number eight hundred and one operations, one
hundred and twelve had been performed within less than a year, at  the time when I
received the observations  of the  physicians, we must believe that the proportion is at
the present time still greater.   If, however, we examine the results of operations per-
formed  many years after the appearance of the disease, that is, at a period in which
it was capable of producing its  degeneration, we find among the operations not
followed by return,  there  are  fifty-two performed more than  five years after the
development  of the disease.   *  *  *  In spite  of  the  transformation in similar
tissues attacked by the cancerous  affection, there are immense differences as to its
termination.  The lips  afford the  proof.  Of six hundred and  thirty-three  men
affected with cancer, one hundred  and sixty-five  were  attacked in the lip, that is
|56ff.   Of two  thousand  one hundred and forty-eight cancerous women, there  were
only fifty-four cancers of the lip, one and half hundredth.   Of one hundred and sixty-
five  men;  one  hundred  and eleven were operated on  with  cutting  instruments,
twelve by caustic.  Of the one hundred  and  fourteen operations there were fifteen
returns, or about one-eighth, when the documents reached me.  Of thirty-four lips
of women, twenty-two  were operated on, and  one  of them  with caustic, seven
returned,  or  one-third.  The   difference in  the frequency of the disease must
evidently be referred to the use of the pipe, and especially those called brule-gueule,
(dudeen of the Irish,)  which workmen and men of that class constantly use.  This
difference of the cause accounts for the difference of the results.  The return of the
disease in  men is less in proportion, because  the greater  number  of cancroid dis-
eases of the lip produced and  kept up by an external cause are not true cancers;
and yet the symptoms, the  characters of the disease do not make known its nature.
  " Cancers in the tongue  are  also more frequent in  men than in women; but the
proportion  of success we have just mentioned no longer exists here.  In both sexes
cancers of the tongue have a termination equally sad.   Of six  hundred and thirty-
three cancers observed in men, eighteen  had been developed on the tongue; of two
thousand one hundred and forty-eight cancers in women, two only attacked that
organ ;  nine operations were performed, three by caustic, six with the knife; eight
men and only one woman.   Of these nine operations, three were performed since
less than a year; six died  after its return.
  "Of tumours of the breast we have the following results:—Of two hundred and
seventy-seven operations, seventy-three were performed within less than two years;
I cannot give the  result.  There remain two  hundred  and four.  Of these two  hun-
dred and four, twenty-two died  in the year after the operation ;  eighty-seven had a
return, the  whole number one hundred and nine, or more than half.  Twenty-seven
were operated on in the first year  of the appearance of the disease.
  " If, however, I were called  on to draw a  practical  inference, a rule  of conduct,
from the documents  I have collected, I  should  hesitate to make it, for 1 believe
           (a) Bulletin de l'Academie Royale de Medecine, vol. ix.  1843-44. 
      TREATMENT  OF SCIRRHUS  AND  CANCER  BY CAUSTIC.  51.1

there are individualities in diseases as well as in other things ; but if it were abso-
lutely requisite, I should say that, excepting cancers of the  skin, including those of
the lips, it would be advantageous not to operate.  I do not, however, wish to put
myself in this situation, and at present would confine myself to the following con-
clusions,,/?^, that the extirpation of  cancroid  tumours does not arrest the progress
of the disease ; second, that there.is  no advantage in performing the operation from
the first, if it were not for the cancerous buttons, or cancerscof the skin :  third, that
it was not necessary to extirpate  cancerous  organs, but in cases where haemor-
rhagies, caused by the ulceration, put the patient's life in danger."—(p.  456-58.)]
   2409.  The treatment for effecting dispersion is precisely the  same
as  that  already given, (par. 68,) for getting  rid of  hardening.   This
mode, when not employed with  the greatest care,  is  easily dangerous;
for  true scirrhus  is  not dispersed  by it, and the  continued employment
of violent remedies destroys the  constitution, and favours the passage of
the  disease into  open cancer.   When  this  treatment,  that  is,  leeches,
blood-letting, spare diet, purging, and remedies acting on  the lymphatic
system, softening and soothing  applications have effected  the dispersion
of scirrhous swellings, there can be no  doubt of the  correctness of the
diagnosis. This mode of treatment therefore can only apply in those cases
where removal is impossible, and the cancer  has  been very tedious in
its  progress, as  in  such cases experience  has proved  that  with  this pal-
liative treatment the  disease may exist for many years  without particular
inconvenience,  whilst by an active  treatment it may be urged  on to a
frightful extent.
  Compression of scirrhus, increased gradually to  a very great degree,  as recom-
mended  by Samuel  Young (a), has been, on repeated  experiment, not found to
correspond with our expectations, but even causes a quicker and more serious pro-
gress of the disease (6).  Recamier's  more  recent experiments, however,  speak
more favourably for this practice.  It appears from his numerous observations, that
in incipient scirrhous swellings, compression can restore the tissue of the diseased
part to its natural  condition without depriving it of its  nourishment; in further ad-
vanced swelling,  the  tissue diminishes, and passes into a  cartilaginous condition.
When the  organ has lost its proper structure, and is converted  into a cartilaginous
or lard-like substance, it may be lessened  by compression, without restoring its-
organization, and  may become atrophic.   The adhesions of the swelling with  the
surrounding tissue is not only  not increased, but lessened, and even the  thin adhe-
rent skin may be restored to its natural state.   By this diminution of the  adhesions,
an actual enucleation of the tumour, after previous division  of  the  skin with escha-
rotics or the knife, may be effected with the fingers.  Recamier also  believes that
the return  of a scirrhus which has been removed after the previous  employment of
compression is less to be feared, than when it has been removed without  it.   Com-
pression may be employed in the most careful and gentle manner, and most  effec-
tually by linen or flannel bandages with soft German tinder  beneath it, and accom-
panied at the same time,  according to the circumstances of the case, with the inter-
nal  and  external  use of suitable remedies, hemlock, mercury, iodine, depletives,
repeated application of leeches, and the like (c)
  [If pressure  be at all employed in the attempt to cure scirrhous tumours, the best
mode of its application is probably by means of the circular air cushion, invented
by Dr.  N. Arnott, which can be  filled  more  or less completely, according to the
pressure the  patient can bear, and over it a sort of wooden bowl corresponding to
the  size of the part to be compressed, which is fastened  on with a  bandage.
  (a) Mi mtes of Cises of  Cancer and can-  the Cancer Establishment of that Institu-
cerou* tendency successfully treated.  Lon.  tion, vol. i. p. 4.
don, 1816-18; 2 vo:s. 8vo.                  (c) Revue Medicale. 1827 ; vol.i. p. 96.—
  (b) Charles RELL,Surgicil Observations;  Sur le Traitement du Cancer.  Paris, 1829 ;
being a Quarterly Rei>->rt of Ca«es in Sur-  H vols. 8 vo.—Bluff, Ueber die Compres-
-gery, treateJ in  the Middlesex Hospital, in  sion  beim Brustkrebse; in von  Siebold's
                                       Journal, vol. xix. part ii.  1835. 
 512   TREATMENT OF SCIRRHUS AND CANCER BY CAUSTIC.

 The only result, however, which I have noticed from pressure is, that whilst it
 diminishes the depth of the tumour, it spreads it in width, and does no real ser-
 vice.—j. f. s.]
   2410.  The removal of the diseased part with the knife, or its destruc-
 tion with escharotics, are  the  only remedies  which  can  be employed
 with the least certainty ; a return of the  disease is, however, under the
 most favourable circumstances, to  be dreaded.   Both  before and  after
 the operation it must  be endeavoured  by treatment to improve the con-
 stitution by the proper use of iodine and  the like, by purging, and suit-
 able regulation of the mode of  living, to ensure, as far as possible, a
 favourable result.   Both modes of proceeding (the knife and escharotics)
 are, on the other hand, contra-indicated  when  the cancer  has already
 made  so great progress, that it must be considered a constitutional af-
 fection, and when  so situated, that  all  the degenerated part cannot be
 removed.   The operation must also be put off', if the health of the patient
 be disturbed by other  causes, and the diseased part be particularly painful.
   The  removal  of a cancerous swelling, when  it has already made such progress
 that no cure can be expected to result from it,  may, however, in many cases, have
 the advantage of alleviating, in many respects, the sufferings of the patient, by the
 removal of the large ulcerating  tumour.
   2411. The mode of proceeding in the removal of cancerous  parts
 varies, according to their  seat  and other circumstances, and is to be
 managed generally according to the directions already for removing en-
 cysted tumours {par. 2258.)   The following points must, however, as
 far as possible, be borne in mind.  Every thing must be  removed which
 is in the least  diseased.   These  changes  mostly appear  in  the  cellular
 tissue, surrounding the hardened parts; so  much of it  must, therefore,
 be taken  away that the  tumour, after its  removal, should be  still  sur-
 rounded with a layer of cellular tissue.  The bottom of the wound must
 be most carefully examined, and every thing  infected  removed.  The
 healthy skin  must  be, as  far as possible, preserved, to  produce quick
 union  of the wound, and to prevent suppuration and an  unseemly scar.
 It seems also  advisable, always to put in  issues  previous to the opera-
 tion, and to keep them up properly.
  The practice of many surgeons, to apply an escharotic paste immediately after the
 operation, or towards the  end of the healing, (Kern,) for the purpose of preventing
 the return of the disease is unnecessary, if it have been completely removed. Mar-
 tinet's proposal of covering the wound with a transplantation of skin, for  the pur-
 pose of preventing recurrence, has also not been  confirmed by experience.
   2412.  The  destruction of a  cancerous part by  caustic can  only he
 undertaken in  cases where  the cancer is superficial, and the whole of its
 glands uninfected, therefore, especially in cancer of the skin.   The re-
 medy most used is arsenic,  in form of Cosme's powder (1);  more rarely
 are employed  bichloride  of mercury, nitrate  of silver, the concentrated
 acids,  and the  like.   Cosme's  powder must be  made into paste with
water or spittle, and  spread with a spatula  upon  the ulcer, which  has
been  dried with lint,  and to such extent, that its hard edges be com-
pletely covered ; if bleeding occur during its application, its further use
 must  be withheld.   The  whole surface  is  then to be  overlaid with
spiders' web, or left uncovered.   The pain  caused by this powder is gene-
 rally very severe for some  hours; considerable swelling  takes place in
the neighbdurhobd  of the  ulcer,  and an erysipelatous inflammation 
       TREATMENT OF SCIRRHUS AND CANCER BY CAUSTIC.   513

spreads over the surrounding parts.  Bags of aromatic herbs, or fomen-
tations of warm milk, are the best  for soothing these effects.   The more
severe these symptoms are, the more effectual may the operation of the
caustic be expected to be.  In eight, ten,  or fourteen days the slough
separates; the loose  pieces only may be cut  off with scissors, without
disturbing in the least that  which remains still attached.   When a clean
ulcer remains after  the  separation  of the  slough,  it  heals with simple
dressing;  but if it be not clean the caustic  must be repeated.
  (1) This powder consists of one ounce of cinnabar, half an ounce of dragon's
blood, one dram of white arsenic, and one dram  of charcoal, very finely powdered
and mixed.
  Among the various remedies proposed for destroying cancerous parts, chloride  of
zinc, in powder alone, or mixed with flour into a  paste, or in solution, has been re-
commended (Hanke, Canguoin, and others.)   Canguoin employs chloride of zinc
in four proportions ; first, equal parts of the chloride and flour; second, one part of
the chloride and two of flour; third, one part of chloride and three of flour; fourth,
one part of  the chloride of zinc, one part of butyr of antimony, and one and a half
of flour.   In widely spread cancer of the skin, these applications are advantageous,
as symptoms of absorption of the arsenic are not to be feared (a).
  2413. A peculiar mode  of applying  Cosme's  powder  has been pro-
posed by Hellmund (b).   The diseased parts are to be carefully cleansed,
either by washing with water, or if there be a crust, by loosening and re-
moving it  with  a spatula.   The diseased  part is then, according to its
form, to  be dressed with  pledgets  of very fine soft lint, spread with
arsenical  ointment  (1), as thick as a card.   The pledgets are to be ap-
plied singly to the different depths  of the ulcer, and very closely pressed
with the probe, so that they may be well applied, and extend beyond the
edges of the sore about two lines, or if there be only spots, upon the sur-
rounding healthy skin.   If the  edges of the ulcer be much swollen, it is
necessary to apply the arsenical ointment, first upon  them, and then  to
put on the pledget.   In this way the dressing is to be applied once a day,
and each time the sloughs must be removed.   Shortly after the applica-
tion of the ointment a burning is felt, which soon amounts to pain, that
often becomes severe.  According  to the  degree  of  pain, and  the in-
flammation in  the  immediate  neighbourhood, it must be  determined
whether the  salve  should be  made more active  by the addition  of
Cosme's powder (2), or made milder by mixing with  it resin  ointment,
On the third or fourth  day, the  pain, swelling,  and  redness  gradually
diminish; but  the  ulcer,  which has increased in  size, assumes  a  foul
appearance.  Its fungous and lard-like bottom which secretes a  sort  of
pus, begins on  the  fourth or fifth day to become putrescent, or  to secrete
a thin ichor.   On the fifth  or sixth  day, this is changed into a soft, moist
slough, which cannot be removed like the slough of an abscess, but must
be again covered with  the arsenical ointment.  According as this treat-
ment proceeds, too  rapidly or too slowly, the arsenical ointment must be
rendered weaker or stronger.   When, on  the sixth or seventh day, this
white, felt-like  slough has  been completely  formed,  the  sore must be
dressed in the  same way as before, daily, with balsamic  ointment (3),
spread as thin as the back of a  knife upon lint or linen. On the ninth or

  (a) Barraud Riofrey, New Treatment of   (b) Bretschler, Acte zusammengest;  in
Malignant Diseasesland Cancer without Ex*  Rust's  Magazin^ vol. xix. p. 55.
csion.  London, 1836.
  Vol. iii.—44 
514   TREATMENT OF SCIRRHUS AND CANCER BY CAUSTIC,

tenth day, the line of separation forms  and spreads  around the whole
slough, which on the fourteenth or  fifteenth day is thrown off", and the
wound-exhibits a healthy suppurating surface.  If this surface  retain its
healthy condition, it must be dressed, till cured, with the balsamic oint-
ment ; but  if any one part still have  a foul appearance,  the  arsenical
ointment must  be applied to it for two  or three days, and when it is in
this way brought into  a putrescent state, without a  slough being formed,
it must be again dressed with the balsamic salve.
  (1) This ointment is composed of one dram of Cosme's powder and an ounce of
the narcotico-balsamic ointment, well mixed together.
  (2) Hellmund's receipt for this powder is, two scruples of white  arsenic, twelve
grains of charcoal, sixteen  grains of dragon's blood, and two drams of cinnabar,
well powdered and mixed.
  (3) The narcotico-balsamic ointment  is made with black Peruvian balsam and
extract of henbane, half an ounce each, four scruples of acetate  of lead, forty minims
of tincture of opium, and four ounces of wax ointment, well rubbed together.
  2414. The length  of time occupied  by  this treatment  varies;  most
commonly,  however,  it  does  not  exceed  thirty  or forty  days, during
which, no particular diet is necessary.    In scrofulous and herpetic dys-
crasy, the remedies already indicated  are  employed.   In erythetic per-
sons, the inflammation and  fever  are often so great, that  special treat-
ment is requisite.   I have several times  noticed, during the use  of
arsenical  ointment,  violent  pains in the belly, and  diarrhoea,  which I
Could not, at least, ascribe to other causes.  I can confirm, from nume-
rous cases in my own  practice, the  advantageous  effect of  this mode of
treatment.  The gradual and progressive effect which may be increased
or diminished at pleasure, and  the  fact, that it can be applied  to  deep
parts and places where  Cosme's powder cannot well  be  used, are the
advantages of this  method.   In  cancer of the  skin, in eating and
sloughing spots, it  is  specially  efficient: in some  cases of cancer of the
breast, it  may be very curative; in fungous cancer, it  has not any effect
at all (a).
  2415. If cancerous degeneration appear  after  repeated removal,  or
repeated application of caustic, or if the cancer be  so situated that these
modes of treatment are not applicable,  we are restricted to the internal
and  external use of such  remedies as  specially  act, partly against the
local, and  partly against  the general  symptoms, which  arise from the
absorption of the cancerous poison.  To the former belong the internal
use  of arsenic, belladonna,  cicuta,  and digitalis,  of  cherry bay water,
mercury,  calendula,  carbonate of  iron^ hydro-chloride of gold, fucus
helminthocorton, iodide of potash, and the like-.  For external application,
weak solution of arsenic, poultices of cicuta, belladonna, digitalis, calen-
dula, of carrots with bichloride of merCury, and of yeast poultices, pow-
dered charcoal, lime water,  solutions of narcotic extracts, leeches, liquor
of ammonia diluted with water, expressed juice of onopordon acanthium,
sulphuret of potash, carbonate  or phosphate of iron,  made into a paste
with  water, and  continued  gradually  increasing  pressure.  With  this
treatment, the mode  of living must'also  be attended to>  animal food
must be avoided, and milk or vegetable diet ordered*
   2416.  In order  to  diminish the  severe pain of an  open cancer, the
(a) Chelius; 'in Heidelb. klinisch. Annalen, vol. iii. 
CANCER OF THE LIPS AND CHEEKS.
515
already mentioned narcotics, opium, belladonna,  and hyoscyamus, partly
serve.  According to my experience, a solution of sulphuret of potash, in
rose water, with the addition of extract of hyoscyamus, applied lukewarm,
on napkins, is very  beneficial for relieving the pain.
  2417. When any part of an ulcer passes into a cancerous state in con-
sequence  of  constant irritation,  improper treatment,  and the  like, a
soothing antiphlogistic treatment, as repeated leeching, warm fomenta-
tions, and  poultices, quietude, and the like, must be employed, together
with attention to the existing constitutional affection (a).
            A.—OF CANCER OF THE LIPS AND CHEEKS.

   2418. Cancer occurs only on the lower lip, at least I have never seen
 it as a primary affection on the upper  lip.   It appears either as a scabby
 or ulcerated spot, which gradually spreads, throws out fungous growths,
 and the like, or forms a hard shapeless  swelling of the lip, which enlarges,
 becomes very painful,  and breaks.   It spreads gradually upon the skin
 of the chin, the  mucous membrane of the mouth, the gums, the glands
 below the jaw, and destroys the entire lip and the bone.
   The above described twofold mode of the production of cancer of the lip has been
 proved, by numerous microscopical observations I have instituted, to be true cancer,
 and hypertrophy of the natural tissues of the lip..   In the latter, the papillae of the cutis
 were hypertrophic, and very considerably lengthened.  Whilst upon the whole sur-
 face of the papillae, a plaster of epithelial cells had been formed, which continually
 grew, and were thrown off as scales ; so was each papilla surrounded at its extremity
 with a thick sheath of epidermis, and  thus  a cylinder was formed, into which the
 base of the papilla, often capable of being drawn  like  a thread out of its sheath,
 entered.  These  cylinders, at first close  to  each other,  were  pushed apart by the
 scaling, though still held together on the  surface by a layer of epidermal scales.  In
 many cases, the epithelium formation was very great, and presented  an appearance
 nearly allied to warts and condylomata.
   Ulcers on the lips are often malignant,  without being cancerous; as the continual
 movement of the lips, and the flow of spittle and the like, prevent their healing, and
 keep up constant irritation.  Syphilitic sores on the lips often assume a malignant
 character; they mostly begin with a vesicle which bursts, and the ulceration spreads
 from  the skin to the other tissues.  Not unfrequently, also, ill-conditioned  ulcers
 are kept up by bad teeth (b).
   2419.  The  only efficient  mode of treating cancer of  the  lip  is, the
 removal of the diseased parts by cutting them out; and this is preferable
 to the use of caustic.   The  operation  is only contraindicated  when the
 cancerous degeneration has  spread considerably on  the inside of the
 mouth, the submaxillary glands and so on, which render the  complete
 removal of the disease impossible.   The mode of operating varies accord-
 ing to the extent of the cancer.
   2420.  If  the  cancer do not spread  down beyond the  red part of the
 lip, and only affect more or  less of  the edge  of the lip, it is best whilst
 holding the diseased part with the left hand, or with Graefe's entropium-
 forceps, and pulling it well up, to cut  it off through the healthy part, by
a slight sweeping cut with a pair of scissors curved towards their surface.


  (a) Henry Earle, On the influence of Local Irritation  in the production of diseases
resembling Cancer;  in Med.-Chir. Trans., vol. xii. p. 284.
  (b) Earle, above cited, p. 271.—Chelius ; in Heidelb. klin. Ann., vol. iii. 
516          OPERATION FOR CANCER OF THE LIPS.
The spouting labial arteries are to be tied or twisted, and the wound
covered with a sponge dipped in cold water till the bleeding ceases en-
tirely.   German tinder is then to be applied, and when  after three or
four days, suppuration is  set up, a linen  rag dipped in lukewarm water
should be put on till the scarring is complete.   In from ten to twelve
days a linear scar is formed by the union of the mucous membrane of the
mouth with  the external skin, in consequence of which the lip draws up,
so that in great loss of substance the alveolar process and teeth are more
or less completely covered again; but in less loss of substance there is
scarcely any noticeable depression of the lip remaining, as  my numerous
cases  have proved.   The ordinary way of removing the cancerous part
by two cuts  meeting at an angle,  causes in these cases a great loss of sub-
stance (a).
  [Notwithstanding Chelius's recommendation, I think the old method of treating
these cases with the  angular  cut is safest; the depth  to which the cut should be
made of course will depend on the extent of the disease.—j. f. s.]
  2421.  If the cancer have spread down beyond the red edge of the lip,
the whole degenerated part  most be removed by two cuts which should
meet at an  acute angle.   In doing this an assistant  steadies the lip with
his fingers on both sides, compressing the  coronary arteries at the same
time.   The operator with  the thumb and forefinger of the left hand grasps
the diseased part, lifts it up a little, places the knife upon the edge of the
lip, carries  it obliquely downwards and inwards, and then makes another
cut in the  same wray on the other side, so that  a V  shaped piece is cut
out.  Its connexion with the gums and chin is then divided, the spouting
vessels twisted or tied, and the edges of the wound brought together as
in the operation for hare-lip with the twisted suture  {par. 727); in doing
which the bleeding is generally stopped without any ligature.
   If the cancer spread from the  corner of  the mouth over the upper lip,
the corner  must  be removed with a semilunar or an  angular cut, and
afterwards the V shaped cut must be made downwards.  The wound  at
the corner of the  mouth  is first to be  brought together horizontally  or
obliquely, and then the remaining wTound readily meets.
   The extensibility of the lip, especially when  separated to a  great ex-
tent from the gums and jaw, permits its union even in cases of enormous
loss of substance, and gradually gets rid of the considerable deformity
often  at first present.
   2422. When, therefore, even in very widely-extended  cancer of the
lip there is great loss of substance, usually by close attention to the above
points, the bringing  together of the lip is  possible, and the at first much
opposed drawing together  and deformity of the mouth gradually ceases {b).
Cutting into the  corner of the mouth for the  purpose of increasing its
aperture, as by some recommended, is not only useless, but even prevents
the due extensibility of the parts concerned  by producing a hard scar.
But when the loss of substance on cutting out a cancer of the lip is  so
great  that the edges cannot be brought together, nothing remains but  to
make a new lower lip {Chiloplasty).

  (a) Richerand, Histoire des Progres recens de la Chirurgie, p. 218.
  (b) Chelius, Gelungene Lippen und NasenbUdung an dem selben subjecte; in Heidelb.
klin. Annal., vol. vi. part iv. 
OPERATION OF CHILOPLASTY.               517
  2423. The different methods  and proposals for  forming an underlip
may be  arranged in  the following  way; first,  the  Italian mode  of
Chiloplasty,  by transplanting the skin of the arm  (Ta&liacozzi, von
Graefe ;  second, the Indian mode of Chiloplasty (Delpech {a), Tex-
tor {b), Dupuytren) (c), in which a  piece, corresponding in size to that
lost, is taken from the skin of the neck, turned round and united? with
the  edges of the wound ;  third, separation of the neighbouring skin, and
adroitly bringing together the  cut and uniting it in different ways; «.
Chopart's method in which a vertical cut i-s made  on each side of the
cancer, extending down below the edge of the chin; the cancer  is then
removed with  a transversely-curved cut, the flaps  raised to  the height
of the edge of the lir> and  there  fastened, the  head being at the same
time kept bowed forwards.   The method of Roux  de St.  Maximin  (d)
corresponds  with this, as do also  those of Blandin and Serre (e), the
latter  of whom  endeavours to preserve  the  mucous membrane of the
mouth, and with it.to cover the upper edge of the wound.   /3. Dieffen-
bach's (f) method* is the following; after the cancer has been removed,
the soft parts are separated to a sufficient extent from the gums and lower-
jaw on either  side;  then, for the purpose of relaxing the  edges of the
wound, two  side  cuts are  made into the mouth itself;  or by drawing
together the  soft parts  from either side, a horizontal cut outwards being
made  at each corner of the mouth, and then a vertical cut carried-down
 to  the edge of the jaw |  \/  [„„  The two flaps: are now drawn together
 in the middle and united with the twisted suture; their outer angles con-
nected with  the corners  of the mouth, and  the upper edge sewn with
several interrupted sutures to the mucous  membrane., y. By  Blasius's {g)
method after the cancerous parts have been removed by a semilunar cut
from each corner of the mouth, uniting in an angle below the chin, a cut
 is made beginning from the right edge of the wound, about half an inch
 above theedge  of the jaw, and carried a good; thumb's breadth down-
 wards, again brought up in  a curve to the edge of the jaw, and* continued
 along it to the edge of the ni^ masseter.   This flap is now to- be separated
 from the jaw, and afterwards a like one having been made on the left side,
 both are to be drawn inwards andupwards, so that they replace the lower
 lip, and are  then  brought together with the twisted suture.  Both angles
 formed by the soft parts on the sides of the chin  are now to be dissected
 up, and so drawn upwards and towards  each other that they touch  the
 line of union  of  the  new underlip, and  the  lower  edge of the  latter is
 brought into immediate connexion with the raised skin, in which  position
 the edges of the wound are to  be kept together partly  by the twisted and
 partly by the  interrupted suture, the head being at the same time bent
 downwards.

   (a) Chirurgie Clinique de Montpellier; voT.   (/) Rost,  Dissert, de Chiloplastice  et
ii. p. 587.                      .      Stomatopoesi,   Lips, 1837.—Zeis,,  Hand-
  (6) Oken's Isis, vol.xxi.; p. 4!)6. 1828.   buch. der  plastischen Chiiurgie,  p. 419.—»
  (c) Diffb'tnite  corrigee par la transport  Baumgartkn, Dissert, de  Chiloplastice et
d'une pirtie du  corps  sur une autre;,  in  Stomatopoesi.  Lips., 1837.
 Revue  ivledicale,  1830, vol. iii. p, 283.        (g) Klinische Zeitschrift fur Chirurgie
  (d) Velpeau, Nouvi:aux Elejareas de.Me-  und Augenheilkunde, vol., i. p., 387,,  Halle
decine Operatoire, vol. ii. p. 33.           1836.—von Ammov und Baumgarten,  Die
  (e) Seu re; in Gizette Medicale de Paris,  plastische Chirurjrie nach ihren bislierigen
vol. iii.  p. 238.  1835.  No. 15.           Leistungen, p. 129.  Berlin, 1842.
                                 44* 
518
CANCER OF THE TONGUE.
  2424.  In considering these different methods and performances of Chi-
loplasty,  with the exception of the very difficult and in its consequence
uncertain Italian transplantation, it must be remembered that in the inser-
tion of a flap tprned round from the skin of the neck, as well as in the
mere drawing up of the separated flaps, the bare part of the jaw indeed
may be covered, but generally the upper edge of the skin which is firmly
connected to* the bone, puckers together, rolls inwards, irritates by the
growth of the beard, and can only assume in some degree  a natural ap-
pearance, if it be possible to stitch it to the mucous membrane of the
mouth.   These circumstances apply in  like manner, though  in less de-
gree, toBLAsius's method ;  and are most favourable  in Dieffenbach's
operation ;  but it is very bad when the side flaps on drawing together do
not meet each other, either at the corner of the mouth, or are destroyed
by gangrene.  In the closure of the side openings,  under both opera-
tions, nature is very active, and may be assisted by touching with lunar
caustic or by making little side cuts  (a).
  2425.  If the  cancer of the lip have extended to the bone or have arisen
from the  bone itself, underwhich circumstances the use of caustic, of the
actual cautery  and the like,  in general  merely increase the mischief, the
only remaining remedy is the removal of the chin first practised by Dea-
dericK and Dupuytren.  In order that this operation should be suc-
cessful, the skin must be healthy to  such distance that  it is possible to
cover the part where  the bone has been sawn off'; and the swelling of the
neighbouring glands and the signs of general cancerous dyscrasy do not
particularly forbid such  operation.   The mode of proceeding will be
hereafter considered w hen the removal  of the lower jaw is treated of. It
is further to be  remarked that in cases where the bone is not diseased, its
removal,  however, may be  requisite, for  the purpose of obtaining room
to bring the soft parts together (Roux)v,
  2426.  In cancer of the cheeks and other parts-of the face, its destruc-
tion is commonly undertaken with Cosme's powder ; where however the
seat and  nature of the  disease permits it being cut  off, that method is
most proper.
                B.—OF CANCER OF THE TONGUE.

  2427.  Cancer of the tongue commonly  begins, with a hard' circum-
scribed, swelling at one side or, other of that organ ; there is lancinating
pain ; the swelling breaks and quickly spreads with the peculiar characters
of cancerous ulceration^,  Various  swellings and ulcers which occur on
the  tongue, very often, assume a malignant appearance; the loose tissue
of the tongue, its continual moisture from the spittle, and pointed, de-
cayed teeth  very commonly keep up stubborn sores.   Not unfrequently
the  papille on the dorsum lingue enlarge and form fungous excrescences.
Syphilitic ulcers of the tongue commonly degenerate into cancer.
  2428.  The prognosis, depends  on the seat of the disease, its extent
and cause.  If an ulcer of the tongue have assumed, in Gonsequence of
continual irritation, or, improper treatment., an ill-conditioned character,
(a) ZEfcS,,abov£ cited}, p, 426. 
TREATMENT OF CANCER OF THE TONGUE.        519
it  may often be cured by proper local and general treatment;  to which
treatment the surgeon is restricted  in those  cases  of ulcerated cancer
which are beyond the reach of any operation.
   Every  irritant, every mischievously projecting, irregular, or sharp
tooth, must be  removed, the  tongue protected by covering the other
teeth with  wax, talking entirely forbidden, the  mouth often cleansed
with lukewarm  water, or a solution of extract  of hemlock with honey,
only bland food taken, and in bad cases all solid food avoided.  If the
glands beneath  the chin be swollen, or  the  ulcer very irritable, leeches
must be  applied repeatedly.   The patient should frequently during the
day hold carrot-pulp  in  his mouth,  which operates partly as a fomenta-
tion, and partly as it  has the effect of completely preventing the patient
from talking and moving his tongue.   Instead  of the  application  of a
solution  of  lunar caustic, or of dilute hydrochloric acid, three  to four
drops in an  ounce of water, and sometimes a* solution  of arsenic, as
recommended by Henry Earle (a), I  employ  mild soothing remedies
with the best effect.   Extract of  hemlock in increasing  dbses  may be
given internally.  For syphilitic  ulcers, mercurial treatment, and Zitt-
mann's  decoction may  be  employed,  and  in  other cases, the several
preparations of gold.  If by these remedies  the  progress of the ulcer
cannot be checked, it is decidedly cancerous ; or if there  be a scirrhous
swelling, the removing  of the degenerated part is necessary, provided
that no general dyscrasie disease  keep  up the  affection  of the  tongue,
that it be not degeneiated at the root, and that  the  neighbouring glands
and tonsils  be not affected.   It must, however, be remarked, in refer-
ence to the last point, that the application of many leeches at first and of
a  few afterwards, often disperses this swelling (b).
   Hevfelder (c) thinks that in scirrhous harctening' of the tip  of the tongue,
the operation may be  deferred  as long as  there is no traee of transition into
cancer.
   2429. The removal of the cancerous part  of  the  tongue is managed
in the  same  way as the operation  for  shortening a? very large tongue
[par. 2162);  it differs, however,  according to the seat and extent of the
cancerous degeneration.  The patient seated on a stool, and having his
head fixed by an assistant standing  behind him, protrudes the tongue as
 far as possible, which is  then to be held  with  the  assistant's fingers
covered  with  linen,  or  with  a  pairr of polyp-forceps,  with which the
back of the tongue  is  grasped, firmly pressed  together and  fixed; the
diseased part is to be held with the fingers,  or with, a  pair of hook-for-
ceps, a hook or a   thread passed  through  it.  The degenerated  part
being now  drawn forwards, is to  be cut off  with  a bistoury, or what  is
better with the  kneed of Cooper's scissors ;  the direction  and shape of
the cut being decided by the seat and shape of the disease.  When the
ulcer or the scirrhus is not  large,  specially if  it  be on the tip of the-
tongue,  it may  be removed! by two  cuts connected at an angle, so  that
the wound  may be brought together with suture; although  Heyfelder
holds it better not to effect the union this way, but to leave it to nature.

   (o Above ci'ed, p. 28i;              voli  ii.  p. 69.—Jaeger,  De exslirpatione
   (b)  Li franc ; in Revue Medicale 1827,   Lingua1.   Erlangen, 1832.
    (c) Ueber Zungenkrebs;  in Studien ira Gebiet eder Heilwisenschaft^voLi. p. 183*., 
520          REMOVAL  OF  THE TONGUE BY TYING.
If the cancer be on one side of the tongue, that organ  must  be divided
by a cut lengthways, and a second cut made  transversely or  obliquely
behind the degenerated  part.   If the disease  extend  far  back,  it  is
necessary first to divide  the  cut on  the  corresponding side  to obtain
more room.   If the  tongue be degenerated throughout its whole thick-
ness and far back, the cheek must  also  be first divided, and when the
tongue has been properly protruded  and  fixed, it must be  cut off with
two  strokes with Cooper's scissors from  the  side towards the middle.
The bleeding which always accompanies  this  operation must be stopped
as far as possible  by ligature, by styptics, by pieces  of ice held  in the
mouth, by solution of alum, or by the actual  cautery.   The  edges of
the wound are  then to  be carefully examined, and  every hard knot or
diseased part seized with  the  hook  or forceps, and removed with the
scissors.
  The  after-treatment must, according  to the degree of the ensuing
inflammation, be  more or  less antiphlogistic; the patient must not talk,
and only eat  mild  nourishing  broth.  When  suppuration takes place,
bland mouth-washes  must be used.   If the suppurating part assume  a
bad  appearance,  it must be  touched with  caustic, or with the actual
cautery, and  at the same time a corresponding  general treatment em-
ployed.
  After the  cure^  the  speech  is more or less affected, according  as
more or less of the  tongue has been removed;  it,  however, gradually
improves if the lost part  have not been very great.
  Fungous growths of the tongue must be cut  off at their base, either
immediately  or after the application  of a ligature around the tongue,
and the bleeding surface  touched with the actual cautery (a).
  Tying the lingual arteries (par.  1444) which has been  proposed  for the spe-
cial object of preventing bleeding in cutting off the tongue, is partly on account
of its great danger  and difficulty  in stout  persons,  improper, but  specially so,
because experience  has shown  that even in deep removal of  the tongue the
bleeding may  be stanched by ligature and other remedies.   Jaeger, for these rea-
sons, thinks it required only  in cases of considerable varicose  or aneurysmatic af-
fections of the-  tongue, or in  its total removal, when the remainder of the tongue
cannot be laid  hold of„
  2430. The remopal of the tongue by tying,  which  is  done  either with
a single ligature, or with a double thread, passed through with  a  nee-
dle, and tied on both  sides, is indeed a security against  bleeding, but
the painfulness  of  this   method,  the  inconvenience caused by the
swelling of the tongue, by its sloughing and the  like, generally leads  to
the preference of removal,  by  cutting;  cases,  however, may  occur,
where a mixed treatment may be requisite.   If, for instance,  the tongue
be diseased  far back on  one side, the diseased may he  separated from
the healthy part by a cut  extending sufficiently far  back, the diseased
mass drawn  forwards with the forceps, and  a ligature  applied  with the
loop-drawer,  at  the  root of the degeneration (6).   Otherwise, experi-
ence shows,  that in such  cases, the removal by cutting  has  favourable
results (c).
  (a) von Walther ; in his  Journal' fur  prend a  la  formation  de  la parole; in
Chirurgie und  Atigenheilkunde, vol.. v. p.  Revue M dicnle, 1832, vol. ii. p. 384.
210.—Jaeger, above  cited.—Delpech, Sur    (6) Lisfranc, above cited.
un Cas  de Cancer de  la Langue, qui a    (c) Jakger, above cited.— Reiche,  Ueber
entraine la perte tot.-.le  da cet organe, et  partielle und totale  Exstirpation der Zunge;
bui a 1'ourni l'occasion d'etudier k part qu'il  in Rust's Magazin, vol, xlvi. part ii. 
MIRAULT'S  MODE  OF  TYING THE  TONGUE.          521
  As Cloquet had previously opened the bottom of the mouth for the introduction of
a ligature, so Mirault (c) proceeded in a case, in which he had fruitlessly en-
deavoured to find the lingual artery on one side, although he had taken it up, with
difficulty, on the other, after which, the tumour diminished, but increased again.
He made a cut from the chin to the tongue-bone, directly in the space between the
m. geniohyoids, through which he pierced the tongue at the middle of its base, and
surrounded the left half with a ligature, the ends of which hung down from the neck,
and were there tied.   Afterwards he tied the other half.  If thus tied at two different
time^, the cancer may be cured without mortification of the tongue, which retains its
shape and activity.   According to Mirault, the cut into the bottom of the mouth is
assisted, if the tongue be drawn well forward with a hook, and a needle curved side-
ways with a handle, like Desault's aneurysmal needle, be thrust through the mid-
dle line of the tongue  from  above,  downwards, so that its point protrude below, at
the part where the tie  is to be made; the  one end of the  thread is now to be held
fast, the  needl6 with the other end drawn back, and then the threads tied.
  With  Mirault's, agrees the practice of Regnoli  (b) for removal of the tongue.
He made three cuts in the form of T from the lower edge of the point of the chin to
the tongue-bone, and on either side to the  front edge of the m. masseter.  The skin,
cellular  tissue, and m. platysma myoides,  were dissected off, a pointed straight bis-
toury thrust behind the chin from above downwards, the  insertion of  the m. genio-
hyoids and genioglossi were cut through, and the mucous membrane of the mouth
divided.   With  a button-ended bistoury, the insertions of the m. digastrici and mylo-
hyoids,  and  the mucous  membrane of the mouth were now cut through up to the
pillars of the soft palate.  After tying a few vessels, the tip of the tongue was seized
with Museux's forceps, and drawn  down  to the lower opening,  so that the whole
tongue was  seen on the front of the  neck, and pulled well down with the fingers.
Several ligatures were  now applied with a  long curved needle around the root of the
tongue;  the  tongue out off with a small pair of shears  in front of the ligature; its
stump returned into the cavity of the mouth, and the wound closed.   Ice was put
into the  mouth to keep down the inflammation.
   [Arnott  (c)  has  also  performed this operation for  a  malignant tumour of the
tongue of a girl of fifteen, which was as large as a pullet's egg, projected  from the
upper and under surface at its right side from nearly half  an inch of its apex to the
isthmus faucium, and protruded at the edge between the teeth.  "The head being
slightly extended, and  the os hyoides felt, an  incision was made over it, upwards and
forwards, an inch and a half in length, on the mesial line, through the  skin, cellular
substance, and raphe of the mylothyoid muscles.  With the edge of the knife, but
chiefly by its handle, way was made for the finger between the two genio-hyoid and
the two  genio-glossal muscles.   A tenaculum was next passed through the apex of
the tongue,  by means of which it was drawn out of the mouth, and held so during
the subsequent part of the operation.  Into the wound  in  the neck a strong needle,
with an  eye at the point, in a fixed handle, was now conducted and passed through
the basis of the tongue into  the pharynx a little to the left of the mesial line:  the
loop of ligature  which it carried was then, by means of a blunt hook drawn forwards
out of the mouth, and the needle withdrawn from the wound over one of  the ends.
The loop being  cut, two ligatures were obtained; one of these was placed along the
upper surface of the tongue, so as to bound the disease on its left side, and carried
through  the apex of the tongue, from above downwards, by means of a large curved
needle, through which  the oral end of the other ligature was now also passed.  Fixed
in a porte-aiguil/e, this needle was next  carried through the floor of the mouth, im-
mediately behind the last molar tooth, on the right side, directed at first, and for the
greater part  of  its course, perpendicularly downwards, then inclined mesial, and
brought  out at the incision  in  the  neck.  There were thus two ligatures, the four
ends of  which  being  out of this wound: one of the loops was so disposed as to
encircle  the  right  half of  the  tumour;  the other was  placed  longitudinally  on
the  upper  surface, of  the tongue,  longitudinally  and obliquely below.  Being
tied,  (and  this was  done   as. tightly  as possible,)  the  diseased  mass was
circumscribed posteriorly, laterally, and,  in some  measure, inferiorly.  A third

  (a) Gazette Medicale  de  Paris, vol. ii. p.    (b) Bulletino delle Scienze Mediche. Jan..
507.   1834.   August. No. 32.              1839.  No. 181.
                      (c) Med..Chir. Trans., vol. xxii.  1839. 
522              CANCER OF THE PAROTID GLAND.
ligature was now passed through  the fore  part of the tongue, so as to isolate, at
this  part, the diseased from the healthy structure." (p.  23-25.)   This proceeding
fixed the tongue in the mouth, and she became-unable to articulate or swallow.  She
was fed for a fortnight on milk by an elastic, catheter passed along the left side of
the tongue into the oesophagus.  The swelling  of the sound part of the tongue, and
the salivation which  ensued, were moderated  by active  purging.  On the second
day,  "the circumscribed portion of the tongue was black  and pulpy, and portions of
it began to  separate.   This continued until the fifth day, when, on removing some
of these, I discovered that the  sloughing was  confined to the surface, and that the
more soft part of the tumour underneath was still alive, as it bled on being scratched.
I endeavoured  to complete the strangulation by carrying a canula over the ligatures,
hanging out of the wound of the neck up towards the root  of the tongue, and tighten-
ing these afterwards by twisting and maintaining them so, but without a successful
result." * * * " On the eleventh day the diseased was  completely separated from
the sound half of the tongue by a deep trench, so as to give it a truly bifid character,
and the trench  was continued across the basis, seeming to extend through the whole
thickness of the  part.  *  * * Reunion by granulation had commenced between the
diseased and sound portions of the tongue, but this was easily broken down by the
probe.   It was now evident that the former part derived some vascular supply from
below, and  the following method was employed to cut  this off.  A loop of silver
wire, properly  bent, was passed over it from the mouth, carried and depressed into
the trench already mentioned as  surrounding it, and being drawn forwards, the dis-
eased part was found  to be placed completely above the level of the loop.  The two
ends of the wire were next passed through a double polypus-canula, and this being
carried home under the tumour, to what may now be considered its neck, the liga-
tures were tightened, the death  of  the part effected, separation ensuing on  the  fifth
day, (the seventeenth from the first operation.") (p. 23-28.)  The case succeeded
completely, and at present, Oct, 1846, she is quite well.]
             C.—OF CANCER  OF THE  PAROTID GLAND.

  Kaltschmied, De Tumore Glandulae Parotidis feliciter exstirpato.  Jenae, 1752.
  Siebold, C, Parotidis scirrhosae feliciter exstirpatae Historia.   Erford., 1781.
  -----------, (Resp. Orth.,) Dissert, de Scirrho Parotidis.  Wirceburg, 1793.
  Siebold, B., Historia Systematis Salivalis,  p. 151.   Jenae, 1797.
  Ohle, Erfahrungeri ueber die Ausrottung der Ohrspeicheldriise; in Zeitschrift fur
Natur-und Heilkunde, vol. i. part i.  Dresden, 1819.
  Klein,  Ueber die Ausrottung mehrere Geschwiilste, besondes  der Schild-und
Orspeicheldriise; in von Graefe  und von Walther's Journal fur Chirurgie und
Augenheilkunde, vol. i. p.  106.  1820.
  Kyp, (Praesid. Walther,) Dissert, de Induratione  et Exstirpatione  Glandulae
Parotidis.   Bonnae, 1822.
  Braamberg, Dissert,  de Exstirpatione Glandulae  Parotidis  et Submaxillaris.
Groning.,  1829.  4to.

  2431.  The parotid gland is  subject to a variety of degenerations of its
tissue, by which its size is increased, and a larger or smaller swelling is
produced.   It  may be the seat of induration, of a sarcomatous degenera-
tion, of scirrhus and cancer, and of medullary fungus.  Encysted tumours
in the tissue of the parotid, or in  its neighbourhood, as well as swellings
of the neighbouring glands, may  be easily mistaken for a swelling of the
parotid itself.
   2432.  The  swelling of the parotid  is characterized by  there being
always a  circumscribed tumour  between  the  mastoid process and the
ascending branch of  the lower  jaw,  which lifts the ear up, and enlarges in
a more or less  irregular, oftentimes egg-shaped or pyramidal form.   The
axis of the swelling always corresponds to a straight line, continued from 
CANCER OF THE PAROTID GLAND.
523
the mastoid process towards the angle of the lower jaw, or little deviating
therefrom,  if the swelling be not very large; and it forms a pyramid, the
base of which lies upon the ascending plate of the jaw, but its apex pro-
jects freely.
   2433. The  following circumstances serve for  the closer distinction of
the several tumours of the parotid gland.   Scirrhus forms a swelling not
very bulky, of stony hardness, irregular on its surface, having clefts and
globular projections,  almost immoveable, protruding little externally,
though it spreads rather deeply, compresses the vessels and nerves, and
declares its cancerous nature by the lancinating  pain.   Induration of the
parotid remains after previous inflammation, (par. 141,) feels less hard
and uneven than scirrhus, and shows no sign of concealed cancer.  In
sarcomatous degeneration, the swelling is softer than in scirrhus or indura-
tion, its growth is  rather quick, it  is moveable, and  may also be raised
from below.   Medullary fungus of  the parotid  forms a  swelling which
quickly attains an  enormous  size,  and  from whence,  on its bursting,
fungous growths  arise, and bleedings frequently  occur.
   2434. From the above-mentioned swellings of the parotid gland, en-
cysted tumours, which are  developed in the parenchyma, or oh the cover-
ing of the  gland  are distinguished by having mostly a roundish form and
regular surface ;  their front surface is  often compressed ; they are not
developed equally; they feel soft,  and fluctuate indistinctly.  In tumours
of the  absorbent glands, there are always several swollen at the same time,
the swellings  are softer, and there is a general appearance of scrofulous
disease.   Tumours of  the submaxillary glands are  distinguished from
those of the parotid by the seat of their development.
   2435. In scirrhus, as well as in medullary fungus of the parotid re-
moval is the only remedy, though a doubtful one.  Various means have
 been  advised for  the dispersion  of induration, as hemlock,  antimony,
 mercury,  barytes,  and iodine ;  for  external  application, mercurial,  or
 iodic  ointments,  poultices, dry bags of hemlock, hyoscyamus, belladonna,
 stramonium, softening steam of these herbs, dispersing plasters.   In sar-
 comatous  swellings  of the parotid, perhaps some  decrease may be
 effected by repeated  applications of leeches, by  issues on the tumour, or
 in its  neighbourhood, and by  a  seton  drawn  through  the  tumour.
 These means lessen  the increased  nourishment of the swelling, by the
 inflammation excited by the seton producing obliteration of the vessels,
 and the swelling is destroyed by the suppuration.   Such modes of treat-
 ment, however, can only be  employed with the hope  of a favourable
 issue,  in  cases of not  long standing degeneration of the  parotid, and
 when  it has little increased in  size.  It must, however, be remembered,
 that attempts at dispersion may  cause a  quicker growth of induration.
 When in  sarcomatous  degeneration, the vessels are  very numerous, the
 introduction  of a seton may produce great bleeding.
    2436. The removal of the parotid gland belongs to the most difficult
 and dangerous operations, and  is bymany considered totally unpermis-
 sive,  as the close connexion of the gland  with  the important neighbour-
 ing parts, renders necessary the wounding of very important vessels and
 nerves, hence the  danger of bleeding, and of  fatal nervous symptoms;
 besides, the swelling of the parotid, in  ordinary cases, is productive of 
524          EXTIRPATION OF THE PAROTID GLAND.
no danger, and is not cancerous (a).   Experience has repeatedly proved
the possibility of extirpating the parotid without the occurrence of these
accidents.
  The parotid gland is  covered wTith a  fibrous capsule; if this be not
adherent to the tumour, and if during the operation it can be spared, the
removal is far easier and less dangerous than when the capsule and tu-
mour are united.   The vessels which may be wounded during the ope-
ration  are, the temporal, anterior aural, transverse  facial,  and external
maxillary arteries or their branches, which are often considerably enlarged,
and even the  carotid artery itself, which is often  completely enclosed in
the parotid gland.   If the surgeon operate with due care, and with inti-
mate knowledge  of the parts, he may almost always avoid injuring the
trunks of these arteries; even, however, if one  or  other be  wounded,
fatal bleeding may be prevented by one or other of the under-mentioned
remedies.   Numerous twigs  from the third branch  of the fifth pair, the
communicating facial,  and from the third pair of cervical nerves  must
indeed be cut through in removing the parotid, but the trunk of the fa-
cial nerve is not  necessarily divided (6).
  The removal of a scirrhous tumour of the parotid gland is always most
difficult and dangerous, because it is firmly connected  with the surround-
ing parts,  and if any of the  disease be  left, no  cure  can be  expected.
In induration  and sarcoma the  tumour is  more moveable, the  surround-
ing capsule may  therefore be left alone, and does not at all interfere.
  Allan Burns (c) believes that in all cases where the parotid  has been held to
have been removed, it Was not the gland itself, but a diseased conglobate gland, of
which there are commonly two accompanying the parotid, the one  under the lobe of
the  parotid, and the other on its middle, and lying opposite  the division of the ex-
ternal carotid, into maxillary and temporal arteries.  The former is not so deep, and
is simply covered with the cervical fascia and the lobe  of the parotid.  Burns at-
tempted the removal of the parotid on the dead body, but even there failed  to re-
move all the diseased substance (d).
  2437. For  the extirpation of the parotid gland,  it is most convenient to
lay the patient upon a narrow table covered with  a  mattress, in  such
way on the healthy side, with the head a little raised, that the  light may
readily fall upon  the swelling.  If the tumour be  not very large, the skin
covering it not connected with it, and not diseased, an assistant  fixes
the swelling on  each side with his  fingers, thrusting it upwards at the
same time, and rendering  the skin  tense; a longitudinal cut must then
be made through the skin  from the mastoid process to the angle of the
jaw.  If the swelling be larger, a crucial cut  must be made ; and if the
skin be attached and  diseased, two semilunar cuts must be made and
connected  above and below, including the  diseased skin.  The m. pia-'
tysma myoides is to be next cut through, and all the spouting vessels tied.
The skin must now be separated  from the surface of the whole swelling;
the fibrous capsule opened sufficiently, and  the tumour shelled out with
the fingers or  with the handle of the scalpel.  The blade of the  knife
must be only used with the  greatest caution, for the  purpose of sepa*
rating the firmer  connexions.  During the  operation, an assistant  must

  (a) Richter, Anfangsgrunde, vol. ivt par.    (d) See  also Berard, Maladies  de la
401, 402.                             Glande parotide et de la region parotidienne<
  (6) Kyll, above cited.                Operations, que  ces Maladies rechmenti
  (c) Surgical Anatomy of the  Head and  Paris, 1841.
Neck, p. 267. 
EXTIRPATION OF THE PAROTID GLAND.           525
 constantly sprinkle cold water to keep the wound clear of blood, on which
 account, also, every spouting vessel should  be immediately tied.    In
 sarcoma, the substance of the swelling is often  not of sufficient firmness
 to permit it being at once shelled out with the finger; it often tears, and
 the  several parts must  be removed  piecemeal.   When the fibrous cap-
 sule adheres to  the  gland, and cannot  be freed, the separation of the
 tumour is exceedingly difficult, and  requires the greatest caution.
   2438. When on separating the swelling at  its hinder part, a very firm
 connexion of it to the carotid artery running  behind, or through its sub-
 stance,  is perceived, a  ligature may be applied round the tumour, after
 isolating as  much as possible; or the trunk of the carotid artery may be
 tied, and the removal  completed (a).   When the tumour dips deeply,
 and its close connexion  with the  carotid artery is suspected, that vessel
 may be tied some weeks before the extirpation,  which will then  be per-
 formed  with  greater safety.  In many tumours of the parotid, the ligature
 of the artery will indeed cause, by the diminution of the flow of blood,
 such decrease of the size of the swelling as to render its removal super-
 fluous (b).
   The previously tying the carotid artery, which was performed by Goodlad* (c),
 does not ensure against bleeding, which quickly follows, from the numerous anasto-
 moses and the quickly-restored  collateral circulation.  Thence Langenbeck's  (d)
 advice, when, on account of the expansion of the vessels, or the firm connexion of
 the tumour, it is scarcely possible to avoid injuring the artery, first, to lay bare  the
 artery, and include it in a ligature, which niustbe tightened if the vessel be injured,
 or the bleeding from its branches be great.  I have, however, in  one  case, where
 the carotid was closely connected with the swelling,  avoided wounding  it in  the
 total removal  of the tumour, by  which the vessel was so .perfectly exposed in the
 wound, that I could  raige it with  my fingers, and in  case of having wounded it,
 could have easily applied a  ligature.
   2439. If,  during the removal of the parotid gland, the  carotid artery
 be wounded, it must be attempted to seize it with a hook, and tie it; but
 if this be  not possible,  the bleeding may, perhaps, be   stanched  by
 pressure, with the fingers,  or by plugging, which,  at least, has been
 done on one  case  of wounded facial carotid  with success (e);  or the
 wounded part of the artery may be  compressed, and the common trunk
 of the carotid artery tied at once.
   2440. After  the extirpation is  completed,  the wound must be  pro-
 perly  brought together, the ends  of the  ligatures   carried out in  the
 shortest direction, the edges  of the  wound carefully closed with sticking"
 plaster,  and  the patient  put to bed with his head  a little  raised, and
 inclined to the diseased side.  The accidents  which may occur after the
 operation, as severe inflammation,  nervous symptoms,  after  bleeding,
 and  the  like, require the ordinary treatment.
   I have, up to the present time,  performed eight extirpations of the parotid gland,
 without any untoward accident resulting from the  operation.
   Cases of extirpation of the parotid gland are related by
   Prieger; in von Graefe und  von Walther's  Journal, vol. ii.  p. 454; and in
 Rust's Magazin, vol. xix. p. 303.
   Berendts;  in the same, vol. xiii. p. 159.
   Schmidt; in the same, p. 312.
  (a) Zang, Operationen,  vol. ii. p. 618.       (d) Biblro'hek, vol. i. p. 400.
  (6) Kyll, above cited, p. 18.              (e) Larrey, Memoires de Chirurgie Mili.
  (c) Med.-Chir. Trans., vol. vii.  p.  112.   taire, vol. i. p. 309.
1816.
   Vol. iii.—45 
526                CANCER OF THE BREAST.
  Weinhold; in Salzburger Medic.-Chirurg. Zeitung, vol. iv. p. 63.  1823.
  Beclard; in Archives Generales de Medecine, 1824, vol. iv. p. 62.
  Chelius ; in Heidelb. klin. Annalen, vol. ii. p. ii.
  Kirby, J., Additional Observations on the Treatment of certain severe forms of
Haemorrhoidal Excrescence, &c.  Dublin, 1825.  8vo.
  McClellan, G.;  in American Medical Review and Journal.   1826.
  [Randolph, J.  in  Philadelphia Medical Examiner, vol. 2.  1839.—
g. w. N.]
                 D.—OF CANCER OF THE BREAST.

  Heister, L., Dissert,  de optima Cancrum Mammarum exstirpandi Rations.
Altorf., 1720.
  Tabor,  (Praes.  Serrurier,) Dissert, de  Cancro Mammarum eumque novo ex-
stirpandi methodo.  Traj. ad Rhen., 1721.
  Vacher, Dissertation sur le Cancer du Sein. Besancon, 1740.
  Pallucci, N. J., Nouvelles  Remarques sur la Lithotome, suivies, &c., et sur
l'Amputations  des Mammelles.  Paris, 1750.   8vo.
  De Haupville, La Guerison du Cancer au Sein.  Rouen, 1793.
  Adams, Observations on Cancerous Breast.   London, 1803.
  Rcdtorffer, Abhandlung iiber die Operationsmethoden sengsperrter Leistenund
Schenkelbriiche, vol. i. p. 122, vol. ii. p. 334.
  Bell, Charles, On the Varieties of Diseases comprehended under the name of
Carcinoma Mammae; in Med.-Chir. Trans., vol. xii.-p. 713.
  Cooper, Astley,  Lectures on Surgery, by Tyrrell, vol. ii. p. 175.
  ;----—--------, Illustrations of the Diseases of the Breast.  London, 1829. 4to.
  Benedict, Bemerkungen  iiber die Krankheiten  der Brust  und Achseldriisen.
Breslau, 1825.
  Cumin, V.,  A general view of the Diseases of the Mamma, with cases of some of
the  more  important  affections of that gland;  in Edinburgh Medical  and Surgical
Journal, vol. xxvii. p. 225.  1827.
  Brodie, Sir B. C, Lectures on Pathology and Surgery, above cited.
  [PArrisH, Jos*  Observations on Affections  of the Mammas, liable to be
mistaken for Cancer, in North American Medical and Surgical Journal.
vol. v.   1828.
  Parsons,  Usher, On Cancer of the Breast,  Boylston  Prize  Disserta-
io ns.   Boston, 1839.   8vo.—g. w. n.]
  2441.  The breast-gland is most Commonly affected with scirrhus; but
in men this  occurs very  rarely.  As  to  its origin  and progress, all that
has been said generally on canCer  of glands  applies; its development
and course,  however, present some differences.
   2442.  Most commonly a  hard lump, round and moveable, arises with-
out any previous  cause, or after a  blow, a squeeze, or the like ;  as it
grows it becomes irregular and knobby; a second and  third lump is
produced,  which  seem  connected  together  by strings of  hardened
cellular tissue.   As these  several lumps enlarge, they become molten
into each other ana with the  gland, and spread  especially towards the
 arm-pit.   Passing, lancinating pains set in, which are not increased  by
 pressure, and spread towards  the shoulder, and over the arm.  As the
 swelling increases, and  the pain  becomes more severe,  they attack the
 skin, which assumes a  channelled,  scat-like appearance^ and the seba-
 ceous glands are often filled with a black substance;   The skin becomes
 attached to  the tumour, which rises  considerably at one  point, reddens,
 and thins;  the veins swell, the nipple retracts, and  instead  of a promi- 
CANCER  OF  THE  BREAST.
527
nence, exhibits a hollow.   The skin at last breaks, and an ulcer forms,
spreading in every  direction, with hard, dusky red, glossy edges,  and
having a foul, sloughy bottom, though not  with any very copious  and
offensively-smelling discharge ;  the ulcer is rather a deep  cleft, without
any fungous excrescences.  The  glands in the arm-pit,  on the collar-
bone, and the neighbourhood, swell  up, if they have not so previously.
At this time, often even earlier,  before the breast has broken, the patient
complains of rheumatic pains in different parts, especially in the loins and
thighs:  nutrition is much  affected ; the countenance assumes a peculiar
bad, earthy  appearance, the arm of the affected side swells, and can no
longer be moved from the body, and  death  follows, under the symptoms
of hectic consumption already described.
   This  form of  cancer of  the  breast  is sometimes developed with a
scirrhous inflammation, under which the whole  breast swells ;  or there
has been previous long existent hardening,  or a milk-knot, assumes the
scirrhous degeneration.
   [Brodie, divides "scirrhous tumours of the breast into two classes;  one where
there is a conversion of the gland of the breast itself into the. scirrhous structure,
there being no well-defined margin to it; the other, where there is  a scirrhous
tumour imbedded in what appears to be otherwise a  healthy  breast, as  if it were
altogether a new growth, there being a well-defined boundary to it." (p. 195.)
   The latter of these, the course of which is above described by Chelius, is the
ordinary  form of scirrhus; the former is comparatively rare, and, as. far as I  have
seen, does not pass into ulceration; but the whole gland, becomes converted into one
hard stony mass, which retains the shape of a plump, well-formed breast.  It, in
general, grows rapidly, and the glands in the arm-pit soon become affected by the
disease, and the patients powers are worn out by its malignant effect upon the con-
stitution, although it does not ulcerate.  I have, very recently, had two cases of this
kind under my care, the one I have lost sight of, but the  other is  slowly sinking
under the circumstances  I have just mentioned.  Brodie justly observes, that in
such cases- "• the operation not only never succeeds in making a permanent cure, but
rather hastens the progress of the disease.  The patient dies within two or three
years, and probably much sooner, from an effusion of fluid into the cavity of the
pleura."- (p.  195.)  I recollect having a case in which both breast* were affected
by this general scirrhous enlargement, in adxlitiioo to which nearly the whole of the
skin covering the front of the chest was closely set with scirrhous tubercles of varir
ous size; but, in this case, both, breasts and skin ulcerated superficially, and the pa-
tient died hectic, about three or four months- after the ulceration had taken place.—
j. f. s.]
   2443. Scirrhus of the breast frequently begins with a single lump at
one particular part of the  gland, and  seems to stretch itself by a string-
like process, towards the  arm-pit.  In the  increasing enlargement, the
whole gland of the breast is changed into a firm, elevated  substance; its
surface  is granular, the skin bluish-red, blackish-red, with a bluish tinge.
The tumour quickly  adheres to  the skin  and underlying parts,  and
stretches towards the glands of the  arm-pit, which  rarely fail to swell.
The ulcer has a dirty bottom*, red, hard, outturned edges, and hard knots
are felt  at various parts in and  beneath the  skin.   The secretion of ichor
in the  sore is considerable, and very ill-smelling; bleedings frequently
occur, and  death follows,  under the above-mentioned symptoms.
   2444. Cancer of the  breast not unfrequently is  developed  as  skin-
cancer.   A  lump, a wart, or a hard little mark  appears at some one spot
of the skin, which gradually reddens, and with lancinating pain, runs into
ulceration.   The  ulcer spreads, with hard edges and bottom, after the 
528
CANCER OF THE  AREOLA.
manner of skin-cancer, more on the surface, and little in depth ; it, how-
ever, extends gradually to the glands.   Swelling  of the arm-pit  glands
follows much later than in glandular cancer.
  2445.  Cancer of the areola begins with  knot-like  swelling of its little
glands, which ulcerate;  the nipple itself  is attacked and  destroyed by
ulceration.   A dusky  girdle in the skin surrounds the ulcerated parts;
the affected breast is full, round,  and elastic ; the neighbouring parts re-
main unaltered.   A fungous growth springs up from the  ulcerated surface,
which is reproduced as soon as destroyed.   If these growths be left alone,
they form a soft vascular fungus,  and general disturbance follows, ac-
companied with throbbing .pain in the breast;  but if they  be destroyed,
the irritable condition of the breast ceases.  Earlier or later symptoms
appear, which show that the constitution has become  affected; the pa-
tient  wastes,  has a yellowish,  earthy countenance, pains in  the back and
loins, and often dies, without the breast-gland being considerably affected
by  the disease.
  2446.  Cancer  of the nipple begins with a round swelling at the  root of
the  nipple, which i&  not  painful, but  is very hard and irregular on its
surface; as it enlarges.it becomes the seat of shooting, lancinating  pains,
which run from  the swelling  to the shoulder.   The nipple ulcerates, is
covered with a yellowish crust, which separates and forms afresh;  more
extensive ulceration follows, the nipple is destroyed, and a scirrhous sub-
stance  is laid bare.   The scirrhus  spreads widely round the nipple, the
pain  becomes more violent, but the diseased  part is  not  tender  to the
touch ; a crust is no longer  formed ; the ulcer secretes ichor, and  some-
times bleeds.   The  glands of the arm-pit swell, and  the usual  symptoms
of hectic consumption close the scene.
  According to. Astley Cooper (a), a fungous regeneration of the nipple begins in
the same way.  Behind the nipple, and firmly connected with it, a round, less hard
swelling than in scirrhus  forms, which is slightly painful on pressure, but otherwise
quite free from pain.  Astley Cooper also mentions a swelling behind the  nipple,
which occupies the space of an  inch, oceurfs commonly between seven and  twelve
years of age, is more frequent in boys than  girls, mostly on one side, rarely on both,
is tender, often painful when touched, moveable, and  over which  the  skin  is un-
changed.  This swelling is benignant, and yields to  dispersing plasters, and  the
internal use of calomel and rhubarb, and the like.
  [Astley Cooper gives the following account of the development  of the nipple in
the foetus, and: of its. subsequent changes:—" In both male and female infants  a gland
exists, which is the nidus of the future nipple, over which the skin in puckered into
a small projection.  This glandular substance lies concealed under the skin until
near the age of puberty, and then it gradually evolves and becomes converted into
the nipple of the adult.   In the male, the tubes through,which themilk of the infcnt
passes become ligamentous cords in the nipple of the adult; and in the female, the
similar tubes become the lactiferous ducts of the nipple.   Thus it is that the nidus
of the adult nipple is protected until the age of puberty.  It is this  structure, then,
of the male and  female  nipple, prior to the age of puberty, at the time when the
evolution of the nipple  is commencing, which  produces  the swelling to which
young people are subject, from the  age of eight years to the period  of puberty; for
when the action is greater than the evolution requires, a hard inflammatory swelling
is produced. ' It is in  this structure that, in future years, the malignant areolar ox m
mammillary tumour forms.   Here the scirrhous tubercle commences,  which de-
stroys the nipple, and ultimately extinguishes the life of the patient.  It is  in this
structure that, the fungus  swelling above-mentioned is formed.   The female is less
(<j) Lectures, above cited, p. 450. 
           SYMPTOMS OF ACUTE CANCER OF THE BREAST.      529

 subject to it than the male, because the mammillary substance is principally ab-
 sorbed, and lactiferous tubes are formed in its stead." (pp. 453, 454.)
   Brodie says :—" A scirrhous tumour may occur in the nipple; and I believe that
 this may properly be distinguished from a scirrhous tumour of the breast itself, and
 that there is a greater chance of a permanent cure from an operation, where the disr
 ease originates in the nipple, than where it originates in the breast."  (p. 201).]
   2447. The symptoms accompanying the development and progress of
 cancer of the breast are, besides those already noticed, subject to many
 varieties.   A scirrhus often exists in  the breast for a considerable time
 without causing-any inconvenience; sometimes it  is quickly developed',
 and accompanied with general affection of the constitution, which in other
 cases only appears at a  later period.   The transitipn into  ulceration is*
 often the consequence of external violence, and often of the discontinu-
 ance of the monthly discharge.   Sometimes open cancer is little painful,
 but generally highly  so; and the more  severe  the pain in  scirrhus and
 cancer, the quicker is their progress; hence may be distinguished/an acute>
 and chronic cancer of the breast.
   Acute cancer begins as  a hard lump, deeply seated in the breast, at
 first moveable, but in, one  or  two months adherent to the skin, which
 becomes discoloured.  The hardness soon affects  the whale breast, but
 only a single part  projects much, is shiny,  purple  red', and'  elastic, as if
 it contained fluid'.  The pain is very violent and shooting, as in whitlow.
 The gland of the breast does not enlarge regularly, but in separate swell-
 ings; the glands of the skin seem, enlarged, the surface is beset with little
 white points, which become more distinct  as the  tumour becomes of  a-
 deeper dusky-red:   A trickling begins on the most prominent part, which
 may lead to the expectation, of suppuration, but this does not take place.
 The scirrhus quickly enlarges, with additional redness and  increase of
 pain; the countenance-  assumes a painful, anxious expression, and the
 skin  a pale-yellow appearance ; and  great feebleness  and depression
 ensue.   The larger lumps in the skin  become.black, burst,  discharge a
 little blood, and afterwards serum.  Unawares  the- surface sloughs to\ a
 great extent, and  the breast is. deeply hollowed- by an  irregular  ulcer
 filled with black sloughs, its edges  raised and beset with lumps, which
 burst, discharge, sltmgh, and form deep, foul ulcers.   The ulceration
 spreads by the sloughing of these tubercles, and spread's incessantly ? far-
 ther and farther.
   That  kind  of breast-cancer  is considered  chronic, which, is1 dry and
 hard as cartilage; when it has acquired  a certain  size, it crumples to-
 gether, so that the swelling  presents  different clefts  from  the  skin
 being drawn  in and' wrinkled, in which the retracted* nipple is. com-
 pletely  hidden.   It  is specially  observed' in old, shrivelled women, with
 dry, tense fibre.   Sometimes  these scirrhi open by superficial ulcera-
 tion, which closes again  with a scar (a).   The pain is not  very great,
 and  the disease may exist for many  years, without making any  great
 progress.
  ["In many cases oft scirrhous. tumouTS of the breast, the skin," observes Brodie,
"is drawn or tucked in, over the tumour, so as to produce the appearance of a dimple
in it.  Where this dimple in the skin exists, you may be almost sure that there is a
scirrhous tumour in the  breast beneath it, and on examination you will feef it,witb

              (a) Dictionn. des Sciences Mpdicales, vol. iii-,. p. 555.
                                 45* 
530
TUMOURS IN THE BREAST
the finger.  *  *  *  But  on what does this appearance depend 1  In a  case
which  I dissected very  carefully, I found a narrow process or elongation of the
disease, perhaps  half an inch in length, passing from the tumour through the
adeps into the skin,  and connecting  the skin  and the tumour  to each  other.  In
fact, the dimple indicates that the disease is not confined to  the breast, but that
the skin is already contaminated." (pp.. 197, 198.)]

   2448. The interior, of scirrhus of the  breast is the  same as that al-
ready generally mentioned.  When cut  into, it  shows  an  exceedingly
hard substance, from the midst of which  white streaks  radiate, between
these  and  similar  connecting streaks, by which a fan  or net-like tissue
is formed, having  deposited between them a  soft, lard-like substance ;
in many instances  the tumour forms  a large, lardy mass, in wdiich the
white streaks  are  fewer, even  entirely wanting, and do not, as  in the
former instance, spread  indefinitely beyond the boundary of the swell-
ing (par. 2395.)   The relation of these white streaks to the tumour is
exceedingly important;  in  general they  stretch much  beyond the irre-
gular  hard lumps,  which can be felt externally.  The  retraction of the
nipple here affords an important character;  it is produced by the streaks
which originate in the  centre of  the  lump, and spread  between the
milk-tubes of  the nipple.   In  the  same way  these  streaks stretch
beyond  the  bounds   of the gland  into,  the  surrounding cellular tis-
sue {a),
   2449. Various tumours  are developed in the breast, the distinction of
which, from cancer  is, in   many instances, excessively difficult  to the
most,clever practitioner; and probably on such mistake inthe diagnosis
rest those  successful cases,,in which the  dispersion of presumed scirrhus
»has been effected by  the use of internal  and external remedies.  Such
tumours, are, «, Inflammatory affection, and painful swelling of the lym-
phatic vessels, which  run from the breast to the arm-pit; or swelling of
the breast-gland itself, in consequence of  chronic inflammation; or contin-
ued  swelling,  after  previous,  inflammation and suppuration.  /3, Milk
knots or lumps,   y, Scrofulous swellings.   $, Herpetic  and  Psoric affec-
 tions, especially, about the  nipple.  ey Encysted  tumours.   ^Steatoma-
 tous degeneration,   v, Medullary fungus.   6, Blood swellings,   i, Hyper-
 trophy- ,  A careful examination of all the  circumstances accompanying
 the origin, of  such  tumours  can  alone  direct the practitioner  in his
 diagnosis.,
    2450.  Chronic  inflammatory  affection of the lymphatic vessels, or of
 the breast-gland,,  is specially characterized by its being painful on pres-
 sure^.which is  not the case-with scirrhus.   Chronic abscesses in the breast
 sometimes form, exceedingly  slowly,  as hard  swellings, in which only
 at a late period, fluctuation is indistinctly felt ; but the soft part is always
 surrounded to  a tolerable  ex-tent with a hard swelling.  It is more readily
 mistaken as malignant,  on account of  the general health  being always
 more or. less  therewith affected;  Irritating applications  and  plasters,
  opening'the swelling, poultices, and general treatment, which improves
  the constitution,  effect the  cure.,  Benignant hardening  is commonly
  observed  in  young  people, most frequently  between  puberty and the
  thirtieth, year*  The swelling is usually  superficial, feels as if a lobe  of
(a) Charles Bell, above cited, pi. i. iii. 
LIABLE  TO  BE  CONFUSED WITH CANCER.        531
the gland were enlarged,  as if several  were united into one  swelling.
It is moveable,  has no  string-like  processes  towards  the  shoulder;
there is no pain in  the breast, shoulder, and  arm ; no injuring of the
general health ;  no affection  of the armpit glands ; and it is not so hard
as scirrhus.   The  disease is in general sympathetic with the state of the
womb, and occurs in unmarried or married women who continue unfruit-
ful.   Its occasional causes,  with previous predisposition from uterine
irritation, are often mechanical  violence,  blows,  and  the  like.   The
swelling enlarges very slowly, never becomes large, remains  long free
from  pain, and in many  cases,  only  after, years, is  accompanied  with
a stabbing, rheumatic pain.
   Dispersing  remedies,  repeated leeching, mercury,  hemlock, iodine
internally and externally,  and means which regulate the functions of the
womb and improve  the general  health, often diminish  or entirely dissi-
pate the tumour.   But if not, if the  swelling  increase, its  removal  is
indicated, and on  account of its mobility, easy ; and  it does not return.
On examining such tumour,  a number of lobes are  observed, connected
with  thick cellular tissue, which, when  cut  through,  look  like  cow's
udder.
   After  the cessation  of  menstruation, a  swelling of this  kind may
become  malignant; it  may also disappear before that period, during
pregnancy  and suckling,  although previously it has  resisted all reme-
dies.
   2451. In very  sensitive persons, between the ages  of  fifteen and
twenty, when menstruation is suppressed, or irregular  and scanty, and
the whites are present, sometimes, if the breast have received a blow or#
push, there may be very great tenderness to the touch, with  or without
swelling of one lobe of the breast-gland,  and pain running from the
breast to the  shoulder and elbow, and  not unfrequently  to the  hand and
fingers.  Previous to menstruation the swelling is greater, but after it  of
less size.  The sensibility is often so great that restlessness  and loss  of
sleep  ensue;  the weight of the breast is sometimes unbearable, even in
bed, and vomiting occurs with the severity of the pain.  The skin  of
the breast is unaltered, and without a trace of inflammation.   Sometimes
only a small  portion, and  at other times the greater part of the breast is
affected, and  sometimes  both breasts  may be  attacked at once.   The
causes of this condition  are  always very irritable  constitution and dis-
turbed functions of the womb.
   Belladonna, opium, extract of hemlock, soap  plaster, oiled silk, and
the like, are employed locally,  and in violent inflammation,  leeches.
Such  internal remedies as diminish the  excited sensibility,  and.regu-
late the functions of the womb, therefore, calomel  and  opium, and
between whiles a  mild  aperient, aqua  lauro-cerasi,  or hemlock  with
rhubarb, should be given; afterwards strengthening remedies, especially
the preparations of iron, with a corresponding dietetic regimen (a).

   [All these remedies and a  vast many others are frequently employed without the
least benefit, and patient and  practitioner  are equally tired of  the complaint and  of
each other.  Matrimony is the most agreeable and most certain cure for this most
vexatious ailment, and should be gently hinted to the patients's friends.^-j. f. s.]
(a) Astley Cooper, Lectures, 214. 
532
TUMOURS  IN THE  BREAST
   2452. Milk-knots ox lumps often present the same hardness as scirrhus.
 They always  occur during pregnancy,  or  after delivery, from whatever
 cause  can produce  inflammation of the  breast-gland, as, for instance,
 cold, vexation,  fright, mechanical  irritation, excoriation of  the  nipple,
 and the like.   At first there are either symptoms of inflammation, which
 subside, or there is not any accompanying inconvenience.   Besides these
 circumstances, milk-knots are characterized by their round smooth shape,
 and by their free mobility;  they are  generally in the middle of the breast,
 near the nipple,  well  defined, not surrounded by  any hardened  cellular
 tissue, and not  connected  by  any strings  to the neighbouring parts.
 They always  diminish  or  disappear  on the  recurrence  of  the  flow of
 milk ;  they diminish in a second pregnancy, and generally lessen when
 menstruation  comes on.
   Milk-knots have a malignant appearance in old women who have never
 been pregnant, if they occur after the cessation of menstruation,  if sub-
 ject to mechanical  injury, if connected with  gout or other general dis-
 eases.   The  swelling is  then  harder and more  irregular; the cellular
 tissue becomes hard  around the knot and is connected by strings with
 the neighbouring parts;  under  such state  scirrhous degeneration is al-
 ways to be presumed (a).
   To this place belong also those eases produced by suppression of ihe milk, or by
 rupture of the  milk-tubes, and. extravasation  of  that fluid into the cellular tissue,
 which form  fluctuating tumours, containing a very  large quantity of milk.   They
 generally begin soon after delivery, with  a swelling, which fluctuates, without pre-
 vious symptoms of inflammation and suppuration, accompanied with a feel of painful
 distention, which increases when the child sucks..  The swelling arises at any one
 part of  the breast from the nipple  to the  edge -r the cutaneous veins are enlarged ;
 out the  part  is  not  discoloured.  Scarpa (b) saw such a  tumour, which occurred
 during suckling, and from which, with a trocar, he drew off ten pints of pure milk.
 The introduction of a seton into the cavity, and its  gradual?lessening by withdraw-
 ing some threads, favours the speedy diminution and complete closure of the cavity.
 In subsequent lyings in,  the secretion of milk in the breast undergoes no alteration.
   [The disease just noticed is that named by Astley Cooper, the Lacteal or Lacti-
ferous Siuelling; and though often containing  a few spoonfuls of milk, rarely ac-
 quires a very considerable size. In 1839 I  had a case five weeks  after delivery,
 which was  thought very remarkable, as more than  a quart of rich, good milk was
 discharged by a puncture with a lancet.   As I was  fearful the aperture might close
 and  the milk eollect again, a tent of lint was inserted in the wouhtf; but in the
 course of twelve or fourteen  hours  she was violently attacked with  irritative fever,
 and when I  saw her next day was exceedingly ill.   The tent was removed, and im-
 mediately a  quantity of very fetid air escaped, and about two ounces of stinking
 milk.   She  continued very unwell  for three or four  days, and afterwards the cavity
 slowly lessened, and she recovered.,  I should certainly-never again, in a like case,
 introduce any tent, and still less should I be disposed to pass  a seton through, as
 recommended by Chelius; for the cavity having been deprived of its support by the
 discharge of its contents, is sufficiently disposed of itself to inflame, without further
 excitement.  And indeed the surgeon has sufficient to do to keep the inflammation
 under;  for I have seen, in two or three instances, when a small milk-swelling has
 been merely punctured, such inflammation eccur, that the skin covering it has quickly
 run into gangrene, and instead of one, three or four  holes leading to the cavity, and
 subsequent  troublesome  sinuses, and a spoiled breast. The only treatment neces-
 sary,  is a free puncture and soothing poultices, with purging, to lessen or get rid of
 the secretion of milk entirely, which keeps  up irritation, and by its constant flow
 prevents the adhesion of. the walls of the cavity.—j. f. s.]

   (o) See par. 149,, and Benedict, above cited    (b)  Of uscuoli di Chkurgia, vol ii 
LIABLE TO BE CONFUSED WITH CANCER.         533
  [Parker, in the N. Y. Med. Gazette for January 1842, has recorded a
remarkable case of a similar kind.—g. w. n.]
  2453. Scrofulous tumours in the breast  may be easily taken for scirrhus,
and even when they have gone into ulceration they greatly resemble can-
cerous ulcers.  The age of the patient,  the general  signs of scrofulous
disease, and especially the circumstance that usually several, often a very
great  many, of these  little  swellings may be  felt  in the breast, should
direct the practitioner.
  The treatment consists in  the employment of anti-scrofulous and such
remedies as improve the constitution, regularity of living, and the appli-
cation of dispersing plasters and rubbing.
  2454. Herpetic  and psoric affections around the nipple can produce
swelling of the nipple, and even  of part  of the breast-gland, and by the
spreading of the ulceration, may cause considerable  destruction.   The
origin bf the disease, the general state of health, and the above-mentioned
{par. 153) mode oftreatment, are the foundation of the diagnosis.
   2455. Encysted tumours in the cellular tissue of the gland of the breast
are often very difficult to distinguish  from scirrhus, especially when the
cyst is very hard  and  firm.   The marks of distinction are, the encysted
tumour has no string-like connexions as  scirrhus has, it is more defined,
rounder, firm and elastic, or distinctly fluctuating, according to the thick-
ness of the cyst.   If the cyst be thin, and the tumour near the skin, the
latter  has a bluish  colour.  The general health remains undisturbed; the
swelling is free from pain, unless there be any disposition to suppuration
in the sac.  When the fluid is emptied it is transparent as water, with a
slightly-yellow colour.  The walls of the cavity often consist of a pretty
thick  fibrous capsule,  on the inner surface of which  are red fungous ex-
crescences of different size.
  Only large tumours of this kind need  extirpation ; smaller ones, with
a thin cyst, may be punctured, and by the introduction of a slip of linen,
adhesive inflammation, and adhesion of the sac, or  its throwing off by
suppuration,  may be effected (a).
  2456. I consider that state  of  the breast-gland, commonly known as
vesicular scirrhus,  or carcinoma mamrne hydatides, as a steatomatous de-
generation of the gland.  The breast-gland, in such cases forms a very
projecting tumour, the  greater diameter  of wdiich  is  not at the base,
where it is connected with the  chest, but at some distance from it.  The
form  of this  swelling is hot globular, but quadrangular, at  some  parts
more, at others less prominent.  The  nipple  is not  drawn  in, but pro-
minent, and of the natural appearance.   At some parts the swelling feels
hard, at others tense and elastic, and  even distinctly fluctuating.  The
veins on the  surface are larger, the swelling moveable in every direction.
It may acquire enormous size, and exist many years before it bursts or
reaches the arm-pit glands.  In  one case which I saw in an unmarried
person, thirty years old, neither one nor  the other had happened.  The
swelling can easily be separated.  The result of the operation is favour-
able,  if, in course  of time, it have not passed into scirrhous degeneration.
On examining the tumour, it is found to consist of large and small
cavities, upon the unequal size of which the  irregular shape of  the tu-
              fa)  Chelius ; in Heidelb. Medic. Annalen. vol. i. 
534                   TUMOURS IN THE BREAST
mour  depends,  which  are  filled with  serous,  gelatinous,  more or less
bloody fluid,  or with a  lard-like substance, the  walls  of which  are  of
different thickness, and even of a cartilaginous nature.
  Astley Cooper distinguishes several kinds of hydatid swellings of the breast.
  " The first species of this disease exists in the form of simple bags, which con-
tain a  serous  fluid.   I should  call them cellulous hydatids ; and  the  symptoms
which  they produce are as follows :—The  breast gradually swells, and  in the be-
ginning is entirely free from pain or tenderness ; it becomes hard, and no fluctua-
tion can then  be discovered in it; it continues slowly growing for months, and
even for  years, sometimes  acquiring  very considerable magnitude, the largest I
have seen having weighed  nine pounds; but,  in other cases, although the bosom
was quite filled with these bags, yet it never exceeded twice the size of the other
breast.   At first the  swelling feels  entirely  solid, so that  it bears  a great resem-
blance to a simple chronic enlargement of  the  breast; but, after a  great  length  of
time, a fluctuation can, at one part, be  discovered in it, and then  the breast begins
to increase more quickly; and, in  several parts, similar fluctuations can be detected.
The  cutaneous veins become varicose;  but, although the breast is eminently en-
larged, it still continues almost entirely free from pain ; but to this there are excep-
tions.  *  *  *  At length one of the fluctuating portions of the breast slowly inflames,
ulcerates, and discharges a large quantity of  serum, or of a fluid having its general
character, but of a consistence  somewhat more glairy ;  and the sac being emptied,
and the external opening closed, if the fluid be entirely discharged,it is a longtime
before it re-accumulates ; and sometimes the sides  of the sac adhere, and  the cyst
ceases  to secrete.  In other instances I have known  the swelling  break and dis-
charge a mucilaginous fluid mixed with serum ; and several of the cells  in succes-
sion, and at distant periods, pass through the  ulcerative process, and form sinuses
which are very difficult to heal.  Excepting  during the process of ulceration, the
general health remains entirely undisturbed,  and the  person suffers so little either
locally or constitutionally, that her friends do not discover her malady; and nothing
would lead  her to consent to an operation for its removal  but the anxiety of mind
and the apprehension which the idea of a cancer produces, and  the  great inconve-
nience and distress which the weight of  a large  swelling  occasions  *   * *  It
is found, upon a careful dissection, that the  interstices  of  the  glandular structure
ifself,  and the tendinous and  cellular  tissue  connecting  it, are,  in a great measure,
filled with fibrous matter, poured  out by a peculiar species of chronic inflammation ;
but, in some of the interstices, a bag is formed, into which a serous, or glairy,  or
sometimes  a  mucous fluid, is  secreted, according to the  degree  of inflammation
attending it;  and this  fluid, from its viscidity, and  from the solid effusion which
surrounds it, as well as from the cyst being  a perfect bag, cannot  escape into the
surrounding tissue.   *  *   *  Vast numbers of these cysts are found  to  occupy
each part of the breast, producing and supporting  a  continued  but  slow irritation,
and  occasioning an effusion of fibrous matter, by which the breast forms  an im-
mense tumour, consisting of  solid and  fluid matter.  Within these bags of fluid,
hydatids, hanging by small stalks  *  *  *  had a  cellular tissue within them,
in which a fluid was collected, which,  although it produced the appearance of
cells, or hydatids on  the outside,  within assumed the character of anasarcous swell-
ings   *  *   *  This  disease, in  its  first stage, resembles simple chronic inflam-
mation, but may be distinguished from it by the absence of tenderness upon pres-
 sure,  and the  perfect health  in which  the  patient  remains,  stamps it to be  an
entirely local disease.  In the second stage, when it fluctuates, it is  discriminated
by observing several distinct seats of fluctuation, and  by the absence of tenderness ;
 but  the best criterion is the puncture of the bag, when the evacuation  of a  clear
 serum, instead of a purulent fluid, at once teaches the  true nature  of the disease.
 From a scirrhous tubercle  it may be distinguished  by the absence of those occasional
 acute  and darting pains which accompany  that malignant affection, by the preser-
 vation of health, and by the excessive hardness, which are concomitants of scirrhus.
 (p. 20-25.)   A further peculiarity of  this disease is, that  it does not attack  other
 parts by absorption, nor has Astlev Cooper seen it in both breasts.
   The treatment consists in puncturing it, if there  be only one large cyst, and in its
 extirpation, when the whole breast is affected ; in doing which all the  hardness
 must be removed to prevent the return of the complaint. 
LIABLE  TO  BE  CONFUSED  WITH CANCER.          535
  Second-. "The breast was, in this case, enlarged,  and, in the  greater part, hard-
ened, by the effusion of fibrin, (coagulable lymph,)  in lobes, into the cellular tissue,
but, in several parts, it contained bags of serum, and formed fluctuating  cysts  of
various sizes.  In each of these cells there hung a cluster of swellings, like polypi,
supported by a small stalk; and the little pendulous projections appeared to float in
the fluid  which had been produced around them, in the different cysts.  Many hyda-
tids were found in a  detached state, both in the fluid within the bags, and in  the
solid effusion in the  breast; and  taking the whole  tumour, vast numbers of them
had been formed in  it.  Their size varied, but the largest did not much exceed that
of a barleycorn, the  figure of which they assumed.   In general they were of an oval
form, or, I ought to say, oviform, as  they were  larger at one end  than the other.
"When opened,  they were  found  to be composed  of numerous  lamellae,  like  the
crystalline humour of the eye, or like the layers  in the onion, which could be readily
peeled from each other."  (p. 40.)   " It is doubtful if these structures are not of the
nature of globular hydatids, and which have perished from  the  pressure of solid
matter with which they are  surrounded ; or, whether they are productions or secre-
tions of the arteries of the part." (p. 41.)   They are rare, and extirpation is the only
remedy.
   Third. " The globular hydatid is contained in a cyst formed in the breast, by the
adhesive process; for wherever it is deposited, it  excites irritation, and  becomes
surrounded and encased by  an effusion of fibrin which is highly vascular;  and its
internal and secreting surface is directly applied to that of the hydatid, and a slight
moisture exists between them, they having no vascular connexion.  In the breast I
have only  seen them exist  singly, but, in  other parts of the body, great numbers
are found.  It is  a semi-diaphanous bag  filled by a clear water, and it is uniformly
smooth on its external surface.   It has no opening or inlet, so that it must derive
its nourishment by absorption from  its external surface.   It is  composed  of two
coats; the external is of  considerable density, and  if any opaque  body be placed
 behind it,  it  has the  shining appearance of mother of pearl, and reflects the rays of
 light from its surface.  It possesses a considerable share of elasticity,  and  rolls
itself up when it is broken.  This external layer is  lined by a very delicate internal
membrane, which appears to be its uterus ; for, from its interior, a multitude of small
hydatids grow, which, at first, adhere to  the membrane, but afterwards become de-
 tached, from its falling into the fluid  which the  hydatid contains.  If, therefore, the
fluid-contents of the hydatid be collected  in a glass, an  immense number of small
hydatids will be  discovered floating in them.   *  *  *  I am induced to  believe
 them to  be distinct animals: first, because they have an existence and growth of
 their own, having no vascular connexion with the part in which they are found, but
 being only encased and surrounded by a vascular and secreting cyst; -secondly, be-
 cause they have  the power  of producing upon their  interior  surface their own spe-
 cies.  *  *  *   When one of these hydatids is produced in the breast, an inflam-
 mation is  excited by it, and a Wall of fibrin  surrounds  it; it feels  hard,  and  from
 the small  size of the hydatid, ^fluctuation cannot be discovered ; but  as the hyda-
 tid grows, although the quantity of  solid  matter increases, yet as the fluid in the
 hydatid becomes more abundant, a  fluctuation in the centre of the  tumour  may be
 ultimately perceived.  Sometimes, when the hydatid has  considerably enlarged, it
 produces a suppurative inflammation ; and when the matter is discharged, either by
 the lancet, or by ulceration, the hydated escapes at the opening."  (p. 47-49.)
    Brodie (a) appears to me to have described Astley Cooper's former two kinds
 of hydatid tumours  under the name  of Serocysiic  Tumour of the  Female Breast.
 With Cooper, he agrees that " it does not contaminate either the skin or the  lym-
 phatic glands; it is not complicated  with any correspondent  disease of the viscera,
 and all the experience which  I have had justifies  the  conclusion, that if care be
 taken that no portion of the breast be allowed to remain, we need not  be apprehen-
 sive of its recurrence, (p. 154.)   It is undoubtedly not malignant in the proper ac-
 ceptation of the term.  It may  go on to inflammation and ulceration,  and the ulcer
 may spread, and slough, and  bleed, but it does not contaminate the  constitution.
 Still I am not prepared to say that it may not, under certain circumstances, and in
 peculiar constitutions, assume a malignant character; this being no more  than may
 happen  to almost any morbid growth."  (p.  156.)]
          (a) Lectures illustrative of various subjects in Pathology and Surgery. 
536
TREATMENT OF  HYPERTROPHY
  The  treatment consists in cutting into and cleaning the cyst, or in the introduc-
tion of a seton.
  This latter form only seems to admit of being held as a peculiar  state of dis-
ease, as in the others as well as in scirrhous degeneration, the formation of larger
and smaller cysts and sacs must be considered as accidental, and resulting from the
distention of certain cells.
  2457. Medullary fungus is developed either in the breast-gland itself,
or between it and the armpit, as a roundish  swelling of which the hard-
ness is not so great as in scirrhus, and  the surface is more regular.  In
its  further growth  the tumour  softens ; the skin covering it, is at first
natural, but afterwards becomes livid ;  the veins swell considerably; the
surface of the skin assumes an  inflamed  appearance, and the swelling
shows evident fluctuation.  The pain is less than in scirrhus;  the armpit-
glands swell more rarely; the nipple is not drawn in, and the skin has not
the puckered  appearance  as  if covered with scars.  When the tumour
opens, it discharges  a bloody fluid ; a fungus soon sprouts from the
opening and bleeds readily ;  a stinking ichor is secreted in great quantity.
Its progress and reaction upon the whole body is generally quicker than
in cancer.   This medullary fungus shows itself at all times of life, but it
is most common after the thirtieth year.
  2458. The blood-swelling of the female breast begins with a gradual
and moderate tumour of the breast, which in delicate women is not unlike
the distention and  fullness which occur  during menstruation,  though
greater, and  attended with more uneasy and continued  sensibility.  By
degrees a superficial  hardness is  noticed ; the  disease,  however, rarely
remains in this state more than a few days ; its  extent gradually increases
till all the neighbouring parts have a feel of softness.   In the midst soon
arises an isolated, small, but not hard swelling, nearly at the part where
at first the breast, on  slight pressure,  with the finger, was more sensible.
This first stage has an indefinite period, two, three, six, or twelve months,
during which the symptoms, after subsiding, occasionally again seem to
re-commence.   The  swelling feels like a small  conical or egg-shaped
body, which is not so distinct from the  surrounding parts that it can be
easily twisted by the  fingers ; it, however, is so loosely connected that it
can be pushed from  side to side.  The skin  is neither red nor warm;
the parts immediately about the swelling suffer dull pain, and  sometimes
an actual numbness.   The tumour is somewhat superficial, and at  the
same time causes a feel as if there were some  soft body between it and
the skin, which can  be moved  about  upon it.  The duration  of  this
second stage also varies;  the  increase of the swelling may be for years
scarcely  perceptible,  but circumstances may operate which may effect
this  in months.  Sometimes the  tumour  enlarges,  but  after  a time
resumes its previous condition ;  and whilst growing,  it always retains a
rounded form.  A diseased  condition of  the  veins is  probably  the
foundation of this  complaint,  in consequence of which, either from
repeated congestion, or from  the effect of external violence, there is an
outpouring of blood into the  cellular tissue,  and a pretty firm tumour is
formed.
  In  its treatment  the general  state of the  health must  be carefully
attended to.   In the  first stages, leeches, dispersing applications and
purgatives must be employed;  in the second, moderate  pressure, and 
HYPERTROPHY OF THE FEMALE BREAST.          537
careful evacuation of the blood by puncture.   Shelling out the sac and
removal of the breast are usually superfluous {a.)
  In consequence of a considerable determination of blood to the breast in girls
under  twenty-two years  of age, there has been noticed, a few days previous to
menstruation, a vibex or a broad streak, as of extravasated blood, with great sensi-
bility and pain, which  gradually spreads over the arm to the fingers.  Sometimes
this ecchymosis disappears a week after menstruation, but recurs more or less regu-
larly with it.   In severe cases it remains till  the  next menstruation.  It is not
dangerous, but indicates  the  necessity of regulating the functions of the womb.
The best dispersive is the application of acetated liquor of ammonia with spirits of
wine (Astley Cooper.)
  Here, also,  must be noticed, the weeping of a yellowish-white or blood fluid from
the nipple, which  sometimes appears only at the menstrual period, but at other times
continues still longer, accompanied with swelling of the whole breast, sometimes
also with several swellings  in the breast-gland, and sometimes with dragging pains.
I have hitherto seen it only in unfruitful women, or in those who are  childless,
towards the cessation  of  menstruation.  With regular living and abstinence from
all sexual excitement I have noticed this discharge, which had continued after the
menses  had ceased, gradually subside.  Only in a single^case, after the quick sub-
sidence of the discharge from the nipple, was  a scirrhous swelling of the breast-
gland produced.   Pigne observed  a like case  in a man fifty years old, in whom
from four years of age there had been regularly  every month a discharge of bloody,
watery fluid  from  the nipple, which, was more Copious  in  spring and autumn.
After sudden subsidence of this discharge, a  hard regular tumour  as large as a
pigeon's  egg was produced, which soon became the  seat of lancinating pain.  The
patient was well  for six months after the operation;  but then the scar burst, a can-
cerous  ulcer formed with  swelling of the armpit-glands, and death ensued  after
some months.  On dissection all the bones were found  softened, very flexible, and
easily cut through with the knife as is often observed in cancerous dyscrasy.
   2459. Hypertrophy of the female  breast is characterized by a regular
and painless increase  of substance, which is produced either suddenly at
the period of development, or more  slowly  at  a  later period.   Some-
times  only one, at other times both breasts are affected at once,  and may
attain  very considerable size  and wTeight, from  ten to twelve  pounds.
At first  there appears, without  any change of colour in the  skin, great
tension, but afterwards with Considerable  increase of size,  a  soft con-
dition, and only  when the finger is pressed in deeply, are the  enlarged
and hardened  acini of  the breast-gland  felt.  When this hypertrophy
occurs in later  years, it  may exist for a long  while without  any general
affection and without  any other inconvenience than its weight, as I  have
in some cases observed, in otherwise healthy  and blooming women.  If
it occur at  the  period  of  development, it generally begins  in  the  right
breast,  rarely in both  at once, with a feel  of prickling or increased sensi-
bility  ;  menstruation is  either wanting entirely, or sparing, and irregular;
but every time it appears, the  above-mentioned symptoms increase, and
the breast suddenly enlarges.   Frequently the voice  at  the  same  time
undergoes  some alteration, it becomes rough  and hoarse; this continues
often  only a  few days during menstruation, subsides and returns without
any cause being discovered.   In gradual enlargement of the breast, the
nipple becomes  flatter  and broader, its areola larger; the  swelling, at

  (a) Monro, A., M.D., Histories of Collec   servationes Chirurgiccs,  pi.  i.—Roddmann
tionsof bloody lymph in Cancerous Breasts;   J.;  in Edin. Med. and Surg. Journal, vol
in Edinburgh Medical Essays and Ubserva.   xxx. p. 1.  1828.
tions, vol.  v. p. 337. 1747.—Richter, Ob.
   Vol.  hi.—46 
538   TREATMENT OF HYPERTROPHY OF THE FEMALE BREAST.

first rather tense, softens,  and only when  the finger  is pressed  in deeply
are the  enlarged  and  hardened  acini felt.  When  the  swelling  has
acquired considerable size, the veins of the  skin swell in consequence of
which it has a bluish appearance, although the colour of the skin  itself
is unaltered.   The swelling now either remains stationary, and may con-
tinue   a  long  while, even  during the whole life, without  any further
influence on the general health;  or there may occur  in the hypertrophic
organ  further connexions, outpourings, encysted  tumours and  the like •
Or there may be with symptoms of affection of the air-passages and lungs,
dry cough, sometimes frothy,  sometimes streaked with blood, difficult
breathing, hydrothorax, hectic fever and  death.
  2460. On anatomical examination of hypertrophic breast-gland, there
is found besides the increase of substance and enlargement of some acini,
no other variation from the natural structure.  More fat is  collected in
the loose cellular tissue; the arteries are unchanged ;  the nerves, indeed,
not smaller and thinner, though backward in comparison with the size of
the breast-gland ;  the veins are always much distended, and their struc-
ture changed, and the milk-vessels swollen  and enlarged.
  2461. The cause of this hypertrophy during the period of development
is always the sympathetic relation of  the breast with the internal gene-
rative organs, which may be increased by various causes, as the use of
irritating exciting  food and  drink, irritation  of the breast by feeling it, by
libidinous excitement, by  washing and rubbing with  irritating substances
2nd the like.  At a  later  period of life, however,  I have noticed this
hypertrophy in  women, in whom the  functions of the womb were quite
regular, and no  further cause could be discovered.
  2462. The  object of the treatment is either the diminution  of  the
excessive formative activity, or the removal of the gland with the knife.
The former mode  oftreatment, which can only have a satisfactory result,
in the beginning of the  disease, when  at  the time  of menstruation, a
prickling  feel in  the breast, or  its  increase of bulk  occurs,  requires,
especially in full-blooded persons, and congestion of the breasts, bleeding
from  the feet, and internally, nitre with  camphor, vegetable and spare
diet, and the avoidance of  those influences which may excite the living
activity of the ftffected part.   With greater swelling, iodine, burnt sponge
with digitalis, rubbing in  ointments of iodide of potash or of  mercury,
and the application of cloths smeared  with camphor, leeching from time
to time, and continued pressure.  After three or four weeks a pause  may
be made, when the patient may live a  little better, and then the previous
treatment may be resumed.  The internal use of extract of hemlock in
increasing doses, and the application of camphorated hemlock plasters, I
have  found,  after previous  antiphlogistic treatment, do good service.
On the failure of these means, Fwgerhuth (a) has seen great effect from
exciting the breast-gland to  action by constant application of a milk-glass,
or of a cupping glass, as although the swelling is thereby at first increased,
the dragging and tense feel subsides,  and in the course of some weeks
the enlargement ceases with the appearance of secretion of the  milk.
   If,  in  spite of this treatment, the enlargement  of  the breast proceeds,
and if the constitution be affected, the removal of the breast is the  only

  (a) Ueber Hypertrophy der Briiste; in Hamburger Zeitschrift, vol. rii. p. 159.  1836. 
PROGNOSIS OF SCIRRHOUS BREAST.
539
remedy, and if the patient will not submit to it, the breast must be sup-
ported with a suspender, attending at the same time to the secretions and
excretions, moderate diet, and exercise in the open air.
   [Huston,  S. C, On Hypertrophy of the Mammae in Amer. Journ. of
the Med. Sciences, vol.  xiv.   1834.—g. w. n.]
   2463. That  which has been already mentioned  generally, applies to
the aetiology of scirrhus  of the breast.   Its causes may be  internal or
external.   In many instances it occurs without any manifest cause, and
the origin of the irritation of the breast may, perhaps, in many cases, be
founded on the sympathetic relations existing between the breast and the
womb.   Hence scirrhus  most commonly appears at the period of decrepi-
tude, in unfruitful women, in whom the functions of the womb have never
been properly  performed;  hence  sometimes  hardening of  the  breast
remains for a long while without any  inconvenience till the time when
the menstrual function begins to be disturbed, on which the passage into
ulceration quickly takes  place.
   2464. The prognosis of scirrhus of the breast rests on the general cir-
cumstances above mentioned.  The only remedy  is its removal, and the
earlier this is done, the  better the  constitution, and if menstruation be
still regular, the  more  favourable may the result  be  expected  to be.
Where the scirrhus is already in the state of concealed cancer, the nipple
much  drawn in, the skin less free and moveable,  the general  health
affected, menstruation irregular or entirely ceased, the result of the ope-
ration  is  indeed doubly doubtful; it  is, however,  the  only  remedy to
prevent certain breaking.  If the  scirrhus be already ulcerated, if it be
immoveably connected with all the pectoral muscles, if there be  also
hardening of other organs, no cure  is  indeed  to  be expected from the
operation; it may, however, in so far, in such case, be  considered as a
palliative, as the  patient  is at least free from  the great inconvenience
attendant on the destruction of a scirrhous tumour  by ulceration.  I have
not noticed a quicker progress of the disease after the operation, but on
the contrary, considerable relief for a long while.   The operation is easy
when there is only a single moveable knot to be taken  away, but more
difficult when the swollen armpit-glands have to be removed,  which also
render the prognosis more unfavourable.   It is self-evident that the gene-
ral circumstances already mentioned, which contraindicate the operation
for cancer apply here also.   It m,ust not be overlooked in deciding upon
the removal  of a scirrhous breast, that in the cases where  cancer has been
very slowly developed and  accompanied with  no great  pain, that after
the operation the ulceration again proceeds even quickly, and thus the
operation only hastens the fatal result.  Before the operation is performed,
an issue should be made in the arm of the affected side, and  allowed to
discharge properly, and  the generally irregular state of the  alimentary
canal should be put right.
   [The question as  to the  propriety of removing a scirrhous breast is most im-
portant; and one about which there has been great difference of opinion.  Brodir
states that "the  late  Mr. Cline, sen., and Sir Everard Home, both men of great
experience and sound judgment, would scarcely ever consent to the removal of a
scirrhous tumour of the breast under any circumstances; whereas, he has known other
very experienced  surgeons who were in favour of an  operation, even in the great
majority of cases.  And, not only has there been this difference of opinion between 
540
PROGNOSIS OF SCIRRHOUS BREAST.
different individuals, but he has known the opinion of the same individual to differ
at different periods."—(p. 193.)  Proof  sufficient this  to  show the importance of
reviewing carefully this point of practice.
   The general recurrence of cancer after  the operation, as more  especially shown by
Leroy d'Etiolle's statistics, has been already mentioned  (par. 2408 note;)  let us
now see how it applies to cancer in the breast.
   Having a vague recollection of hearing Sir  Astley Cooper mention the very
small number of cases in which cancer of the breast did not  recur after the numerous
operations he had performed for its extirpation, I took the opportunity  of  inquiring
of my friend Bransby  Cooper, whether he could afford me any  positive information
of his  uncle's experience on this point.  His reply  is:—"I cannot find anything
relating to the query you put to me, respecting the statistics of his (Sir Astley's)
success, but have  a recollection  of  something like  your own  impression, that he
acknowledged not more than nine or ten  out of the hundred extirpations he had per-
formed did not return, and generally within three years at farthest."
   Brodie says:—"In the larger proportion of cases in which  the operation is per-
formed, the patient is not alive two or three years afterwards ; and in a great many
cases, instead of the operation stopping the disease, it actually seems to hasten its
progress."  (p. 192.)   This statement fully bears out that of Leroy d'Etiolles.
   Brodie then at length proceeds to mention the circumstances under which scirrhous
tumours are not likely to be cured by operation, and in which, therefore,  it is im-
proper; and these  are briefly  pointed out  by his enumeration of the conditions suit-
able for the operation, in his reply to the question,  "What are the cases, then, in
which  the removal  of the breast is proper?"
   " Where, on careful examination, no appearance of disease can be detected in the
skin ; where there is no dimple in the skin over the tumour ; where there is no dis-
eased gland in the axilla; where there is  no sign of internal mischief;  where there
is no adhesion of the breast to the parts  below; and where  the patient is  not very
much advanced in life ;—in a case where this fortunate combination of circumstances
exists, we may presume that  there is a reasonable chance of an operation being suc-
cessful.  Still, I must not be misunderstood, as  saying, that in every  one of such
cases there will be a permanent cure; nor do I say more than this, that the chance
of a cure is sufficient to warrant you in recommending the patient to submit to  an
operation;  and that I have the satisfaction of knowing several persons on whom I
have performed the operation under these circumstances, who are now alive and
w:ell, and who, otherwise, would certainly have been dead long ago." (pp. 199,200.)
He then mentions  two cases; in the one, the patient was operated on fourteen, and
the  other thirteen  years since, and  both  are  at present  (1845) in good health.
Bransby Cooper informs me, that he had " removed the undoubted-malignant breast
of Mrs.------, and it was eleven years and a half before it returned in  the cicatrix,
and then killed her."  In the summer of 1836, I removed a scirrhous tumour in the
breast  from a woman  of sixty-one years of  age, its size that of a small  bean, which
had been discovered only two months.  In  this case there has been no recurrence of
the disease, and the woman has been and still  is in good health.
   The most remarkable case, however, of which I am aware is one operated on  by
my friend Callaway, and this  woman was not destroyed by the disease till twenty-
two years after the operation.
   Notwithstanding these few favourable  instances, surgeons should be cautious in
urging a patient to  submit to  an operation for a scirrhous tumour, and still less, when
it has  become a cancerous sore, and the  neighbouring glands  in either case  have
become affected.   He cannot promise a cure by  the operation; nor can  he even say,
that the patient's condition will not be made worse.   I have often heard it stated,
that though the operation will  not  cure, it will  put off the evil day, and retard the
ulcerative process; but this I do not believe, for I have known many instances to
the contrary.  The only thing  that an operation can do, is  temporary  palliation, if
the patient be subject to severe shooting, stabbing pain, which is not  indeed very
commonly the case, unless the disease be worried by local  attempts to cure.  The
practitioner ought, when  consulted under these circumstances, to break to the patient
cautiously the nature of her complaint; should inform her that all which can be done
by operation is  at best  merely palliative; and  should  leave  her to  decide  upon
whether she will yield herself  to  the operation, knowing the risk and the slender
hope connected with it; rather than urge  her to an operation which is without doubt, 
EXTIRPATION OF SCIRRHOUS BREAST.           541
as regards  scirrhous  swellings, the  most unsatisfactory in the whole course of
surgical practice.—j.  f. s.]

   2465. The removal of a scirrhous breast is effected either by extirpation,
leaving, however,  a sufficient quantity of skin to coyer the wound, or by
amputation, that is, taking off the tumour at its base.
   2466. Extirpation of the  scirrhous breast is generally performed in the
same way  as the removal of an encysted  tumour.   The patient lies upon
a table (1), or is seated in a chair, and whilst an assistant makes the skin
tight,  the   operator makes  two  cuts  extending from the  breast-bone
towards the shoulder, which should include the nipple and a large portion
of skin, so that the two  folds of skin should be sufficient after the opera-
tion to cover the wound.   The lower flap-of skin must be separated from
the swelling, which is then  to be taken hold of with the fingers or with a
hook, lifted up, separated from the pectoral muscle, and  afterwards from
the upper flap from within outwards,, or from without inwards ; and wTater
is to be sprinkled on the wound to keep  it clear of blood.   The bleeding
vessels must, during the operation,  be compressed by the fingers of the
assistants,  and after its  completion,  tied (2).   The wound" must then be
cleansed,  carefully examined,  and  every diseased* part  seized1 with  the
hook  or forceps,  and  removed.   The  edges  of the  wound*  are  to  be
brought into perfect contact, and* fastened with sticking plaster, lint and
compresses  applied, and'  the whole  supported with a  broad breast-
bandage (3).   The after treatment is according to the ordinary rules.

   [(1), The horizontal posture  on:a table  is preferable to sitting in a chair, because
the patient  can be more completely steadied, and also because there is  much less
chance of her fainting; for if, as sometimes happens, there be a large escape of blood,
she faints so completely that the-operation must be delayed till she be restored.
   (2)  If the scirrhous tumour involve the whole breast, and be very large, with full
swelling veins, the operator must carefully  look to the  bleeding, and I think, tie at
once either arteries or veins, which may pour freely, as  in a very few minutes very
serious and even fatal consequences may ensue; ofsuch a case I have a very painful
recollection.  I operated many years since upon an, elderly woman who had an
enormously large scirrhous breast, and the veins of the  skincovering.it were much
swollen.  Before the operation I feared there would be severe  bleeding, and pro-
posed' taking up the vessels as they were cut through during the  course of the ope-
ration, but  this was  overruled, and  pressure  with the fingers was-determined on,
leaving the  vessels to be tied  after the  operation.  The bleeding was.terrific, and
poured from so many veins.that it was not possible to grasp and.close them.  The
operation was not tedious, but I had hardly removed the swelling before the woman
had died.  A lesson  not to be forgotten.
   (3)  The less dressing the wound of the operation is subjected to the  better; and
it is certainly advantageous not to dress it immediately, for many little vessels
which have ceased bleeding whilst exposed, and the patient is faintish, burst forth,
often furiously, when the wound has been brought-together at once, and the patient
gets warm  and has the circulation restored, so that in the course of two or three
hours, the  whole ca.vity formed by the removal,of  the breast, becomes distended
with blood, and then  the bleeding, makes its way through the plaster,,the patient is
drenched in Wood, and instances have not been wanting in which her life has been
lost in consequence., It is, therefore, better always to leave the wound'.open for a
few hours,  and lightly covered  with  merely a piece of linen, not lint, the fl'uff of
which  sticks  to the  wound, and cannot be got off without  great difficulty, and
indeed not  then even completely, so that it prevents adhesion, and is only thrown ofi
by the establishment  of suppuration,  which  is not desired.  Neither  is the linen to
be jammed and kneaded into every crack and cranny of the wound, and left there for
hours, as if it be, the  adhesive matter soon- glues it fast to the surface of the wound,
and  it  can  only be  removed with  great difficulty and pain to the patient, which is 
542            AMPUTATION OF SCIRRHOUS BREAST.
quite  unnecessary.  The linen is merely to be moistened with cold water, laid
lightly over the wound, and replaced every ten minutes,  or thereabouts,  till the
bleeding  ceases.  Any vessels which bleed, must be taken up as they are found,
and after  four or six hours, the  edges of the wound must be gently drawn together,
and retained in place by long strips of plaster, which should be half an inch apart, to
allow  the escape of the serum as it separates.  A wet piece of linen may also be
advantageously laid over the strapping, and  repeatedly changed, which quiets the
arterial action of the part, and keeps down inflammation.  I never put on compress
or bandage at the  first dressing.  With this mode of treatment, the wound rarely
requires dressing before the fourth or fifth day,  when a poultice should be applied
for a few  hours, to soften the strapping, and facilitate its removal.  If soon after the
operation the breast become tender and inflamed, a light bread and water poultice,
without disturbing the  dressing,  is  very grateful to  the  patient's  feelings, and
encourages suppuration at any parts disposed to that process, after which the inflam-
mation quickly subsides.  The principal use of a roller round the chest is  to keep
the skin  close  to the  muscle beneath, so as to prevent the pus bagging, if the two
surfaces  have  not completely united.; and under  such circumstances, compresses
may also be requisite at any period of the healing of the wound.   But as a  general
rule, the lighter and less the dressing is, the better the  case proceeds.—j. f. s.]

   2467. In  amputation of the breast, the skin  must be divided by two
cuts carried around the base of the tumour, which must be detached from
the pectoral muscle from below  upwards.  This method is at least more
sure to save the skin than removing the swelling, by one or more strokes
with  art amputating-knife,  or than  by  the method recommended by
Galenzovsky, of  drawing the  knife upwards  (a).  When  the  vessels
have been tied,  the wound must be filled  with lint, and this fastened with
sticking plaster and  a  bandage.  When the   granulations  have  risen
equally  over  the  wound,  its edges must be  attempted  to be  drawn
together with sticking  plaster,  to favour their scarring.  The  wound
should be dressed only with lint, without,  digestive or other applications,
and only towards the end of the treatment, with narcotico-balsamic oint-
ment.
   Benedict (b) considers moistening  the wound with tincture of opium, and a
dressing  of opium ointment, as the best  means to  prevent return of the disease.
Experienae, however, speaks as little in favour of this practice as  for the trans-
plantation of a flap of skin, recommended by others.
   [I do  not think amputation is to be preferred  to  extirpation  of the  scirrhous
breast, unless it be so large, or the skin so extensively diseased,  that it cannot be
avoided.  But  I have seen  amputation occasionally performed, and it is remarkable
how quickly and how completely a large wround  thus made fills and draws together;
but what the issue of-such,  cases has been I do not know.-r-j. f. s.]

   2468. Opinions vary  as to the preference of extirpation or amputation,
as well, also,  as to healing the wound by  quick  union, or  by  suppuration
and granulation.  Extirpation and quick  union  are  generally held to be
the  most  preferable  mode of treatment,  because   the  cure  is thereby
effected most quickly, a regular scar is formed,  and the wound is not so
long  subject  to  irritation  as  in  suppuration,  which,   under  existing
disposition;,, more readily  leads  to  scirrhous  degeneration.  But it  is
supposed  that, as the ligamentous white  strings so commonly extend in
the cellular  tissue beneath the  skin, beyond  the bounds of the tumour,
and  even are still left by the  most cautious  extirpation,  amputation
must have the  preference, at least when the skin,  though only at some

         (a) von Graefe's und von Walther's Journal, vol., xii. p. 606.
         (fr) Above cited. 
CANCER OF THE PENIS.
543
spots, is not quite moveable, or even degenerated, and the nipple much
drawn in.   That recurrence of the disease is more ready from the irrita-
tion accompanying the cure  of the wound by suppuration, I must from
experience deny:  as  I have  certainly seen,  by this  plan of treatment,
with simple and  proper management  of the wound, more successful
results than after extirpation and quick union.
   After the removal of the scirrhous breast, the surface should always be
carefully examined and considered, whether it be covered with a layer of
healthy cellular tissue, or whether there be any trace of the divided liga-
mentous strings remaining, under which circumstance  the still remaining
parts must be taken away with the greatest care.
   2469. Swollen armpit-glands, if superficial and moveable, may some-
times be removed; for which purpose a hook is thrust  into the outer
corneg of the wound, and the gland drawn forth.   This, however, is never
advisable;  it is best  to lengthen  the cut from the outer corner of the
wound  into the armpit, because there are, in most cases, stringy hardenings
along the edge, and even under the great pectoral muscle,  which must
be removed.   The vessels are to be tied  as the gland  is shelled out.  If
the seat of the  gland be  so  deep, that it cannot be  extirpated without
danger of wounding the vessels, the gland must be separated as near as
possible to its base, pulled forcibly down, and a ligature put around it.
   When the armpit-glands are swollen they must be removed, although in many
cases the swelling is benignant, and seems to be merely sympathetic (a).
   2470. Separate and  moveable lumps in the  breast may be managed
with a simple cut, and shelled out.  Though most practitioners give the
better advice of removing the whole breast.
   If the cancerous degeneration have extended  to the ribs ani: pleura, the diseased
parts should, according to Richeran (b), be cut out.
   2471. If the wound do not close perfectly, if several  parts have an ill
appearance, or if a scirrhous swelling spring afresh from the  scar, it
must either be destroyed by caustic, or stilt better, be removed with the
knife.
   When the wound has scarred, it should be covered with a soft rabbit's
skin, the patients mode of living attended to, and issues kept up.
                  E.—OF  CANCER  OF THE PENIS.

  Pallucci, N. J., Nouvelles Remarques sur la  Lithotomie suivies de plusieurs
Observations sur la Separation du Penis, &c,  Paris, 1750.   8vo.
  Loder; in his Chirurgisch-Medicinische Beobachtungen, p. 79.
  Richter, Dissertatio de optima, membrnm virile amputandi methodo.  Konigs-
berg.  1804.
  Thaut, Abhandlung uber den gesunden und kranken Zustand des mannlichen
Gliedes.  Aus dem Latein.  Mit Zusatzen, von Eyerel.  Wien, 1815.
  Siebold; in his Chirurg. Beobachtungen, vol. iii. p. 349.
  Schreger; in his Chirurgische Versuche, vol. i. p. 212.
  Biener,  Dissertatio de Exstirpatione Penis per ligaturam.  Lipsiae, 1816.
  Dzondi; in Beitrage zur Vollkommung der Heilkunde, vol. i.  Halle, 1815.
  (a) Klein, Chirurgische Beobachtungen,  sur le danger de la Resection des C6tes et
p. 263.                               de l'Excision de la Pleura  dans les Mala-
  (b) Histoire d'unc Resection des C6tes et  diesCancereuses. Paris,, 1818.
de la Pleura. Paris, 1818.—Nicon, Dissert. 
544
CANCER OF THE PENIS.
  2472. Cancer of the Penis begins almost always on the glans or on the
prepuce, in a hard knot or wart, generally at  first unaccompanied  with
pain, but when it is irritated, or of its own accord it becomes painful, and
runs into ulceration, which is  accompanied with  an  ichorous, stinking
discharge, and  with  a hard  swelling  of the neighbouring  parts.   The
urethra is often destroyed  at different parts, and  the  urine flows  from
many  openings; the  neighbouring  glands in the  groins are affected.
Persons who have  the  prepuce long, and a collection of cheesy matter
upon the glans from want of cleanliness, are  most frequently attacked
with  cancerous degeneration; and the  prepuce  inflames,  excoriates,
swells, thickens, and narrows still more.  Ulceration increases on account
of the  difficulty  in passing the water; the aperture  of the prepuce some-
times closes completely, and the urine  flows through several openings in
the destroyed prepuce,  which may often be degenerated to a  great extent
before  the  disease has  attacked  the glans.   In  aged  persons cancer
most commonly begins,  in the way just mentioned, upon the prepuce,
because, by the retraction and wasting of the penis, the orifice of the
prepuce is more influenced by the discharge of the urine.
   The diagnosis of cancer of the penis requires  the greater  care, as not
unfrequently syphilitic  ulcers assume a  cancerous  appearance,   with
fungous growths, hard  out-turned edges, and  lancinating pains, accom-
panied with  swelling of the  neighbouring glands; in  which  case  only
the ordinary mercurial  treatment, in connexion with sedative remedies,
is requisite {a).
   2473. When the disease has arisen from a narrow prepuce and want of
 cleanliness, in the  early  period further destruction  may be prevented by
purifying injections, by softening poultices, by drawing off the urine with
a catheter constantly worn, or by the operation for  phimosis (b)  If the
warty excrescence have a neck, it may sometimes be  easily removed
from the base.   Sometimes the cancer only attacks the  prepuce, without
the glans itself being affected, under which circumstance the removal of
the prepuce is sufficient.  If the cancer be already on the glans, and spread
further, amputation of  the penis is the only remedy.   This  operation is
in general more successful  than the removal of cancer from other parts,
but an important point  is, that the testicles, the skin about the pubes, and
the ingiunal glands should be free from hardening.
   [The observations I have  made as to  the recurrence of this disease certainly do
not confirm Chelius's statement of the successful result of amputation of the gent's,
even in the early stage, as the disease almost invariably returns.  I  remember one
very remarkable case, in which, under favourable circumstances, the younger Cline
removed the whole.penis as low down as  the membranous part; by detaching it as
far as possible from the pubic bones in front of the scrotum, and then making  a cut
into the perinaeum, he turned the penis down through  it, and completely scraped off
the crura to their very origins from the  bones, and removed  them and the bulb,
leaving only the membranous part of the penis ; but the wound in a few weeks took
on  a  cancerous  disposition, spread quickly,  and destroyed the patient probably
quicker than if he had been left alone.—j. f. -s.]
   2474.  Amputation of the penis is performed  either by the knife or by a
ligature.   Previous to the operation'  the glans should be carefully  exa-
mined, to ascertain whether the prepuce, alone  be affected.   As much as
        [a) See my Bericht uber die Einrichtung der chirurg, Klinik, u. s. w.
        (b) Earle; in Med.-Chir. Trans., vol. xii. p. 289. 
AMPUTATION OF THE PENIS.
545
possible of the penis should always be preserved, as thereby the discharge
of the urine is rendered easy, and  even connexion itself is still possible.
   2175.  Amputation of the penis  by the knife varies, as it is performed
near the hinder part of  the glans,  or in the middle, or at the root of the
penis.
   2476.  In amputation of the glans alone or near its hind part, an assistant
grasps the penis, behind the diseased  part, with his thumb and finger, and
draws the skin back.   The  operator then takes hold of the fore part of
the penis, which should  be wrapped in linen, draws it a little towards him
and cuts it off' at a stroke with a small amputating knife through the
healthy part.   The bleeding vessels are then to be tied, and the weeping
of the blood from the spongy bodies stanched with cold water, and after
the wound has been cleansed, a  silver catheter or piece of elastic catheter
is to be  introduced into the urethra, and the edges of the wound closed
from  above downwards with sticking plaster.   Some wads of lint are
then to be put over it, and  a Maltese cross bandage fastened over it with
a  narrow  bandage.  The tube  in the urethra  must be fixed by tapes
through  its eyes.
   2477.  If the penis  be amputated in the  middle, the assistant and the
operator grasp it behind and before  the  part where it is  to be cut off',
without drawing the skin either backwards or forwards.  The rest of the
proceeding is as in the former case.
   2478. In removing the penis near the pubic bones, Schreger has recom-
mended  the cut to be made  with repeated strokes, to prevent the retrac-
tion of the stump, and render the application of the ligatures more easy.
An assistant presses up the  bulb from the perineum forwards towards the
pubic angle, and then, the operator having  first drawn  the penis and the
skin forwards, divides the skin upon  the dorsum penis and ties the dorsal
arteries ;  after malting the second cut, he proceeds in the same way with
cavernous arteries of the penis, and after the third, with the cavernous
arteries of the urethra,  and the bleeding having been thus stanched, the
remainder of the  penis  must be cut through.  The dressing is to  be
made as already directed.    If the  bleeding from the spongy bodies can-
not be stopped by sprinkling with cold water, the wound must be sprinkled
with  some styptic powder,  covered with lint, and this fixed as already
directed.
  Langenbeck (a) proposes to prevent  the retraction of the penis in the following
way:  he cuts through the dorsum penis  so deeply into the cavernous bodies, that he
can see their white edge and the septum ; a loop is then drawn through both, and the
penis completely cut through.   The ligature serves to keep the stump steady, and to
draw it forwards.
  To prevent the retraction and drawing together of the urethra, Barthelemy (b)
advises introducing  an elastic  catheter, which is to be bent down by an assistant
beneath the arch of the pubes, and then the pern's and catheter to be cut through.
   2479.  Of the  accidents  which  may occur after the  operation, after-
bleedin^ requires special attention.  If it occur from a vessel which has
not been tied during the operation, it must be taken up at once.  If from
the spongy bodies, it must be endeavoured to stanch it with cold water,
styptic powders, and pressure, or when this is inefficient, and the length

  (a) Neue Biblioihekfur die Chirurgie und   (6) Archives generales de Medecine, vol.
Ophthalmologic, vol. i. p. 737.            xxiv. p. 133.  1830. ' 
546
REMOVAL OF THE PENIS BY TYING.
of the stump permits, pressure is to be made on  the tube already intro-
duced with a roller, or  strips of sticking plaster;  but if these  means be
fruitless, the actual cautery must  be  employed.   Violent inflammation
and spasmodic retention of urine must be treated according to the ordi-
nary rules.
  The tube in the urethra must not be removed till the scarring is com-
plete, otherwise the opening of that canal is narrowed;  and even then it
is often necessary,  as I have sometimes seen, to prevent the contraction
by leaving a bougie in; on the other hand, there  are  cases  in  which
without any bougie, no narrowing of the urethra ensues.
  After the most successful operation, even  in aged persons, whose pro-
creative powers have ceased, there, is often no means of preventing low-
ness of spirits and melancholy.
  2480. In removing the penis by tying, a silver  male catheter must be
passed through the urethra into the bladder, a waxed silken thread applied
beyond the diseased, and  upon the .healthy part of the penis, and intro-
duced into a loop-tier or some particular instrument for tying a ligature.
This instrument must be screwed so tight that the part before the ligature
shall  be deprived of all feeling;  the  instrument is  to  be fastened with
sticking plaster, and the cancerous part covered  with lint and compresses.
On the second  or third day, usually the largest  portion of the dead penis
may be removed with scissors or bistoury, without bleeding or pain; and
on the fourth or fifth day the ligature separates.   The catheter may now
be removed ; a small silver or gold tube introduced into the urethra, and
the suppurating part dressed simply till it scar {a).
  2481. Amputation of the penis with the ligature is preferred by most
practitioners to that by the knife.   The inconveniences, however, which
usually arise from  the  former,  as  great  and continued pain, by which
fever, convulsions  and the like'may be produced, and the noxious effect
of the sloughing  mass upon the whole system, by which Graefe's mode
of operation is beset,  must not be overlooked.  The  most important
advantage of tying is security from bleeding, which  may be very severe
at or after the operation, although proper caution will prevent this, as my
experience has proved.
  [I have never seen  any  trouble or difficulty from the bleeding at or after the  re-
moval of the penis with the knife, and should think  the scarring would be more
quick, and much less painful by this method than by the ligature, of which, how-
ever, I have not had any experience.—j. f.  s/]
  2482. As in many cases, although the carcinomatous swelling increases
the penis to double its size, it does not attack its whole  substance, but is
confined  to the  cavernous bodies, so that according  to Lisfranc, the
degenerate mass may be removed  by a cut made from before backwards
beyond the diseased part, from the back of  the penis, by short strokes of
the knife, carefully cleansing  the  wound with a  sponge till the  whole
fibrous covering of the cavernous bodies has been laid  bare.   If this be
found healthy, the  diseased mass must be  carefully removed, and only

  (a) Biener, above cited.—Speier, E., Dis-  von Graefe angegrebencn und verbesserten
sert. de Castratione.  Berol, 1820.—Michae-  UnterbindungstOcken; in same, vol. v. p.
lis, Ueber die Exstirpation des Penis durch  356.—Michaelis, Neue Erfahrungen iiber
Ligatur; in von Graefe und von Walther's  Graefe's Amputationsweise des Penis; in
Journal, vol. iv. p. 331.—Bloemer, Ueber die  same, vol. siii. p. 210. 
CANCER OF THE TESTICLE.
547
when the degeneration has penetrated more deeply should the penis  be
amputated.   This opinion is  supported by some successful cases, {a).
                F.—OF CANCER  OF  THE TESTICLE.

  Pohl, Programma de Herniis et speciatim de Sarcocele.  Lips., 1739.
  Heise, (Praes. Heister,) Dissert, de  Sarcocele.  Helmst., 1754.
  Warner, Joseph, An Account  of the Testicles, their Coverings and Diseases*
London, 1774.   8vo.
  Pott, Percival, A Treatise on the Hydrocele or Watery  Rupture, and  other
Diseases of the Testicle, its Coats and  Vessels; in his Chirurgical Works, voL ii.
London, 1783.   8vo.
  Marschal, Von der Castration.  Sajzb.,  1791.
  Bell, Benjamin, A Treatise  on the Hydrocele, on Sarcocele or Cancer, and other
Diseases of the Testes.   Edinburgh, 1794.  8vo.
  Loder, Ueber die Castration;  in Neue Medic. Chirurg. Beobachtungen, p. 110.
  Ehrlich, Beobachtungen von der Entmannung; in Chirurg.  auf Reisen gemach-
ten Beobachtungen, vol. i. cap. xiii.
  Daun, (Praes. Metzger,) Dissert, de Exstirpatione Testiculi.  Kcenigsb.,  1800.
  von Siebold, C, Praktische Beobachtungen uber die Castration.  Frankf.  1802.
  Mursinna, Ueber die Castration; in  neue Medic.-Chirurg. Beobachtungen 33-37.
  Sauernheimer, Dissert, de Sarcocelotomi.l.  Col. 1807.
  Zeller, Abhandlung  iiber  die ersten Erscheinungen venerischer Localkrank-
heiten, sammt Anzeige  zweier neuen  Operationsmethoden, namlich die verwach^
senen Finger und die Castration betreffend.  Wien, 1810.
  von Siebold, C, Chiron, vol.  i. part i.
  ------------, Sammlung chirurgischer Beobachtungen, vol. i.
   Ramsden, Thomas, Practical Observations on the Sclerocele, and other morbid
enlargements of the Testicle; on  Hydrocele and on Aneurisrri.  London, 1811. 8vo.
   Wadd,  William, Cases of Diseased Bladder and Testicle.  London, 1817. 4to.
   Speier, Dissert, de Castratione.  Berol,  1820.
   Cooper, Sir Astley, Bart., Observations on the Structure and Diseases  of the
Testis.  London, 1830.  4to.
   Curling, T. B., A Practical Treatise on the Diseases of the Testis and  of the
Spermatic Cord and Scrotum.  London, 1843.  8vo.

   2483.  The various chronic swellings to which the testicle  is subject,
 and by which its parenchyma is converted  into a foreign substance, are
 usually comprehended under the general designation Sarcocele {Sarcoele,
 Hernia carnosa, Lat.; Fleischbruch, Germ.; Sarcocele, Fr.)   Under this
 term, are ranged together induration, scrofulous and  syphilitic swelling
 of the testicle,  scirrhous,  sarcomatous  degeneration, varicose swelling,
 and medullary fungus.   Some writers  confine Sarcocele  to  cancerous
 degeneration of the testicle; others name as Sarcocele  a variety of ele-
phantiasis, in which the skin of the scrotum becomes a fleshy substance,
 attached as  it were  to a neck, and with which  generally the  testicle  is
 unconnected: it is  most proper,  however, to  restrict the term Sarcocele,
 simply to the sarcomatous degeneration of the testicle.
   2484. Scirrhus of the  Testicles is generally preceded  by inflammation
 or other external injury, or it occurs  of itself without any apparent cause.
 The testicle swells,  becomes hard;  may continue a  long while in this
 condition  without causing any inconvenience; at last, after  some acci-

   (a) Margot, Sur le diagnostic des divers   lesquels on a preserve les Malades h l'Am-
 degres  de profondeur  des Cancers de  la   putation du  Penis; in Revue  Medicale,-
 Verge ; ct Observations sur deux Cas, dans   1826, vol. iv. p. 337. 
548        SCIRRHUS AND SARCOMATOUS DEGENERATION

dental irritation,  or of its  own accord, the swelling becomes greater,
harder, irregular, and knobby, and lancinating pain runs along the course
of the spermatic  cord.  The scirrhosity spreads over the cord, which
thickens and becomes  firm  and knotty; the neighbouring glands swell;
the skin of the scrotum  adheres to the swelling, at  last bursts, and an
ulcer with hard out-turned  edges,  and  a discharge  of stinking ichor,
or with  fungous growths,  is  produced, and the  pain becomes  very
severe, in  the region of the loins  and spermatic cord.   Whilst this  is
going on in the testicle, the general health  becomes very much affected,
and  the previously-mentioned symptoms set in.  The  interior  of the
hardened testicle consists of a hard tallow-like substance,  of a grayish
or brownish colour, oftentimes containing distinct  cells filled  with a
sanious fluid.
   2485. In  Sarcomatous degeneration of the  Testicle, its substance  is
changed in the same way as already described of Sarcoma in general,
(par. 2281.)  There is an excessive collection of coagulable lymph in the
parenchyma of the  testicle;  the spermatic arteries and the branches they
give to the coverings of the testicle  are sometimes pretty numerous, and
considerably enlarged.   In sarcoma the testicle  often retains its shape
for a long while, is oval  and flattened on both  sides, its larger end is
directed upwards and forwards, its smaller one  downwards and back-
wards.   Its weight, in proportion to the size of  the swelling, is  always
considerable.  This disease generally causes no other  inconvenience
than  that of dragging  on the spermatic cord, if  unsupported by  a bag-
truss.  It is free from pain, the skin  covering it has its natural condition,
which is  only first  changed on very great enlargement of the swelling.
The spermatic cord may indeed swell, but does  not  become knotty and
knobby.  If such sarcomatous swelling be left alone, or if it be irritated
by treatment, it may run into cancerous degeneration.
   2486.  During  the  progress of  scirrhus  as  well as  of sarcoma  of
the testicle,  a  collection  of  wrater is not  unfrequently formed  in the
scrotum, (Hydrosarcocele,) which is to be considered as a consequence of
the degeneration of the organ.  There is then felt a firm, regular swelling,
and frequently distinct  fluctuation.   Sometimes the surface of the testicle
unites with the vaginal tunic into one indistinguishable mass.
   2487. The distinction of scirrhous  and sarcomatous  degeneration of
the testicle from other swellings which occur in its parenchyma or its
coverings, is in most  cases exceedingly difficult, and requires  careful
examination of the swelling and of the way in which it arose.  Swellings
of this kind  are, first, thickening  of the  cellular tissue of the scrotum;
second, hydrocele ;  third, hydatid or cystic tumour of the testicle; fourth,
hardening  of the tunica  albuginea  of the testicle ; fifth, fungus  of the
tunica1 albuginea  or of the testicle ;  sixth, induration of the testicle con*
sequent on acute  inflammation  ; seventh, scrofulous and syphilitic swell-
ing of the testicle ;  eighth,  medullary fungus.
   2488. The thickening of the  cellular tissue of the scrotum,  which
is infiltrated by  a  quantity of fatty, watery, or bloody fluid, forms  a
swelling with a broad base, and at the same time attached  to a stem, of
which the  size is sometimes so considerable that the penis  is complete-
ly covered ;  the dpening of the prepuce has the appearance of a navel 
OF  THE  TESTICLE; TREATMENT.              549
at the end of the swelling, and the  patient  is  prevented walking.   Its
weight is sometimes as  much as one hundred  pounds.  Externally the
tumour  presents  various degrees  of roughness, separated by the hol-
lows which  correspond  to the crypte mucose or the  roots of the hairs.
Upon a  large portion of the tumour when it has long existed are formed
yellowish crusts or scales, which as they drop off leave a corresponding
number  of ulcers bare, and secreting an ichorous fluid.   The swelling is
painless, bears  even violent pressure in various directions, is  at some
parts hard,  at others soft, and is only troublesome  to  the patient  by its
weight.   The testicle and spermatic cord are generally natural, only the
spermatic vessels are lengthened.    This disease is most common  in hot
countries, although it has also been noticed in France, England, and Ger-
many.   According to  Larrey, who frequently  saw it in Egypt, persons
who sit  at  their work  are peculiarly subject to it.  Syphilis and other
vicious states of the juices may be reckoned among its internal causes;
the  patient  is  frequently at  the same  time subject  to elephantiasis, of
which this disease seems only a modification.
   When the disease has not attained a very great height, its dispersion
may be  attempted  by antimonial,  mercurial, and  diaphoretic  remedies,
by the alterative use of mineral acids  in small quantities  with  mucila-
ginous drinks.   Externally by lotions of dilute sulphuric acid,  solution
of bichloride of  mercury, of sulphate of iron,  and of hydrochlorate of
ammonia.
   If notwithstanding this treatment the  tumour  become larger, the ope-
ration is the only remedy.  For this purpose two cuts are made  in front
of the aperture  of the  prepuce which separate  below»from  each  other,
and run down on both  sides, below the  testicles.   In  these  directions
all between  the cavernous bodies of the penis and  the testicles, in  wrhich
care must be taken to avoid  the testicles, spermatic cords, and cavernous
bodies,  and  the whole  mass below the line  of the cut  removed.  The
remainder of the  sarcomatous mass must be  shelled out.  The bleeding
vessels  must be  tied  at once, and the edges  of the  wound  brought
together with sutures, sticking plaster, and a proper bandage {a).
   [This disease does not generally exceed such size as might  render it  liable  to
be mistaken for disease of the  testicle itself; but with  careful examination it is
scarcely possible  to mistake the one for the other.
   In some instances, however, the scrotum seems  to  participate rather than give
origin to  similar growths of cellular tissue, with adhesive deposit in its cells, which
has been already  mentioned, (p. 451,) and which  has, perhaps, been not very cor-
rectly spoken of as elephantiasis of the scrotum.  These sometimes acquire very enor-
mous size, and have occasionally been removed.   Some  such  have been already
noticed, but as their removal is attended with considerable danger, it would seem,
from the  sudden loss of venous blood, it will not be improper to advert to the sub-
ject again.
   In  Liston's case (b), already cited, of the  tumour which weighed  nearly fifty
pounds, and  was removed  from a man of twenty-two years  of age, the disease
"had commenced when he was only ten years of age,  and had gone on increasing
gradually from that  time.  It measured forty-two inches in circumference, and forty
  (a) Ephemeridcs Nat. Curiosorum, 1692—  und von Walther's Journal fur Chirurgie
Morgagm, Epistolae Anatomicae. xliii  Art.  und Augenheilkunde, vol.  ii. p. 647.—von
42.—Larrey,   Memoires de  la Chirurgie  Froriep's Kupfortafeln, pi. cxxvi.
Militairc, vol. ii. p. 110.—Richerand, Noso-   (b) Edinburgh  Medical and Surgical Jour-
graphic Chirurgicale, vol. iv. p. 432.  Fifth  nal, vol. xi\. p. 566.  Ib23.  This account
Edition.—Titley ;  in Med.-Chir.  Trans.,  is the most circumstantial, and is  that here
vol. vi. p. 71.—Delpech ; in  von  Graefe  quoted.
   Vol. iii.—47 
550          REMOVAL  OF  SCROTAL TUMOUR BY KEY;
 from the verge  of the anus to the pubes, betwixt which parts it was attached.  The
 greater bulk of the tumour lay behind, and extended lower than the patient's knees.
 *  *   *  The incisions were  made  from behind.   I had intended  to preserve  as
 much of the genitals as I might find it possible to do, on examiningtheir attachments
 and connexions with  the diseased mass.   But immediately on the  bistoury being
 carried  round  the base of  the  tumour, the haemorrhage was so profuse that any  at-
 tempt of the kind had to be abandoned, for the more essential and immediate object
 of saving the  patient's life.  *   *  *  The tumour was  therefore detached as rapidly
 as possible,—in not very many seconds,—and the mouths of the  large and numer-
 ous vessels running  into it covered  as they were divided, by our fingers.  The
 flow  of blood was compared  by  those present to the discharge  of water from a
 shower-bath, so instantaneous and abundant was it.   Before half the vessels could
 be tied, the patient had sunk off the table without pulse, and with  relaxed muscles,
 voluntary and involuntary."  From  this condition he was recovered, and then,  in
 his Practical  Surgery Liston  states, the  remaining vessels were from  twelve  to
 sixteen, but whether  they  were arteries or veins is not mentioned.   In  three weeks
 he was able to walk  about, and soon after the complete  cicatrization of the wound
 took  place.  The tumour is in the Museum of the  Royal College of Surgeons  of
 England.
   The  following is Key's case  (a), which  from its enormous  size excited great
 interest:
   Hoo Loo, aged thirty-two years, ten years previous to his admission (March 17,
 1831) into Guy's Hospital,  "first perceived the extremity of the prepuce to swell
 and become hard, and it continued to  increase for about four years.  At the end of
 this period the scrotum began gradually to enlarge up to  the present time, when  it
 had  acquired  the  enormous magnitude  of four  feet in circumference, its increase
 having  been for the last two years remarkably rapid.  *  *  *   The appearances
 of the tumour at the time of operation (April 9) were as follows:—Its body was of
 a flattened  spheroidal form, four  feet  in circumference, and attached by an equila-
 teral triangular neck of half that size, which, opposite the pubes, measured exactly
 eight inches across, and extended about two inches and a half beyond each external
 abdominal  ring.  The other sides corresponded  to  the lateral boundaries of the
perinaeum,  and met at an acute angle immediately before  the anus.   Its length was
 such, that  when the  man  was erect, its lowest point was about opposite to the
 tubercles of the tibiae.  On its neck  and  lateral  portions, the integuments were
 healthy  in appearance, whilst on its anterior part they were considerably thickened,
 indurated, and had a tuberculated  honey-comb appearance, with a few small ulcera-
 tions, from which  a slight serous transudation took place.  Near the centre of the
 body  of the tumour, an  irregular projection, supposed to be  elongation of the
 prepuce, concealed the orifice  from  which the  urine escaped.  The  integument
 covering this  projection, seemed more  diseased than that of any other part of the
 tumour, being closely studded  with numerous small elevations of the cutis, and from
 this projection, an elevated ridge  extended backwards  through the medium line of
 the tumour, and  evidently was the enlarged raphe of the scrotum.   The plan of the
 operation was this :—To make three flaps ; one  from the upper part of the neck of
 the tumour, to  envelope  the penis, and a semilunar one on each side to form  a
 covering for the testicles  and perinaeum."  In making the first lateral  " incision,
 several  large veins were divided,  which bled freely, but were immediately secured
 by ligatures.   This  flap  was then  dissected back,  during which several large
 vessels  were tied.  At the lower part  of the flap, one particularly large vein was
 secured.  A flap of the same  kind was made on the  opposite side, during which,
 but comparatively few vessels were divided.  The next step of the  operation con-
 sisted in laying bare  the cords;  and  in cutting  down upon the right one, a small
 artery,  the  first  that was  seen,  Was tied.  At  this  time, the  patient's  powers
 appeared so depressed, that it was determined " no farther attempt should be made
 to save  the penis and  testes."   Mr. Key,  therefore, " passed a temporary ligature
 round each spermatic  cord, and then divided them;  A band was then passed round
 the penis in the same  manner,  which was then cut through about an inch and a half
 from  its root.   The tumour was now  dissected from the perinaeum, which occupied

   (a) Removal of an immense Tumour, occupying the region of the Pubes and Perinaum;
 in London Medical Gazette, vol. viii. p. 93.  1831. 
BY  O'FERRALL.
551
but a very short time; in this separation,  two small arteries  were divided, and
instantly secured.  The ligatures were then  removed from the cords and penis, and
each spermatic artery tied  separately.   During the greater part of the operation,
and especially towards its latter end, the man's powers were greatly depressed, and
two fits of syncope occurred, yet after it was finished, his pulse, though weak, could
be felt at the wrist.  However, in a few minutes another fit of syncope came on,
from this he  never rallied."   Every means  to restore him, including transfusion,
were in vain.   The operation lasted an  hour and three-quarters; this was principally
occasioned by the necessity of tying so many vessels, the whole of them veins,
with the exception of three very small arteries, besides the two spermatios; and
by being delayed during the  two fits of syncope.   Although upwards of thirty
ligatures were applied, not more than twenty ounces of blood were lost, and of this
scarcely one ounce arterial."   *  *  *  The weight of the tumour, when removed,
was fifty-six  pounds, eight ounces.  Mr.  Key was  decidedly of opinion, and
expressed himself to that effect, that the patient's death was occasioned by the loss
of blood, which, though  by no means excessive,  from the precautionary measures
adopted, yet made an impression on  the feeble  system of an Asiatic, which his
powers were unable 1o overcome.  *  *  *  The tumour was found to consist of
the cells of  the cellular  membrane enlarged, and containing a yellowish dense
serum.   Some parts of the tumour contained indurated masses, resembling cartilage.
The tumour, when entire, undulated, and was thought by some to contain a large
quantity of fluid in one cyst; but the  fluid was contained, as is usual in elephantiasis,
in cells of various dimensions, but none exceeding a marble in size.
   Warned by the fatal result of this case, and also from the violence of the bleeding
in Liston's patient, 0'Ferrall(«), to guard against such untoward circumstances, in
operating on "an enormous tumour of the scrotum of a man forty-four years of age,
which descended nearly to his knees, disabled him by its great weight,  and had
nearly exhausted his strength by profuse bleeding from large veins on its surface,"
adopted the plan " of placing the patient on his baek, and having the tumour poised
for a sufficient length of time  to empty its vessels before the  incisions were com-
menced,"  and the result justified his expectations.  The disease had  commenced
ten years before, in " a hard swelling on the cord, the size of a  marble, about an inch
above the left testicle,"  which  "continued progressively to enlarge.  * * * The
last haemorrhage from the veins of this tumour amounted, he was convinced, to two
quarts of blood.  The exhaustion was very  great, and rendered him for some time
unable to pursue his avocations."  When admitted into St. Vineent's Hospital,
"the figure of the tumour was irregular; it arose by a  pedicle from the pubes and
perinaeum, and expanded in its descent into a huge mass, the widest portion of which
was about four  inches above its lowest part.  The integuments which covered  the
pedicle were  evidently borrowed by traction from the abdomen and groin, and pre-
sented four distinct and prominent folds; the skin covering the tumour was smooth,
it was marked by numerous large venous trunks, which traversed its surface, and
lay in furrows  easily traceable by the finger.   A small ulcer in the integuments
over one of these veins marked the point from which the haemorrhages had taken
place.   The left lateral aspect of the tumour, near its neck, exhibited several trunks
of veins, larger than swan's  quills, running parallel  to each other, and, when  the
patient was in the erect position, projecting in strong relief.  When poised upon the
hands it gave the impression of considerable  specific weight;  its consistence was
unequal; its hardest portion was an irregular mass of  the size of an  orange, of cartU
laginous density, and situated about an inch below the left external abdominal ring.
The  greater portion of the tumour was solid, though  not gristly to the touch.  At
two or three points of the remainder there was a degree of elasticity closely resem-
bling fluctuation.  *  * *  Of the penis, the glans was the only portion visible, it pro-
jected from the integuments  at a point about three inches below the pubes.  The
remainder of this organ was buried  in the morbid growth. *  * *  From the pubes
to the fundus of the  tumour measured twenty-eight inches; the circumference about
its middle was  twenty-two inches and a half.  The weight of this enormous mass
was the principal source of inconvenience."  The operation was performed on  the
29th November, 1844.  After making a puncture into  the elastic part of the tumour

   (a) Malignant Tumour of the Scrotum;  Science, vol. i. p. 521.   1846.   New  Se-
in Dublin Quarterly Journal  of  Medical  ries. 
552
REMOVAL OF SCROTAL TUMOUR
with a trocar, through the canula of which nothing but a little blood came out, and
the patient being placed in the position for lithotomy,  "with a large broad-backed
bistoury, O'Febrall made in the perinaeum two straight incisions meeting at an
angle, salient towards the anus.   Keeping close  to the  tumour, the incisions were
carried rapidly round its under and lateral surfaces, exposing on the right side the
covering of the testicle, and on the left a bunch of cylindrical convolutions as large
as the finger. *  *  * Their uniform blue  colour, solid feel, and entire absence of
gaseous contents, at once convinced us that it was an enormous varix of the cord of
the left side.  The tumour  being now  detaehed as far as possible laterally and
underneath, was allowed to descend to a nearly horizontal position, in order to com-
plete the operation in front.   Two straight incisions  carried downwards from the
groins, were made to meet at an angle, so as to include a portion of integument capable
of covering the urethra, and fitting into the incisions previously made.   The tumour
was now rapidly detached, and the cord being held, was cut across.  A few strokes
of the  bistoury completed the separation of this enormous mass from the body of the
patient.  The vessels of the cord and a few small subcutaneous branches were now
secured, and the  patient was put to bed.  The loss of blood was very inconsiderable,
not  exceeding perhaps  four  ounces."   The  operation was  completed in eight
minutes.   After  a few  hours  the flaps of integument  were brought together with
sutures.   About  nine days after the operation the patient was attacked with erysipe-
las, which spread down the  thighs, upwards over the body to the shoulders, then
over the scalp and face, and after about seventeen days subsided completely.  Shortlv
after he had a fit of acute rheumatism, from which,  however, as well as the general
consequences of the operation, he rapidly recovered.   On examination of the tumour,
"a loose capsule of cellular tissue enveloped the morbid growth.  A section carried
through its middle  showed that  the whole was perfectly solid, and  without the
slightest appearance of a cyst.  The cut surfaces reminded  us strongly of the section
of the larger varieties of fibrous  tumour of the uterus,-  whitish, with  the slightest
possible tinge of yellow.  The substance appeared to consist of a number of lobules,
separated by lines of condensed cellular tissue, and marked here and there by minute
granules of ealeareous deposit.  The greater number of bloody points presented by
the seetion, however, distinguished its appearance from that of the fibrous tumour of
the uterus.   Some of the lobules almost resembled in density a section of the inter-
vertebral substance.   Others more elastic appeared  to have undergone a change ap-
proaching the character of encephaloid disease.  This impression was confirmed by
Dr. Houston, who found that  it  presented under the microscope  the  mixture of
fibres  and  cells, characteristic of malignant structure.   It  was in these situations
that the deceptive feeling of a cyst had previously existed.   The left testicle was,
after a careful  search, found to occupy the position  mentioned by the patient.  It
was atrophied,  but otherwise unchanged, and lay  enclosed in its moist and polished
tunica vaginalis.  The cord above it was lost in the tumour."
   In the very remarkable case related by Bennet (a), the  disease had commenced
"nine or ten years before, in the form of a swelling on each side of the groin, which
gradually increased in size, descended, and, he says, united and formed one mass,
entirely covering the perns."   The tumour has been gradually increasing from that
time, and has  now reached to the insteps.  The weight of the  tumour, so far as
could be ascertained, was  about ninety-six pounds avoirdupoise, and  tbe size, by
careful measurement, was found to be as follows :—The length from the crest of the
pubes to the base (bottom)  of the tumour, two feet five inches; circumference of the
upper part, just below the pubes, twenty-one inches; of the centre, four feet; of the
largest part, just below the  urethra, four feet eight inches.  The tumour was at some
parts smooth, at others had a wrinkled appearance, excepting at the lower part of its
right side, which was tubereulated  and  livid; the  general colour, however, was a
dirty yellow.   It was very callous to the touch, except at the upper part about the
pubes, and a few inches below.  The tumour was composed, as appeared on cutting
into it, of an indurated substance, about the consistence of cartilage, and  of a similar
white colour.   No operation was performed.
  In all these cases it will have been noticed, that the scrotum was only secondarily,
not primarily affected.]

  (a) Case of enormous Tumour of the Scro.  (Otaheite,) Southern Pacific Ocean; in Lon-
t«ra  ia a. Native,  of the Island of  Tahiti,  don Medical Gazette; vol. viii. p.. 101.  1831. 
CYSTIC SWELLING OF THE TESTICLE.           553
   2489. A simple hydrocele  cannot well be  confounded with sarcocele.
 Only at first, when the collection of water is not great, it is  sometimes
 accompanied with severe pain on account of the distention of the vaginal
 tunic, which, in connexion with the great hardness of the swelling-, may
 lead to  a mistake.  But when that tunic is considerably thickened,  and
 even cartilaginous, the feel is easily confused, and the practitioner may
 mistake the swelling  for hydrosarcocele.   In this latter complaint, how-
 ever, the hind  part of the swelling is generally harder and knobby ; the
 spermatic cord is also usually knotty, and  there is lancinating pain.   In
 doubtful cases, puncture always resolves the difficulty.
   2490. Cystic swelling  of the testicle begins with  a thickening of
 .the  epididymis ; it is,  however, generally only first noticed when the
 disease  has spread  over the  testicle, and  has made some progress.   In
 addition to the swelling, the testicle retains its natural form, round in
 front, flattened  on the sides,  and not so bean-shaped as in hydrocele.
 Between the testicle and the epididymis, usually,, though not always, the
 natural  line of  distinction still remains.   The sweLling is not tender  if
 not  subjected to violent pressure, but when smartly pressed, the patient
 feels as  if the testicle were squeezed.  The- tumour  yields to pressure,
 though it does not show true fluctuation :  if it be compressed at one part
 with the finger, it is  not  raised at another part, but merely  appears to
 yield all over.   Pain and uneasiness in the  loins are produced by the
 weight and size of the testicle, although the disease still remains local.
   On examining a testicle of this kind after removal, the vaginal tunic is
 found  thickened,  in  part adherent,  and  the tunica  albuginea firmer ;
 the  testicle  appears to consist partly of firm tissue and partly of cysts, the
 size of  which varies from that of the head of a la*ge pin  to  that of a
 musket-ball.  The  smaller cysts, of which the walls are very vascular,
 contain  a serous, clear, or yellowish fluid,  and  the large s-, of  which the
 walls are thick, have a mucous substance.   Astley Cooper believes the
 cysts to  be  obstructed  efferent tubes, into  which a diseased  secretion is
 poured  out.  Nothing precise is known of  the occasional causes, the
 patient often ascribes  the disease to cold, or to a blow.
   This tumour may be most easily confounded with hydrocele; the cystic
 tumour, however,  is  more compressible than  fluctuating, heavier,  the
 form of the  testicle  is retained, but rather  more bean-shaped, is  not
 transparent  when a light is held behind it, and when violently pressed is
 painful as when the testicle is squeezed.  In  hydrocele, the testicle can
 be felt behind, although indistinctly.
   The removal  of  the testicle is the only remedy, and the recurrence of
 the disease  not to be dreaded if the cystic disease be not complicated with
 medullary fungus,  as  may be seen  after the removal  of this organ, and
 always renders the prognosis unfavourable.   True hydatids may also exist
 in the testicle {a).
   2491. The tunica albuginea of "the' testicle is sometimes thickened, irre-
 gular, cartilaginous, and sometimes bony, the  testicle, however,  still
 retaining its natural condition.  The swelling is in these cases painless,
 makes only  irregular slow  progress, and in general theie is  a collection
of water in  the vaginal tunic.   The disease has* no relation to cancer of

                    (a) Astley Cooper, above cited, p. 63.
                                   47* 
554         MEDULLARY FUNGUS  OF  THE TESTICLE.
the testicle, and does not require  extirpation.   Scirrhus may, however,
be developed  in the tunica albuginea which has adhered to the vaginal
tunic, in which case, the scirrhosity in general attacks the epididymis, but
the testicle, although surrounded with some serous fluid, is either little or
not at all altered.  Several observations appear to prove that after extir-
pation of the testicle, its recurrence is to be but little dreaded (a).
   2492.  Fungus of the testicle  or of the tunica albuginea, is a peculiar
disease, easily mistaken for sarcoma.   In general, after external violence,
or after a clap, a swelling of the testicle begins, which is often very con-
siderable  and  hard.   A small abscess forms, with severe pain, bursts,
and out of the aperture a fungus gradually grows.   If, in this complaint,
after the inflammatory affection of the testicle has diminished, the testicle
itself be not very greatly enlarged or hardened, it is best to remove the
fungus and the diseased part of the testicle, without taking away the
latter completely.  This is  best done with the knife, and in some  cases
the ligature or caustic may be employed.   When the whole substance of
the testicle  is attacked  with this fungus, it must be completely removed.
The mere swelling and induration of the testicle, often ceases gradually
after the extirpation of the fungus, and with proper treatment (b).
   2493.  Induration of the testicle, as a consequence of previous  acute
inflammation,  presents  a  hard, usually  irregular,  though  not rarely,
knobby swelling, whieh is  more or less painful on examination, but gives
the patient  no  lancinating pain.
   Repeated application of leeches, softening poultices, rubbing in mer-
curial or  iodine ointment, and continued rest, usually effects its disper-
sion.
   Scrofulous swellings  of the  testicle  are less hard and painful than scir-
rhus: the testicle is  thereby converted into a yellowish-white coagulated
substance,  like  that found in scrofulous glandular  swellings;  but the
spermatic cord is, for  the  most part, in its natural state.   The swelling,
however, frequently runs into ulceration, forms a painful readily bleeding
fungus; the spermatic  cord swells, and not  unfrequently there is scro-
fulous degeneration.
   In most cases these swellings are resolved by proper general treatment,
and by the local application of resolvents.
   Syphilitic swellings of the testicle and spermatic cord, in consequence
of an inveterate pox,  arise slowly,  without any occasional cause, and
commonly are developed in the epididymis.
   A regular mercurial  treatment most commonly effects their dispersion.
   2494.  Medullary fungus of the testicle is distinguished from sarcocele,
by the more speedy growth  of the  swelling  to a large  size, by the
absence of all  hardness and irregularity, by the very indistinct  pain, by
the delusive feel of  fluctuation, by the quick affection of the spermatic
cord, and the spreading of the disease into the belly (par. 2295.)
   2495.  Most of the above-mentioned diseased states are distinguished
from  cancer of the testicle; they may, however,  even if left alone or
treated improperly, run into  cancerous degeneration.   It is, therefore,

   {a) Dictionnaire des Sciences Medicates, vol. i. p. 13-15.
   (b) Lawrence; in Edinburgh Med. and Surg. Journal, vol. k.p. 257.—Dictionnaire
 des Sciences Medicale, vol i. p. 16. 
EXTIRPATION OF THE  TESTICLE.
555
necessary when suitable treatment has been employed without effect for
some time, to extirpate the testicle, because thereby alone is the passage
into cancer  prevented.   For  scirrhus of the  testicle there  is no  other
remedy  than extirpation.   In sarcomatous  degeneration, by repeated
local bleeding, by dispersing applications, and by the internal  use of
such remedies as promote absorption, the unnatural vegetative process
may be kept down, or by tying the spermatic artery, the tumour may be
diminished, or its growth  prevented.
   2496. Extirpation of the testicle {Castratio, Lat.; Entmannung, Germ.;
Emasculation, when both testicles are removed) is for  the patient  a very
painful, and,  in cancerous degeneration, as to  its  consequences,  a very
doubtful operation, as recurrence of the disease is very common.   The
expectation of a favourable result is greatest when the disease has been
the consequence of external violence, is  not connected with, any general
affection, and all the degeneration  has  been completely removed.  It
must be held to be  contraindicated when there is  any existing general
disease, on which the disease of the testicle depends;  when the  neigh-
bouring glands  are swollen, and there  is  also disease  of the spermatic
cord, when  the  hardness extends  so far up,  that excision in a healthy
part is not possible.   If in such  case there be  also dragging pain extend-
ing up into the loins ; if the swelling of the spermatic cord be hard, knotty,
and the  seat  of lancinating pain.   From this scirrhous degeneration of
the spermatic cord, which in rare cases may precede the swelling  of the
testicle, a simple sympathetic  swelling of the  cord  may be distinguished
by its regularity, by not being knobby, and by diminishing towards the
abdominal ring,  and by the pain lessening when the testicle is supported
by a bag-truss.   A swelling of  the  spermatic cord may al*o depend on
serous infiltration into its vaginal sheath.   When with sarcocele swellings
in the belly are connected (1), which on closer  examination  can often be
distinctly felt, as well as with decided appearance of cancerous dyscrasy,
the operation can only hasten death (a).
   (1) The swellings which often form enormous masses m the belly, occur, indeed,
 generally in medullary fungus of the testicle; I have, however, seen them  also in
true cancer of that organ.
   2497.  For the purpose of rendering the removal of the testicle in sar-
 cocele superfluous, Walther {b) has proposed tying the spermatic artery,
which has been  performed successfully by Maunoir (c).   This operation
can, however, only apply to those diseases of the testicle, in which  a very
 copious deposit of plastic  lymph into the cellular tissue of the testicle has
 caused unnatural development of vessels and sarcomatous degeneration,
but no passage into cancerous degeneration.
   In relation to this practice  stands  cutting through the spermatic eord with inter-
ferring with the testicle, which soon wastes (d).
   2498.  Tying  the spermatic artery in sarcomatous swelling of the tes-

   (a) Rust, Zwei Beobachtungen iiber eine    (b) Neue Heilart des  Kropfes, u. s. w., p.
eigene Erhartung des Hodens, als Folge   40.  Sulzbach, 1817.
einer Varicositat der Lymphgefiissc, beson-    (c) N uvelle Methode de traiter le Sarco-
ders der Cysterna  chyli  und  des  Ductals   cele sans  avoir recours & PExtrrpation du
Thoracicus;  in Horn's  Arehiv. IS 15.—   Testicule.  Geneve, 1830.  8vo.
Girel, Ueber den Fungus, die Struma testi-    {d) Weinhold; in  Hufeiand's- Journal,
culi;  in Neue Chiron, vol. i. p. 273.         vol. viii. part iv.  1842. 
556
EXTIRPATION  OF THE TESTICLE ;
tide is unaccompanied with any difficulty.   A cut half an inch long must
be made at the abdominal ring in the direction of the  cord, which being
laid  bare, the pulsation of  the very much  enlarged artery may be felt.
The vessel is to be isolated as high up as possible, by  slightly cutting the
cellular tissue surrounding the spermatic cord, and passing a single thread
with  Deschamps' needle around it  without including the vas deferens,
nerves, or veins.  The wound  is to  be brought together with sticking
plaster,  (par. 1538.)
  2499.  The  removal of the testicle is performed in the following way.
The scrotum  and neighbourhood of the  abdominal  ring  having been
cleared of hair,  the patient  should  be placed  horizontally on a table.
The operator standing on his right side, nips up the skin in  an oblique
fold  over the  spermatic cord, gives one  end of it to an  assistant, and
himself holds the other with the thumb and finger of the left hand.   This
fold  is now cut into in the course  of the  cord, and  extended upon a
director up towards  the  abdominal ring  and down to  the bottom of the
scrotum.   The cellular tissue surrounding the spermatic cord is now to
be separated by some  cuts lengthways on  the  sides, and the  cord lifted
up, the cellular tissue beneath it being thus  made tense, is cut through
with the knife held flat, and as the  knife is brought back, the  operator
passes the forefinger of bis left  hand into this opening, thereby stretches
the remaining cellular tissue, and with  his finger separates the cord up
to the abdominal ring.   The testicle being lifted up to lessen the  stress
upon the spermatic cord, an  assistant grasps  the  cord above where it is
to be  cut through, and the operator holds  it below,  passes  the  knife
beneath and divides it at a stroke.   The arteries are now to be taken
up with forceps or with a hook, and  having  been cleared are to be tied.
The testicle is to  be shelled out of the scrotum, by  which wounding of
the urethra and the septum scroti are avoided.   All the bleeding vessels
are to be tied immediately*
  When the skin of the scrotum is diseased, or firmly adherent to the tumour, it must
be included either between two semilunar cuts, or  after the  eord has been divided,
and the arteries tied, the  testicle, and the skin covering it,  must be removed with
the knife, by which all injury to the Septum is avoided.  Any other practice for
stanching the bleeding, than tying the vessels, is improper.
  If  the cord escape from the assistant, and retract into the inguinal canal, it must
be attempted to seize it with the  forceps and pull it out, or even the external wall of
the canal must be cut into (1).
  Aumont (a) cuts through the skin at the hinder part of the  scrotum, which  is to
be raised and turned to the opposite  side, from the bottom of the swelling to the ab-
dominal ring.  The testicle, which  is laid bare  by this wound,  is then to be dis-
sected up, and the cord bared to the  abdominal ring; the testicle  is then held by an
assistant, and the cord, with forceps, by the operator, who cuts through it, and ties
the  arteries.  The advantage of this is, that a smaller cut is  made upon the least
feeling part of the scrotum, and that the cord is more easily laid bare to the abdominal
ring; hence  its division and the tying of the vessel's  is more  easy, there is less
danger of after-bleeding, the eseape  of the secretion of the wound is more free, and
its union better.
  [(1) The escape of the cord immediately on its  division is a very tiresome, and,
to a  young operator, very perplexing accident; to  prevent its occurrence, Astley
Cooper used to advise  passing a thread through the cord, above-the place at which
the division was to be made, which  gave full' power over the upper end of the cord
after its division, and the thread was removed after the spermatic vessels were tied.
(a) Bulletin de k Societe d'Emulation de Paris.  1822.  April. 
TREATMENT OF UNDESCENDED TESTICLE.         557
 I prefer passing a strong tenaculum  through the cord, which answers the purpose
 quite as well, and is more quickly done.—j. f. s.]
   2500.  If the spermatic cord be degenerated so far towards the abdominal
 ring that  it cannot be held fast  by the  assistant, a  ligature should be
 passed round, after isolating it, which should-be bound  to a piece of
 wood, and there  held  till the artery have been  cleared and tied.   To this
 case alone should the complete tying of the whole  cord, by many con-
 sidered as the proper mode of proceeding, be confined.   The tie should
 then be made as tight  as possible, which alone prevents the severe symp-
 toms caused  by lying nerves.  If the degeneration extend so high  up on
 the spermatic cord that  it cannot be cut through in a healthy part, the
 inguinal canal must be opened,  and the healthy part of the cord there cut
 through {a).
   [Much stress was formerly laid upon not Aying the whole cord before dividing it,
 on account  of the severity of the pain;  I cannot say, however, that I ever noticed it
 so violent as stated, or, indeed, worth  noticing, in the many times I saw it tied by
 some of the older surgeons, in the early part of my studentship.   But tying the cord
 is objectionable, for a much better reason, which is the length of time the ligature
 requires to  ulcerate through.  The younger Cline managed ihe matter differently;
 he used to pass a strong thread around the cord, brought both ends through a piece
 of pewter catheter, tied them upon a stick at the top end, and then twisted stick and
 string, till like a suck-tourniquet, which it really was, it had compressed the vessels
 so completely as to  prevent bleeding, when the cord was cut through.  The thread
 was left on till the fourth  or fifth day, then untwisted, and one end having been cut
 through, the thread was removed, if there were no bleeding.  This practice I have
 often seen him pursue with great success.—j. f. s.]
   2501. When the removal of the testicle is completed, the wound is to be
 cleansed, the extremity of the cord laid  lengthways in it, and the ligatures
 fastened with  strips of plaster.    The wound is  brought together  with
 three or four  stitches, and with  strips of plaster, upon which  are placed
 some soft  lint, and compresses, and the whole fastened with a T bandage.
 The patient must be kept for the first twelve days pretty much in  the
 horizontal posture.
   The after-treatment depends on the degree of  the inflammatory and
 nervous symptoms which set in, and is  conducted according to the  usual
 rules.
   2502. A not unfrequent inconvenience after the operation is bleeding,
 which, if  not  quickly attended to, may produce very considerable  infil-
 tration and distention of the loose cellular tissue of the scrotum.  If, after
 removing  the dressing, some bleeding vessels be discovered, they must
 be tied.   If the bleeding  be from  the whole  surface, as if from a sponge,
 which, even  at the time  of the  operation, may happen, attempts should
 be made to prevent it by cold water, and other styptic remedies, together
 with moderate pressure.   If the bleeding will not so stop, the varicose
 part of the edge of the wound must be removed ; in one case I found it
 necessary  to stitch along the whole edge of the wound with a needle and
 thread.
   2503. If the testicle have not descended into the scrotum, but remain
 lying in the inguinal canal,  or at the abdominal ring, so much earlier do

  (a) For peculiar instruments to tie the  pi. xii. fig. 1-4.—Rudtorffer, above cited.—
 spermatic cord, see Ravaton, Pratique Mo-  Joachim,  in Thault, above cited.—Graefe,
derne de la Chirurgie, vol. ii. pi. ix. fig. 1,2,  in Biener and Speier, above cited. 
558
DISEASED UNDESCENDED TESTICLE.
the  symptoms of disease appear, partly from  its confined position,  and
partially by the various results of violent exertion, and the like.   There
may occur inflammation, induration, scirrhous degeneration, and collec-
tion of water in the cavity of the vaginal tunic.
   In all cases where the testicle lies at  the groin, it is advisable to bring
it down into the scrotum, by opening the scrotum and the abdominal ring.
The spermatic cord offers no obstacle thereto, as it  has its natural length,
and lies coiled up behind the  testicle.   To keep the testicle in its place,
a loop  may be passed through the  vaginal tunic  and the  bottom of the
scrotum, and moderate pressure made at the abdominal  ring (a).  If any
such testicle be hardened, it may be exposed  in  the same way, and the
spermatic cord, which is easily distinguished,  divided.
   [The operation here  recommended should  not be performed as it is useless and
cruel.   The testicle, though seated in the groin, performs its functions equally well,
and if there be any fear of its situation rendering it liable  to injury, it may be pro-
tected with a cup truss.
  It is of great importance that persons who are subject of this  unusual position of
the testicle, should be acquainted with the fact of it being matter of not the slightest
consequence to their condition, as very serious mental alienation has occurred from
their notion of being unlike other people, and incapable of performing an important
function.  In some instances, indeed, the horror of their presumed condition has led
to self destruction.   Neither must it be omitted to mention  that, although the testicle
has been seated for  many years  in the groin,  yet that occasionally,  without any ap-
parent cause, it will descend and take its natural place in the scrotum.—!, f.  s.
  There is  not any reason why the testicle  remaining in the groin should not be
attacked with disease, as it is after its descent into the scrotum ,• but such cases, as
far as I am aware, are exceedingly uncommon ; the  following three examples are
therefore very interesting; the first two are histories attached to casts in the Museum
of St. Bartholomew's Hospital,  for which I have to  thank my  friend Paget;  and
the last is now (November) in the Middlesex Hospital, under the care of my friend
Arnott, who has kindly furnished me with his notes.
   Case 1. The man was a labourer, aged forty-four years.   His  mother said, that at
the time of his birth a small tumour was  observed in  his groin, which has remained
there ever since.  Seven years before his death it began to increase considerably in
size, and six weeks previous to Mr. Sargant  seeing him, in November 1830, it had
attained such bulk as to incapacitate him  from following his usual employment.  At
that time  it seemed attached to the anterior superior spine of the ilium,and to the
upper part of the pubes, and hung down  over  the thigh; and was  considerably in-
flamed. Treatment was adopted calculated to remove this  condition: and soon after
he came to St. Bartholomew's Hospital; but in January  1831, he  returned  to Mr.
Sargant's care.  The tumour  had then  greatly increased  in size, and was slightly
inflamed, accompanied  with considerable fever and  general disorder.  Mild anti-
phlogistic remedies were adopted, and after the application of a blister, were main-
tained for a week; the tumour pointed at its  most depending part, and having been
punctured, a pint and a half of green, offensively-smelling matter  was discharged.
He was allowed nutritious diet, with wine, &c, and was soon able  to leave his bed
and walk  in the open air, about eight ounces of matter, however, being discharged
daily.   In the following April, his strength having regularly increased, he was able
to walk four or  five miles in the day, and the tumour continuing to discharge, was
much decreased in size.  On the 1 Ith of the same month, haemorrhage, to the amount
of about a quart, took place, it was supposed  from a branch of the epigastric  artery.
After this he seemed, for a time, to have  recovered his previous improved condition;
but  in the beginning of June was attacked with fever, occasional shiverings, great
and most distressing pain in the loins, and the tumour again rapidly and consider-

   (a) Brevting, Dissert, de Testic. retropr. chelegenden Testikels. Munchen, 1820.—
post bine extirpat. cum adn. circa monorch. Chei.ius; in Heidelberger kliniach. Annalen,
et testicondos.  Landgli., 1814.—Rosenmer- vol. ii. part iii.
eel, Ueber die Radicalkur des in  der Wei- 
chimney-sweeper's CANCER.                559
ably enlarged.  The discharge at this time was lessened; but on the 20th of the
same month, a fresh opening was spontaneously made near the former one, and from
this  a copious discharge ensued, accompanied  about every three days with a dis-
charge of about eight ounces of blood.  The bowels now became obstinately costive,
and he had great irritability of stomach, with constant retching and vomiting.  He
continued  in this state, but gradually becoming worse, and on the 27th of July died.
On examination, the stomach, liver, and spleen were found healthy.  The mesenteric
glands were considerably enlarged  and indurated, and on being cut into, discharged
the brain-like substance observable in medullary sarcoma.  The testicle could not
be found ; nor could  the spermatic  cord be traced beyond the tumour,, though it was
carefully sought for.   What remained of the tumour was a mass of soft encephaloid
substance.
  Case 2.  Was under the care of Lawrence of Brighton, and the cast was made on
account of its  similarity to the former.   In this also the testicle had not descended
into the scrotum, and  it was presumed  that it was an encephaloid tumour of  that
organ which had produced the enlargement.
  Case 3.  Richard Long, aged 43 years, was admitted into Middlesex Hospital.
  Nov. 3, 1846. On account of a tumour  in the right groin; it is large, prominent,
and of an oval shape, with its long diameter nearly in the direction of Poupart's liga-
ment, which, however, it covers somewhat obliquely; the greater part of the upper and
outer end  of the mass of the tumour being above the ligament, the greater part of the
lower and inner end being below its level.   Over the surface it  measured nine inches
in the long direction,  and six and a half in the short.  It extended  from within two
and a half inches  of the anterior and superior spinous process of the ilium, to a little
beyond  the pubes, where it was in  contact with the root of the penis.   Its  surface
was uniform and  smooth ; it felt firm  and resisting, and gave the  idea of solidity,
but at one part communicating an indistinct sensation of some fluid being present;
it is  nowhere diaphanous.  No impulse is communicated on coughing, although
from the motion on its surface during this action, it is evidently covered by at least
the superficial fascia of the  abdomen.   It can be grasped, and is to a certain extent
moveable, but it cannot be fairly raised from its attachments behind.  The  scrotum
and testicle  on this side are wanting.  The patient, a farm-labourer, of hale appear-
ance, and father of seven children, states,  that  he never had a testicle in its proper
place on the right side, but that up to four years ago, there was a small swelling, the
size of  a  nut, in the  groin, and he points to a situation above Poupart's ligament,
corresponding to  the  internal  abdominal ring,  or upper  part of the inguinal canal.
That it was unattended by pain.   Four years  back, as he was one day engaged at
his work, making trusses of hay, it came lower  down; and he tried to get it up again,
but without success.   It was then, he states, the size of a walnut, and has continued
gradually to enlarge  ever since, but without pain or inconvenience, except from its
increasing bulk.
   " Viewing the case," says Arnott, "as one of disease of the undescended testicle,
but unable to determine its precise nature, whether hydrocle or haematocele with a
thickened tunica vaginalis, cystic sarcoma or malignant disease, I this day (Nov.  5)
told the patient that it would be necessary to puncture the tumour, and then proceed
according to its nature, so as even  to remove it  if necessary.  His mind not having
been prepared for this, and no application having hitherto been used, he wishes some
trial of these to be made in the first instance; and as he has but just entered the
house, he will be indulged."
   Nov.  13.—The operation Was performed to-day, and the case found  to be one of
medullary sarcoma of the testicle, which had never got out of the external ring, the
diseased mass being  covered with  the tendon of the external oblique, which  I had to
slit up over the whole length of the swelling.]
                 G.—OF CANCER OF THE SCROTUM.

  Pott, Percival, Chirurgical Works, vol. ii. p. 225.  Edit. 1783.
  Simmons, W., Observations on Lithotomy;  to which are added, Observations on
Chimney-sweeper's Cancer.  Manchester, 1808.   8vo. 
560        TREATMENT  OF CHIMNEY-SWEEPER'S CANCER.

  Earle, Henry, On Chimney-sweeper's Cancer;  in Med.-Chir. Trans., vol. xii.
p. 296.
  Travers,  Benjamin, On same; in same, p. 344.
  Earle, Henry; in London Medical Surgical Journal, vol.i. p. 6.  1832.
  Cooper, Sir Astley, Bart., Observations  on the  Structure and Diseases of the
Testis, p. 226.
   2504. Under  the  name  of Chimney-sweeper's Cancer, Pott has  de-
scribed a peculiar cancerous  degeneration of the scrotum, to which  the
chimney-sweepers in England  are subject (1).  A  warty  excrescence
sprouts upon the lower part of the scrotum, which may remain unchanged
for months and years ;  it forms  a superficial  but painful ill-conditioned
ulcer, with hard and outturned edges.  Almost invariably young persons
are attacked with this complaint, so that not unfrequently it is taken for a
venereal  affection, but antispyhilitic  treatment of all kind,  renders it
more painful and makes it worse.   In a short  time the ulcer spreads over
the skin of the scrotum, penetrates deeply, and attacks the testicles, which
swell and become hard.   Hence it spreads along the spermatic cord to the
viscera of the belly;  the glands in the groin swell, and  the  patient sinks
under the  severity of the  pain from extensive  ulceration (2).
   [(1) " Other people," says Pott, "have cancers  of the same parts, and so have
others besides leadworkers the Poictou colic, and the consequent paralysis, but it is
nevertheless a disease  to which they are peculiarly liable ; and so are chimney-
sweepers to  the cancer of the scrotum and testicles." (p. 227.)
  According to Dr. Paris (a) " it deserves notice that the smelters are occasionally
affected with a cancerous disease in the scrotum, similar to that which infests chim-
ney-sweepers, and it is singular that Stahl  in  describing  the putrescent tendency
in the bodies of those who die from this poison, mentions in  particular the gan-
grenous appearance of these parts." (p. 97.)
  Although  the disease almost invariably is produced in  the scrotum, yet  in rare
cases it is seen on other parts.  Earle mentions '"a remarkable instance of its oc-
currence at the wrist of a  gardener,  who was every spring employed to distribute
soot for the destruction  of slugs, which is related by  his father in the last edition of
Pott's Works" (p. 297.)   Astley  Cooper saw chimney-sweeper's cancer twice,
and Keate once upon the cheek.
   (2) Earle states that when from infection by this disease, the tpsticle "becomes
greatly indurated, ulceration,  and sometimes  sloughing, then take place, leaving a
deep excavated ulcer, that penetrates  into the body of the testis, which does not ap-
pear disposed to the formation of fungous growth similar to what occurs when the
scrotum is the seat of the disease.   The same observation applies when  the com-
plaint has extended itself to the inguinal glands; its progress in glandular structures
appears to be more rapidly destructive, without the slightest  effort at reparation.
The disease in every instance  that I have seen, except one, extended itself to the parts
immediately contiguous.  The inguinal  glands  are often  enlarged, but they will
generally subside on the removal of the diseased scrotum,  clearly proving that the
disease  is not commonly communicated in the course of the absorbents.  This is a
very important feature in the  complaint, and  one which most materially influences
the prognosis and treatment.  I know but one exception to  this rule, where a bubo
formed, which suppurated, and the sore assumed the same  character as the primary
affection in the scrotum." (p. 298.)   This statement of the  subsidence of a swelled
inguinal  gland, is very remarkable, and if generally supported, would form  a very
important and  hopeful  feature in the disease; but I  am afraid experience does not
verify it.—j. k. s.
  Travers (b) says:—"The disease resembles  lupus of the cheek  and eyelids in
destroying  the  skin and  cellular  texture, leaving  the testicles and  ligamentous
covering of  the crura penis, as that does the sclerotic, bare and wasted, but other-

          (a)  Pharmacologia, vol. ii.  London, 1825.  8vo. Sixth Eition.
          (b) Med.-Chir. Trans., vol. xvii.  1832 
CANCER OF THE WOMB.                   561
wise uninjured.  This sore has no tendency to slough or penetrate deeply by ulcera-
tion.  The  lymphatic  glands  are rarely, and seldom, specifically affected."  (p.
345.)]
   2505. The cause of the disease must be considered to be the ingrim-
ing of soot into the  wrinkles of the scrotum (1).  It rarely occurs before
thirteen years of age (2), and appears  at first to be simply a local disease,
although there may  be a general disposition thereto {a.)
   The only remedy to prevent the progress of the disease is cutting out
the ulcerated part of the scrotum, or  its destruction with arsenical oint-
ment.  If the operation be put off till the testicle be affected, extirpation
has  in general an  uncertain  result; and in  many cases  although the
wound have completely healed, the disease may re-appear  some  months
after (3).   When it has once spread so far that the removal of the testi-
cle is no longer  possible,  palliative treatment  according to the general
rules, alone remains.
   [(1) It may be this  disease depends on some chemical peculiarity of coal soot, as
foreign writers take no notice of  its occurrence in countries where wood is used for
fuel.—j. f. s.
   (2) Pott says he never saw chimney-sweeper's cancer under the age of puberty.
And Earle  states:—"It very  rarely attacks  persons under the  age of thirty, who
form a very small proportion of the number engaged in the business.  The greater
proportion of cases which I have seen, have  occurred between thirty and  forty; I
have seen three  instances between  twenty and  thirty, and only one at  the age of
puberty. A solitary instance is recorded by my father, where it occurred in an in-
fant under eight, but I have never met with any similar case." (p. 299.)
   (3) I have lately had  under my care a  man, for whom my  colleague,  Green,
removed a  chimney-sweeper's cancer nineteen years since;  the  disease having
recurred.  The return of the disease seems evidently to depend  on exposure to the
cause which originally produced  it, as so far as I am aware, if persons change their
occupation, it does not recur, if removed before the glands have become tainted.—
j. f. s.]
                   H.—OF CANCER OF THE WOMB.

  Roederer, S. G., De Scirrho Uteri.  Gottingae, 1754.
  Haller, Comment, de  Uteri Scirrho.   Gottingae, 1756.
  Joeroens, Ueber den Scirrhus  und das Carcinoma der inneren weiblichen  Ge-
burtstheile;  in Hufeland's Journal, vol. ix. part. i.
  Wenzel,  C,  Ueber die  Krankheiten des  Uterus.   Mannheim, 1817;  with
plates.
  Beyerle, F. J,, Ueber  den Krebs der Gebarmutter.  Mannheim, 1817.
  Patrix, Traite du Cancer de la Matrice et sur les Maladies de Voies urinaires.
Paris, 1824.
  von Siebold, E., Ueber den Gebarmutterkrebs, dessen Entstehung und  Ver-
hutung.  Berlin, 1824.
  von Siebold, E. C. J.,  Dissert, de Scirrho et  Carcinomate Uteri, adjectis tribus
totious Uteri exstirpationis observationibus.   Berol., 1826.
  Schmidt, W. J., Erfahrungs-ResultUe iiber die Exploration bei dem Scirrhus,
Krebs und anderen krankhaften Zustanden des  Uterus;  in Harless's Jahrbiicher
der deutschen Medicin und Chirurgie, vol. i. p. 74.
  Schmitt's obstetr.  Schriften, p. 100.   Wien, 1820.
  Bn ndell, James,  M.D., Extirpation of the Uterus; in  London Medical Gazette,
vol. ii. p. 291, 733, 7H1.  1828.
  Montgomery, W. F., M. D., Observations dn the Incipient Stage of Cancerous
Affections of  the Womb;  in  Dublin  Journal of Medical  Science, vol. xx.  p. 433.
1842.
                      {a) Earle, Med.-Chir. Trans., p. 299.
  Vol. in.—48 
562                          DIAGNOSIS
  Churchill, Fleetwood, M.D., Outline of the Principal Diseases  of Women.
Dublin, 1835.  12mo.
  Ashwell, Samuel, M.D., A Practical Treatise on the Diseases peculiar to Wo-
men.   London, 1844.  8vo.
  Simpson, James Y., M.D., Case of Amputation of the Neck of the Womb fol-
lowed by Pregnancy; with Remarks on the Pathology and Radical Treatment of
the Cauliflower Excrescence from the Os Uteri;  in Edinburgh Medical and Sur-
gical Journal, vol. Iv. p. 104.  1841.
  2506.  Cancer of the womb almost  invariably commences in its neck,
and in general upon the hind lip of its mouth.   At  first the symptoms
are doubtful, and not distinguishable  from any other irritable state of the
"womb.  Most commonly menstruation is  irregular,  sometimes a sanious
sanguinolent discharge, or  a copious white discharge, with  an uneasy
sensation of tightness  and  dragging in the  loins, frequent disposition  to
void  the urine, tenesmus and  darting stabs through the neck of the womb.
  On examination, the vaginal  poition  is  found partially or completely
hardened, and in some parts loosened  up.   The mouth of the womb is
also notched, irregular, and half open.   On pressure with  the finger, a
sanious fluid mixed with blood flows  out.
  [" In the great majority of instances," observes Montgomery, " the first discover-
able morbid change, which is  the forerunner of  cancerous affections of the uterus^
takes  place in and around the muciparous glandulae or vesicles, sometimes called
the ova Nabothi, which exist in such numbers in the cervix and margin  of the os
uteri; these become indurated by the deposition of scirrhous matter around  them,
and by the  thickening of their coats, in consequence of which they feel at first al-
most  like grains of  shot or gravel under the mucous membrane ; afterwards, when
they have acquired  greater volume  by further increase  of  the morbid  action, they
give to the part the unequal, bumpy or knobbed  condition, like the ends of one's
fingers drawn close together.  When this second stage (usually described by writers
as the first) is established, all means hitherto devised have failed in producing any
permanent benefit." (p. 439.)]
   2507.  The  disease  may remain in this state many months, and  even
years,   The symptoms become more severe, spread over the pubes and
thighs, the discharge becomes  very ichorous, stinking, and mixed with
pieces  of slough  and  clots  of  blood ;  frequently there are very violent
bleedings.   The  general health is much  affected ;  all the symptoms  of
cancerous  consumption,  with  the characteiistic   leaden  countenance,
make their appearance, and  death ensues, either quickly, or after a se-
vere bleeding, or as is usual, under  the horrible tortures of hectic con-
sumption  (1).
   On examina'ion of this advanced state of the  disease, the vaginal por-
tion  is found ulcerated, more or less destroyed, beset with warty growths
 and  hard knots, which ascend into the cavity of the neck of the womb.
 Sometimes the womb itself, sometimes the upper part of  the vagina is
 hard and  degenerated ; the ulceration may even  extend to the rectum and
 bladder, in consequence of which the sufferings become more severe.
   [(1) " The popular opinion, that cancer of the womb is invariably accompanied
 by acute suffering is," observes Ashwell, "certainly incorrect.  But it is true that
 in some instances,  scarcely any infliction  can equal, and certainly hone can exceed,
 its agonizing, burning and lancinating pain.  * *  *  By most the pain is de-
 scribed to be lancinating, as though sharp  knives  were constantly being plunged into
 the  neck of the womb ; and so constant  is this characteristic, that some  authors
 found on it the diagnosis between corroding ulcer and cancer.  There are, however,
 Hot a few cases in which the  hot burning character constitutes its great aggravation. 
OF CANCER OF THE  WOMB.                   563
 In the milder forms, where the progress is very slow, the pain is wearing and con-
 stant, but endurable."  (p. 414.)
   "These pains,"  remark Bayle and Cayol (a), "are sometimes so acute, that
 persons have been known to die of convulsions, or delirium, occasioned by cerebral
 fever." (p. 415.)
   Montgomery (b) mentions an instance in which " the last five or six weeks of
 the patient's life were grieviously embittered by the most uncontrollable and inces-
 sant vomiting, accompanied with slight pain and tenderness  on pressure  over the
 stomach, but not in other parts of the abdomen."
   And Ashwell mentions a case, "where the malignant ulceration, commencing in
 the indurated deposit of the urethra, extended  into the vagina,- the aggravated pain
 was greatly alleviated by belladonna and conium, used topically;  the  appetite and
 health were so  far improved, and the  ravages of the disease so much checked for a
 considerable time, as to inspire the  hope that a respite of at  least many months
 might have been  obtained.   But just as these expectations were at their height,
 agonising pain  suddenly and inexplicably recurred, and the patient sank in less than
 a week." (p. 334.)
   2508.  Cancer  of the  womb,  like cancer in  general,  exhibits many
 varieties in its progress ;  in persons with  dense fibre, it is rather the pro-
 gressive ulceration of scirrhous  parts, but in pasty persons it is  mostly
 accompanied with fungous growths and  very copious  bleedings.
   The diagnosis is in general easy, and the more so as the practitioner
 is usually only first consulted when the disease has made some progress.
   Those diseased conditions, which at  first  have some resemblance to
 cancer of the womb, but are easily distinguishable, are  chronic inflam-
 mation  and  benignant  hardening, steatomatous   (fibrous degeneration,
 eversion of the  womb, polyp, and medullary fungus.
   [The " Cauliflower Excrescence from the Os  Uteri," as it  is  called  by Dr.
 Clarke (c), is  a  form of disease by some regarded  as truly cancerous, and  by
 others as a morbid tissue, not necessarily of a malignant or carcinomatous nature.
 Upon this point Simpson observes:—" A number of circumstances appear to me to
 show, that, in reference  to, at least, the  first stage  of cauliflower excrescence,  the
 opinion of these latter authors is probably correct.   The  occurrence  of the disease
 in some cases as early as the twentieth year of life ;  its occasional shrinking, and
 almost  total disappearance upon the application of a  ligature, or after death ; the
 frequent slowness of its  general progress during life; the apparent absence of dis-
 eased deposits in the neighbouring tissues and  parts upon the dead body; and above
 all, the alleged  restriction, and even complete removal of the tumour in one or two
 instances, by the use of astringent applications and other simple means, form so
 many circumstances strongly pointing to the opinion, that in the earlier part of its
 progress, the tumour cannot be regarded as  of a carcinomatous  character.  Has it
 any analogy in  its pathological nature and origin—as it certainly has  in its physical
 characters—with the soft warts and condylomata that sometimes form  on the mucous
 membrane of the vulva and entrance of the vagina?  These warts and  condylomata
 have the same tendency to degeneration after their imperfect removal, and present to
 us a striking exception to the  general  pathological law of the local reproduction of a
 morbid growth  being a sign of its malignancy.  But whatever  view we may take
 of the primary nature of the  cauliflower excrescence of the cervix uteri, we have
 sufficient evidence for believing either that this disease  has been often confounded
 with carcinomatous  or medullary fungus from the cervix uteri, from the want of ade-
 quate diagnostic marks to distinguish them; or that, though non-malignant in its
 commencement, the cauliflower excrescence  may, like  some other local benign
 growths, become the seat of carcinomatous deposit and malignant action, during its
 progress."  (p. 109.)  May the degree of mobility of the cervix uteri serve in  any
case as a source ofdiagnosis ?  " The tendency of cancer," as observed by Muller (d),
  (a) Quoted by Ashwell.                provement  of   Medical  and  Chirurgical
  (ft) Dublin  Hospital Reports, vol. v. p.  Knowledge, vol. iii. p. 21. 1809.
 434.                                      (d) Neue Zeitschrift  fur  Geburtskunde,
  (c) Transactions of a Society for the Im-  vol. iv. 
564         MODE OF USING THE SPECULUM VAGINA,

" is to interfere with the natural structure of surrounding parts, while those forma-
tions which are of a benignant nature, leave the neighbouring healthy tissues un-
altered."  (p. 176.)  In carcinomata of the cervix uteri, we thus generally find, even
at a pretty early stage of the disease, that the organ  has become more fixed and im-
moveable than natural, in  consequence of the morbid deposit affecting both the
structure of the neck of the organ and the  contiguous surrounding tissues.  Does
the reverse of this hold good with regard to cauliflower excrescence of the cervix
uteri? (p.  110.)]
   2509.  Cancer  of  the  womb may be developed at every period after
puberty;  it however, most commonly appears between the fortieth and
fiftieth years in women whose  sexual functions have never been in proper
order, and who have had much  trouble and care.  Mechanical injuries
operating on the  womb,  rough treatment  in delivery, constant irritation
of the womb in its dropping down or protrusion; irritating astringent
injections for flooding or for the whites, very frequent  connexion, espe-
cially  with disproportion of  organs,  as well  also as frequent venereal
excitement without  connexion, and luxurious living at  the  climacteric
period, must be  considered as the  most  common and active causes of
cancer of the womb.  Syphilis, gout, and scrofula, are also frequently in
causal relation with cancer of the womb; and hereditary disposition is not
unfrequently noticed.
  ["Cancer is not often a disease of the young; although some years ago," says
Ashwell,  "I attended  a case with Dr. Pierce, where the patient had not reached
her twentieth year.  Boivin  and Duges, in four hundred and nine examples, found
twelve under  twenty years of age; eighty-three,  between  twdnty and thirty; one
hundred and two, between thirty and forty; one hundred and six, between forty and
fifty-five; and ninety-five, between forty-five and fifty.  Mr. Carmichael saw a
case at twenty-one years of  age; and Wigaud  adduces one of scirrhous uterus at
fourteen years." (p. 375.)]
  2510. The cure of cancer of the  womb has been attempted by internal
and external remedies, and by the destruction or removal of the diseased
part.
  2511. As to the employment of internal and external  means, only in
such cases may a  favourable result be expected from them when the dis-
ease is not actually cancerous, but is simply benignant swelling and hard-
ening, or that state of ulceration which, under neglect or  improper treat-
ment, may run into actual cancer.  Hence, the successful issues which
have been observed by means of proper antiphlogistic treatment, repeated
application of leeches to  the sacrum and to the upper part of the thighs,
and in full-blooded persons even blood-letting, and  at the same time the
use of calomel, hemlock, digitalis,  belladonna, aqua lauro-cerasi and the
like, soothing baths and injections into the vagina, purgatives, and when
the cause has been syphilitic,  properly managed mercurial treatment.  In
true scirrhus or cancer, the remedies directed (par. 2415) for cancer in
general may indeed  lessen the sufferings, but never  effect a cure.  This,
as in  cancer in general, so in  cam;er of the womb, is only possible by the
removal, or by the destruction of the scirrhous  or cancerous mass.
  2512. It is self-evident that the circumstances already mentioned {par.
2410) as  regarding operations on cancer in general, which either render
them  difficult, impossible, or  contraindicate them, are still more weighty
in reference to their application to cancer  of the womb, as decision upon
the extent of the degeneracy,  and the participation of the patient's health,
is, subjeqt, to still greafer diffipulty than under other, qircumstance,s. 
IN CANCER  OF THE WOMB; EXTIRPATION.          565
  2513.  Examination with the greatest attention can alone ascertain the
condition of the womb, as well also as an inspection of the parts by means
of the speculum vagine which  must be passed into the vagina as high as
possible, so that the  neck of the womb may be received into its upper
opening, which can alone be distinctly distinguished when the speculum
is illuminated with a candle.

  The specula  uteri et  vaginae are rather conical cylinders of tin polished on their
interior (Recamier,  Dupuytren,  Dubois  and  others); or  two-armed (Lisfranc,
Jobert, Duges, Ricord); or three-armed  (Busch, Ehrmann, Weiss);  or many-
armed (Grillon Beaumont, Colombat.)  The two-armed  are  usually most con-
venient.
  The following circumstances are to be attended to in  the introduction of the
speculum uteri.   The patient  is to be laid opposite the  light  upon the edge of a bed
or table, with her buttocks a little raised, and her feet supported by assistants, or
resting on a stool.   The practitioner standing between  the thighs, separates with the
fingers of his left hand the labia, and holding in  his right hand the speculum, warmed
and smeared upon its external surface with grease, passes the part next the commis-
sura labiorum posterior some lines deep into the vagina, presses it upon the commis-
sure, and  at the same time  raises the handle, so that the part resting against the
pubes descends from the urethra into the vagina, and is  carried to its very end.   The
two arms  of the speculum are now separated by gentle pressure on the handle, and
then by the admission of the daylight, or by holding a  taper, the state of the vaginal
part of the womb can be observed (a).
  [Simpson (b) has  made the following valuable observations, in reference to the
mode of using the speculum vaginae.  "It is  almost unnecessary, we  believe, to
insist at the present day, upon, the importance o*f the early and accurate  local ex-
amination of the uterus, in  all cases  of suspicious vaginal discharges.   In  some
instances, examination by the finger may be sufficient, but  in every doubtful  case
the speculum should likewise be resorted to, if there is  any affection of the vagina or
cervix.  We have found it often  confirming, and not unfrequently, also changing
and rectifying the opinion which the mere tactile  examination had led us to adopt.
In this country great  difficulties have been placed against the more general introduc-
tion of the speculum  into practice, in consequence of the disagreeable and revolting
exposure of the person of the patient, which is usually considered necessary in its
employment.  We have latterly in our own practice endeavoured to avoid this very
natural objection, by teaching ourselves to introduce and use  the instrument  when
the patient was placed on her left  side, in the position usually assumed in making
a tactile examination, and with the nates  near  the edge of  the bed.   We strongly
recommend our professional brethren to follow this plan, as by it, and with attention
to the management  of the bed clothes, we have found that the instrument can be
perfectly employed  with little, or  indeed without  any exposure of the body of the
patient.   The speculum is introduced easily without the assistance of  sight, and the
mouth of it only requires to be afterwards uncovered,  in order to enable us to ex-
amine the cervix uteri and top of the vagina.  We have made trial of many different
forms of specula, and find, fo* almost all purposes  that of Ricord by far the  most
manageable.
   " In exposing the cervix uteri for the purpose  of drawing blood from,  it by scarifica!-
tions, in cases of chronic congestion and metritis, we have occasionally employed a
tubular speculum with advantage, but even in this case thedouble-bladed instrument
is equally useful, and in some instances preferable.  In a case of ulcer of the os uteri,
which we are at present attending  with. Dr. John Gairdn.er, and where the passages
are much relaxed, and the uterus very low in the vagina, we have, on Dr. Gairdner's
suggestion, employed with much advantage a short tubular speculum of only an inch
and  a half in length, and with a deficiency or opening along the course of one side
of it, of sufficient size to enable us to pass our  finger,,  for the purpose of placing the
diseased part in the proper centre of the instrument.  We have thus been  enabled to

  (a) Lisfranc, Du Toucher;  fn his Cfinique Chirurgicale; in Gazette Medicale, vol. i. p.
591.  1833.
  (b) Above cited.
                                     48* 
566         TREATMENT OF CANCER OF THE WOMB
touch easily the ulcerated surface with different, applications; while with the usual
instruments it was found a very difficult task, to fix in this instance the very mobile
cervix uteri."  (pp. 105, 106.)]
  2514. Cases of successful extirpation of prolapsed and everted womb
(par. 1289) first inclined  B. Osiander to the performance of this opera-
tion for cancer  of the womb, or rather of its lower part thus degenerated.
Osiander has described two modes of performing this operation.
  First.—The fungus is to be first removed, then the womb fixed in the
bottom of the vagina by means of a thread drawn through its neck or by
means, of forceps, and afterwards the degenerated  neck cut off by an
arching cut with a curved, narrow, round-ended bistoury.   The bleed-
ing must be stanched by plugging, or, by styptic powder.
  °Second.—lf the greater part of the neck of the womb be destroyed by
Gancer, if it have spread far, and its cavity be filled with knobby, carcino-
nxatoxxs fungus, and the mouth of the womb  cannot be seized and drawn
down with needles, the patient must be placed in the horizontal posture,
the womb thrust down by pressure on its fundus, which must be fixed
in the cavity of the sacrum with the forefinger of the left hand, the middle
and "ring-fingers introduced into the cavity of the womb, and whilst they
perform the  cut with a panvof curved-bladed scissors, or an extirpating
instrument, all  the fungous irregular scirrhous parts are removed  in small
pieces.  The cavity is then filled with sponge moistened  in wine and
styptic powder, and after the-bleeding is stanched a sponge dipped in
lead wash and vinegar is  to be passed up,   When suppuration comes on
if must be encouraged- by a mixture of extract of green walnut-shells,
honey  and  red precipitate  applied upon a sponge immediately to the
surface of the wound.   As the suppuration increases the mixture is to be
used in smaller, quantity, and. without the precipitate.   At the same time,
internal strengthening medicine must be given (a).
   2515.  Dupuytren's method is more simple and efficient.  The patient
having been placed in the same position as for lithotomy, he introduces
the speculum vagine and  gives it to an assistant to hold.  He then grasps
the neck, of the womb with a pair of forceps, draws it slowly towards him,
and cuts, off'the whole of the degenerated part of the.neck of the womb,
 either with a.dbuble-edged  bistoury curved towards its  side, or with  a
pair of scissors curved-in  like manner, which are used above, below, and
 on both sides in such way that their concavity is always directed towards
 the neck of the womb.   The bleeding in  this operafion is generally in-
 considerable, though it may be great and even severe, in which case,  if
 ^proceed from  any one  single spot of the  wound, that may be touched
 with a,small actual cautery iron ; but  if the bleeding be from the whole
 surface, it must be stanched by tightly plugging the  vagina.  If inflam-
 matory symptoms  occur, corresponding antiphlogistic treatment must be
 employed.  After suppuration  is set up, four, or six injections  of warm
 water must be made,  and afterwards a weak  solution of chloride of lime
 thrown up.  If there  be a, luxuriant growth  of  granulations they must
 be touched with nitrate  of silver.  In two or three weeks at  most the
 wound has scarred (b).
    (a\ Reichsanzeiger.  1803-.  No. 300 ; p.    (fc) Sabatier, Medecine Operatoire, vol.nL
  3926.—Gottinger zelehrter Anzeiger. 1808;  p. 97. 1824.' New Edition.
  p. 1300. 
BY CAUSTIC POTASH \ ITS EXTIRPATION.           567
  Canella (a) has given a peculiar speculum vaginae, together with forceps and a
curved knife, with which, when the neck of  the womb is drawn, into the cavity of
the speculum, the degenerated part may be cut off.
  J. Hatin (b) has also proposed  a  speculum, vaginae, which may be expanded at
pleasure, and by it an instrument can  be introduced into the cavity of the womb, for
the purpose of fixing it, and then with a jointed uterotome the projecting part of the
neck of the womb can be cut off.
  von Walther, in a case, the account of which is still to be expected, first sepa-
rated  the pubic arch, and then cut off the neck of the womb.
   When the neck of the womb, on account of its softening or destruction, will not
permit the application of the foreeps,  the vagina and peritoneum must, according to
Recamier, be cut into before and behind, and  the womb then seized with the forceps,
drawn down, and the degenerated part cut off.
   Lisfranc  (c) employs a speculum vaginae, consisting of two half cylinders of tin
connected by a hinge, and which may be separated from each other.  After its intro-
duction, the  enlarged neck of the womb can be seen, and the  necessary instruments
introduced.  With Museux's hook-forceps, made longer and stronger than usual,
he seizes the neck of the  womb, and  with an artificial lever,  acting for from five to
fifteen minutes, produces a  prolapse, and cuts off the degenerated part  with a bis-
toury at several small strokes.
   Colombat (d) has, for  the purpose of preventing the pain in drawing down the
womb, invented a hysterotome, with which, after the introduction of the speculum
vaginae, the neck of the womb can be seized and  cut off.
   Bellini (e) has invented a spoon, with a cutting edge in front and a long curved
handle ; and Cenulli (f) and Aronsohn (g) other, instruments for extirpating the
neck  of the womb.
   2516. When the degenerated neck of the womb is so soft that  it can-
not in any  way be fixed  without tearing, or wThen the  disease recurs after
it has been removed^ its destruction by caustic  is indicated;   For  this
purpose Recamier uses nitrate of silver, and Dupuytren nitrate of mer-
cury dissolved in  nitric acid, and caustic potash, which is preferable.
   Mayor's (h) practice of tying the neck of the womb with the assistance of forceps-
must also be mentioned*.
   2517. The caustic potash is to be applied in the following manner: —
The  patient having been placed  in the  same posture as for excision,  and
the speculum vagine introduced, the cancerous surface is to be eleansed
with a wad  of lint, pressed against it with the forceps for a sufficient
time.  If the surface  of, the ulcer be  irregular  and  beset with fungous
growths, they must be removed  with-scissors  curved towards-their  sur-
face, or with  a proper extirpation-knife.   A wad* of lint  must then be
placed below the  surface of the ulcer, to suck  up all  the fluid part of the
caustic which escapes during the process ;  the whole  surface of-the ulcer-
is now carefully dried withjint,  and a conical  piece of caustic  potash, at
least an inch broad  at its  base,  blunt  at its tip, and fixed on a holder,
must be applied for at least a minute,  unless  the  patient  should suffer
very great pain, which  is rare.   After this the vagina must be injected
  (a) C('nni:deH'  Estirpazione della Bocca
c del Collo dell' Utero et Pcscrizione del Me-
trotomo, etc.   Milano, 1821.
  (6) Memoire sur un nouveau procede pour
l'Amput;itionMiu Col de la Matrice dans les
Affections Cancereuscs.   Paris, 1827.
  (c) Costeh, Manuel de Medecine Opera-
toire, p. 138.
  (d) Memoire sur 1'Amputation du Col de
la Matrice dans les Affections Cancereuscs,
Buivant un nouveau ptocede; in Revue Medic
cale.  1828; vol. ii. p. 194>—Lisfra\c, Me-
moires eur l'Amputation du Col de I'Uterus,
par Avenel; in Revue Medicale.  1828; vol.
iii. p. 5, p. l!)9.
  le) Omodei, Annali Universalis vol. xkii.
p. 355.  1828;
  (/) Archivo delle Seienze Med.-Fisiche
Toscm. 1837 ; pi. i.
  (g) Hamburger Zeitschnft, vol. i. part iv.
  {h) Archives Generales de M&Jecine, roL
xvi. p. 91.  1828;. 
568                     TOTAL EXTIRPATION

several times with water, the speculum and wad of lint removed, and the
patient put into a lukewarm bath.   In four or five days, when the irrita-
tion has  passed off, and the slough has separated, the operation is to be
repeated  in the same way, if the state of the  parts seem to require it.
Should  symptoms of inflammation of the womb and of the peritoneum
occur after the operation, strict  antiphlogistic treatment will be requisite.
This mode of practice, although it will not ever effect a cure,  in most
cases relieves the patient considerably (a).
   2518.  It is evident that this mode oftreatment is alone indicated, and
a cure thereby effected, when the disease is in its beginning, when there
is not any accompanying general exciting cause, nor any ensuing affection
of the whole constitution; when the exhaustion is not  very  great, when
there is not any aff'ection of the  neighbouring parts, and when the seat of
the disease is such that the whole degenerated part can be removed.  The
result of the operation is, however,  here just as doubtful,  and even  still
more so  than  in the extirpation of any other cancerous  part;  because,
cancer of the womb is liable to escape the most careful examination of
the extent of the disease.  On  the other hand, however, it  must be re-
membered, that  in  cancer which arises in the neck of the womb, the
boundary between the healthy and degenerated part is in  general sharply
defined,  whereby the result of the operation can be the earlier determined,
as cancer  of the neck of the womb, as it is commonly developed, is  a
consequence of continued local ailment  (b).   Experience,  however, is
opposed  to those who  have  denied the successful  result of  such partial
extirpation (c).  But a  review  of these cases proves that, on the other
hand, the value of  the operation has been overrated, as  it brings about
temporary, but very rarely lasting  benefit, whilst fatal  results have  fre-
quently  ensued;  and  in the successful  cases  the  correctness  of  the
diagnosis may  perhaps be doubted.
   2519.  Extirpation of the whole  womb, if  there be no accompanying
prolapse, has by some been considered impossible ; by  others absolutely
fatal; by some holding out no hope  of a favourable issue; because in the
case indicating it,  the disease has so far advanced that  no resistance can
be expected from its extirpation (d)
   Struve (e) proposed to effect a prolapse of the womb by drawing  it down with
forceps, separating the vaginal portion with a semicircular  cut, tying the vessels,
and freeing the womb from its ligaments.
   Gutberlat (/)  proposed extirpating the womb, having  previously made a cut
through the walls of the belly, in the linea alba.
   C. Wenzel  (g) proposes the extirpation of the whole womb, having first pro-
  (fl) Bulletin de la Faf,ulte de Medecine.
No. VI.  Juin, 1819.—Patri.k, abov'' cited,
p.  145.—Sabatiek,  above  cite<l.—»Wed.r-
meier ; in Langenbeck's  Neuer BibliotKek
fur Chirurg. und Ophthalmol., v"1. ii. |>. 5.76.
—Ammon, l arallele der franzOsischen  und
deutschen Ch.uurgie, p. 257.
  (6) Canella, Giornale di Chirurgia Prat-
tica.  Aug., 1825,
  (c) Siebold; in his Lucina, vol. i. p. 403.
—Wenzil, C, U ber dio Krankheit n. des
Uterus.  Mainz, 1816..—Zang, Operationen,
vol. iii. p. 392.—Joerg, Aphonsmtn ueber
die Krankheiten des Uterus, zur Wurdegung
zweier von  Hofrath Osiander; in Leipzig
unternotnmenen Operationen, Leipzitr, 1820.
  (d) Paulv, Maladies de l'Ute,rus d'apr&s
les  Legons  Cliniques  de M.  Lisfranc.
Paris, 1836.—Pigne; in his French transla-
tion of this liandbuch.
  (e) Hufelani>'s Journal, vol. xvi. part iu.
p. 123.  18:3.
  (/) Siebold's Journal  fur die Geburt-
shi'ilfe, vol. i. par? ii.
  (g) Abuve cited. 
OF  CANCEROUS WOMB.                   569
duced an artificial prolapse, by means of a pair of strong, toothed polyp-forceps, and
then tying it with a ligature round its base, which is gradually tightened.
  Langenbeck (a)  undertook the extirpation of a protruded carcinomatous womb;
he dissected off the protruded vagina from its  connexion with the womb, without
cutting it through ;  separated the peritonaeum from the  substance of the womb, till
the  upper edge of the base  of the latter  was  freed from its  peritonaeal covering,
which he then cut off in such way that a small healthy portion of its substance still
remained attached.  After this shelling,  the peritonaeum formed with  the vagina an
empty  sac,  which, when the bleeding was stanched,  he  filled with lint.   The
ovaries and round ligaments  should be removed together with the womb.
  Laud Wolf (b) extirpated a scirrhous prolapsed womb with a fatal result.
  Recamier (c) successfully  removed one by tying it.   He also  (d), in a case of
cancer with polapse of the womb, removed it, after ascertaining that no bowel was
contained in the sac of peritonaeum, by means of a needle carrying a double thread,
and tied on each side.
   2520.  The  assertion of the  impossibility of  extirpating  the  whole
womb, has  been  disproved by  a case in which Sauter (e) performed
this operation  successfully.   He considers this  operation, having never
seen any cure by partial  extirpation, as suitable and  practicable, when
there  is  in the  vagina,  around the  neck  of the womb,  still sufficient
space to allow the  knife being carried around all the diseased part, and
when no general  symptoms exist which contraindicate  the extirpation.
  [That a patient can recover after extirpation of the womb, even under most un-
favourable circumstances, is proved by the case related1 by Rossi (/), in which, after
the delivery  of both child and placenta, the midwife, on  passing her hand into the
vagina, felt a swelling, which she mistook  for another child.  This she pulled with
such force, that the tumour, which was the womb, was dragged from its attachments,
and then cut it off the vagina with a knife, and removed  it entire.  Notwithstanding
this horrible treatment the woman recovered.]
   2521.  Sauter lays  down the following rules for  this operation:—
After emptying the bladder and the rectum, the  patient  is laid across  a
bed and properly fixed.   An  assistant passes his hand  over the pubes, in
such way, that with the flat of it he' can press down the womb into the
pelvis, whilst with the back, the bowels are kept up and away from the
pelvis.   The operator introduces the fore and middle  fingers of  his left
hand into the vagina, till  they reach the hollow-it forms around the neck
of the womb;  then carries a curved bistoury, with a short blade and long
handle,  between the  fingers, up to this  part, cuts  through the vagina
upon  the womb, about two or three lines deep, and carries this cut
around the whole neck.  A pair of scissors,  curved towards their edge,
with long handles,  are now passed  between  the  two fingers, and a  snip
made between the  bladder and rectum upwards through the peritoneum,
keeping  close to the  neck of the womb,  whilst with  the  fingers like a
hook, the tough cellular connexions  are grasped, directed into the scissors,
and with these carefully cut through.   When the division is so far made
that the  two fingers can be passed  through the opening into  the  cavity
of the belly, the separation may be made in a like manner between the

  (a) Neue Bibliothek fur die Chirurgie    (e)  Die ganzliche Exstirpation der carci.
und Ophthalmologic,  vol. i. p. 551.          nomatosen Gebarmutter, ohne sdbst ent-
  (b) Archives generales de Medecine, vol.  standenen oder kunstlich bewirkten Vorfall
X. p. 105.   1826.                        vorgenommem und glucklicli vollfuhrt; mit
  (c) Revue  Medicate.  1825; vol. iv. p.  naherer  Anleitung,  wie diese  Operation
393.  December.                        gemacht werden kann;  mit  Abbild. in
  (d) Recherches sur le Traitement du Can-  Steindr.  Constanz, 1822,
cer, &c.                                 (/)  H Raceoglitore. 
570                       EXTIRPATION
rectum and womb, with scissors curved towards their blades, and kept
close upon the womb.   If the fingers can be passed on the hinder sur-
face of the womb through the peritoneum into the cavity of the belly,
this hinder connexion  may  be completely divided through  the  whole
depth of its deeper sinking,  up to its connexions on the sides, after the
finger like a hook has been passed over the peritoneum, and that has
been drawn down, with a concave knife or a pair  of scissors curved  on
their side.  .The height to be  separated should be about an inch.  The
further the hind connexion  be separated from below upwrards  on the
sides, the easier and safer can the operation be  completed, after  separa-
ting the connexions on the sides.
   2522.  Thus far, by the introduction of the two fingers of the left hand
into the vagina can every thing be effected as to the management of the
knife  and scissors, but now the whole hand, or at least four fingers, must
be passed between the urinary bladder and the womb up  into the open-
ing in the peritoneum, so that  its inner surface  may be  turned back.
Then with the fore and  middle fingers, hooked, the highest connexion
on one side being drawn down from above,  and somewhat forwards, a
concave knife is introduced, carried above the side connexions by means
of the fingers, and  then  keeping close to the womb by continued sup-
porting and carrying the knife with and between the fingers, the side cut
downwards towards the vagina, is made, and  afterwards in like  manner
on the other  side, before the division of the former is completed.   The
remaining side connexions  are now set free, for which the two fingers
are alone needed, keeping close on the womb  and endeavouring not to
cut from the vagina, but continuing  the division into the first-made cut
in the vagina.
   2523. If there be much bleeding,  a wad of dry lint should be first
passed into the vagina, then large pieces of German tinder placed round
its wall within the pelvis, and the vagina plugged  with either more Ger-
 man  tinder or lint.   If the bleeding require  no attention,  after a  wad of
 iint has been passed into the vagina, dry lint, or mixed with gum-arabic,
 must be introduced, but the vagina is not to be plugged.   The patient is
then  to be put to bed in the horizontal posture,  and then the assistant
removes his  hand, which had prevented the descent of the bowels, from
 above the pubes.
   The after-treatment must be conducted according to the general rules,
 with special attention, that  the horizontal posture, with rest, should  be
 continued for at least fourteen  days, and if purifying injections into  the
 vagina be necessary, they should be  made carefully, so that nothing pass
 into the cavity of the belly.  The vagina must never be  stopped below
 with lint.
   2524.  von Siebold (a) has twice performed extirpation of the whole
 womb.   He  introduced  a  catheter into  the bladder, so as more  surely
 to avoid it, and then  with Savigny's fistula-knife, divided  upon two
 fingers behind the transverse branch of the share-bone, the right side of
 the vault of the vagina, close  to the vaginal portion of  the womb,  and
 afterwards the left side.  For the  purpose  of passing the whole hand,

   (a) Beschreibnng einer vollkommenen Exstirpalion der Scirrhosen nichtprolabirten Ge-
 barumtter.  Frankfurt, 1824. 
OF CANCEROUS WOMB.                  571
the perineum must be cut through, so that the ala vespertilionum may be
divided with the polyp-scissors to the very fundus of the womb.   In the
second case, after the division of the top of the vagina, a thread is passed
by means of a flexible silver needle through  the neck of the womb, for
the purpose of preventing the recession  of that organ.  Langenbeck (a)
has extirpated the  womb once  through the vagina, and  once by a cut
through the white  line as proposed by  Gutberlat.  Palletta (b) ex-
tirpated the womb wTith  a sarcoma attached to its neck;  in this case he
 drew the sarcoma  inwards, cut into the  upper part of the vagina, with a
pair of long curved scissors, and completed the removal partly with them
and partly with a sickle-shaped knife.   Holscher (c) proceeded in a
like manner.
   2525. Blundell {d)  made a cut into the hind part of the vagina,
 passed in  two fingers to enlarge the opening, and  then again used the
 bistoury to increase the cut  on both sides to  the root of the round liga-
 ments.  He then  introduced his whole hand into  the vagina, and two
 fingers through the opening  in the peritoneum;  upon these,  a hook,
 which he fixed  in the hind surface of the womb, and therewith  drew it
 down, at the same time using the finger of the hand he had introduced
 as a blunt hook to act upon the fundus of the womb.   In this  way he
 brought the whole of the diseased mass near to the external opening  of
 the vagina.   He now cut off the ligaments and the Fallopian tubes close
 to the womb, and the vagina from the bladder with care, so as to wound
 neither  its neck  nor the  ureters.  The operation occupied an hour.
 Five  months after the  patient was well, well nourished, and perfectly
 cured.  Blundell also  undertook the extirpation of the  womb in other
 three cases but all were fatal.
   Banner (e) seized the neck of the womb writh a strong hook, drew it
 down, and fixed it with a loop carried through it.   He then divided
 with a semilunar cut, the hinder uppermost part of the vagina, where it
 is attached to  the womb, and separated the womb from the  bladder.
 The body of the womb  was  then  turned forwards,  and  the ligaments
 were divided.  The patient lost about six ounces of blood, and died on
 the fourth day.
    2526. Delpech (f) considers a partial removal of the neck of the
• womb as never sufficient in any cancerous  affection of the womb ; as
 every mode of examining the extent of the diseased change is fallacious.
 Nothing, but the  complete  removal of  the womb can be of use.  The
 dangers  of this  operation  are, wounding the  peritoneum, tearing the
 parts, bleeding, and especially tying the broad  ligaments of the womb.
 All  these dangers are greater  in extirpating the  swelling through the
 vagina, but less in that through the white line,  where isolated tying of
 the vessels  is possible.  In one case,  Delpech made a  semilunar cut
 through the skin  above the pubic symphysis, and  another in  its axis in
 the  peritoneum.   With one finger in  the vagina and  another in the
 wound,  he  passed  a  pharyngotome  through  the  vagina,  and thrust
   (a) The same, p. 31.                   (e) London Medical Gazette, vol. ii. p.
   (b) Journal von Graefe und von Wal- 582. 1828.
 TH*R, vol. v. part iii.                      (/) Mdmoire  sur l'Ablation del'TJterus;
   (e) The same.                     in Memori 1 des Hdpitaux du Midi.   Oct.^
   (d) Above cited, p. 295.              1830; p.  695. 
572
EXTIRPATION
it  through the upper wound, whilst  a hollow  cylinder kept  up the
vagina.  He then passed an  elastic sound, and  a  metallic  loop, drew
the broad ligaments into the  tube, divided them and tied  the  vessels
singly.  A loop was  next carried round the womb, which was  then
cut off'.  The result was fatal,  in consequence, as  Delpech supposes, of
the tying.
  For the removal of the womb, whilst still in its  place, Delpech gives
the following directions: first, separation of the bladder from the womb'
through the  vagina, after having passed  a catheter into the bladder;  the
finger to be  pressed up to the peritoneum, which must be penetrated
with the finger-nail;  second, a  cut above the pubic symphysis, in which
a semicircular flap is  first  formed  through  the skin, and the white line
which is at its base being  divided  to the extent of five inches, the peri-
toneum lifted up with the forceps, and cut into ; third, one finger being
then passed from above downwards between the bladder and the womb,
to the one or other side of the neck of the latter, raises the corresponding
part of the bottom of  the vagina, and with it  the  lateral ligament of the
womb on that side into the wound.  A cut is now made upon the finger
or upon an elevator in its stead, from above  downwards, and as each
vessel is cut through it is tied.  The other side is managed in the same
way.   The womb is  then pulled forwards, and its  connexion with the
rectum divided, and sponge passed into the vagina.
  2527. According to Dcjbled {a), after the neck  of the womb has been
seized and drawn down to the  entrance of the vagina, the upper and fore
part of the  latter must be cut  through, the opening enlarged with  the v
finger, and the peritoneum stripped off;  and the same must be done on
the hind part.  A ligature  is then passed over the free edges of the  lateral
ligament, and that part of the latter surrounded which encloses the vessels
of the womb, after which  the  lateral ligaments are  cut  through.   The
womb is then easily thrust down, and  its diseased part cut through by a
transverse cut, without interfering with  its fundus.   The patient died
twenty-two hours after this operation.
  2528. Recamier (b) proposed a  mode of proceeding, which like that
of Sauter is specially distinguished by avoidance of bleeding, and in
one case wTith  success, the patient being cured on the forty-third day.
Clysters were given on the evening and morning before the operation.
The patient was placed as  in the operation for  the  stone, and the neck of
the womb having been seized with Museux's forceps, was drawn down
as low as possible.   The vagina was then cut through with a convex
button-ended bistoury, introduced on the left  forefinger, on the fore and
Under part of the  swelling.   The cellular tissue between the bladder and
womb was separated with  the left forefinger up to the folds of the peri-
toneum, and the convex bistoury passed along the finger, following  the
upper  surface of  the  womb, opened the peritoneum, into the cavity of
"Which the finger was introduced upon  the body of the womb.  With a
straight button-ended hernial  knife, introduced  in  the  same way, this
opening was  enlarged right and  left, till  two fingers could  be readily
placed upon the  body of the womb, so as to bear it more forcibly  down.
(a) Journal Hebdomadaire, vol. vii. p. 123.
(b) Above cited, vol. i. p. 519. 
CANCEROTJS WOMB.
573
 With the same knife the two upper thirds of the left broad ligament were
 cut into close  to  the  left side  of the womb, and  immediately after the
 right broad ligament in the same way, the left fore-finger carrying in the
 bistoury.  The left fore-finger was n6w passed behind the remainder  of
 the right broad ligament, and the thumb placed on  its outer and fore part,
 so that with these fingers it was grasped  and  a thread  carried round it
 with  a  needle  having a stem and an eye at its point.  In this part of the
 ligament the uterine artery was found, taken up and tied  moderately tight
 with  a  loop-tier.  The same was afterwards done on the left side.  The
 left fore-finger being now placed behind and the thumb before the liga-
 ture,  the rest of the  broad ligaments were cut through with a button-ended
 bistoury, carried close to the si-de of the womb, whilst  the fingers pro-
 tected  the ligature.   The same was afterwards done on  the left side.
 The womb being now thrust out of the vagina, the  bistoury was tarried
 between the womb  and the rectum, upon the fold of the peritoneum, and
 divided it, and the edge of the  knife being directed obliquely from above
 downwards, and  from before backwards, cut through at last the upper
 and hinder  part  of the vaginti.  Both  loop-tiers  were  now turned up-
 wards,  and with their threads  laid upon  the pubes.   If  the omentum  or
 bowel protrude,  they must be 'Carefully replaced ; and the perfectly hori-
 zontal posture  of the patient will prevent its recurrence.   The urine must
 be drawn off' with a catheter, and the treatment must correspond to the
 symptoms which  occur.   If the suppuration be of bad  kind, careful in-
 jections of lukewarm water should be used.
   In dividing  the l&pper third of the broad ligament, the  little artery of the ovary
 cannot, according to Recamier, well give rise to bleeding on account of the exten-
 sion of the ligament, and if it be  not divided with a very sharp bistoury.  This part
 may be compressed  with the finger, torn, and even a thread  carried round it with a
 much-curved needle.  The ligaments of the womb should always be cut  through
 gradually,so that the divided parts maybe kept close to the external pudic aperture.
 Roux has extirpated two cases of cancerous womb  in this way.   Both died on the
 second day.
   2529. It is  superfluous to speak particularly of the  difficulty of this
 operation, and  of the dangers which may follow it.   Of all the cases men-
 tioned in the preceding paragraphs, the whole excepting Sauter's, Blun-
 dell's  and Recamier's, had a quickly fatal result, and even in these
 three cases  the  consequences  were not permanent.  Sauter's  patient
 had a vesico-vaginal fistula, and died four months after of exhaustion and
 consumption ;  Blundell's died within  the  same year of cancer of the
 vagina, and  Recamier's patient can scarcely stand  or walk, so doubtful
 is the permanent result.  But without it, according to our present know-
 ledge, those who suffer from  cancer of the womb,  are certainly doomed
 to a most painful death.  Of the several modes of practice described, that
 of Recamier seems to be the best.
  Gendrin (a), after having collected all the known cases of extirpation of the womb,
 proposes the following mode of extirpating the womb, by which he endeavours spe-
cially to ensure stanching the blood, and lessening the painful dragging in bringing
 down the womb, as he considers that nearly in all the cases which have died in the
first two  days, death has not been caused by the inflammation, but by the depression
of the powers from the pain in dragging down the womb during the  operation.

  (a) Observations et Remarques sur l'Extirpation  de l'Uterus; in Journal General  de
Medecine, p. 91. 1829.  Oct.
  Vol.  iii.—49 
574    EXCISION OF WOMB BY THE ABDOMINAL SECTION.

  The patient is placed as in the operation for the stone, and a wooden gorget intro-
duced into the vagina for the purpose of pressing aside any excrescences at the neck
of the womb, and fixed at the highest part of the vagina on the right edge of the
neck of the womb.   Upon this gorget a bistoury wrapped in linen to within six lines
of its tip, the extremity of which is covered with wax, or a pharyngotome  is  pushed
to the upper part of the vagina six lines deep from below upwards, and from  behind
forwards, so as to pass into the broad ligament of the womb.  A blunt-ended hernial
knife is now carried into this  little opening and  enlarges it from above downwards
in the wall of the vagina to the length of eight or ten lines according to the extent
of the disease.  After removing the  bistoury and gorget, the hand is  passed into
the vagina, and the  fore-finger into the wound ; the uterine artery is found along this
cut in the upper third of the vagina, six lines in front, at the bottom of the  triangular
space forming the boundary of the connexion between the vagina and bladder.  The
parts are to be  separated  either along the cut or further up, where it is  distant at
least-ten lines from the vagina, so as to  get at the womb in the broad ligament.   A
ligature can then be passed round the womb either with a blunt, curved, aneurysmal
needle, or what, is easier with a thickish leaden thread, to which a ligature is attached
and held by its outer end.  If it be not possible  to get hold of  the artery alone, it
may be compressed with  the wall of the vagina by a plate of lead.  The same is to
be done on the left  side.  A button-ended bistoury very concave  on its cutting edge
is now passed  into the cut on the left  side, with which the wall of the  vagina is
divided horizontally to the right; the instrument must be  supported by the right
fore-finger, introduced half its length into the vagina, and the handle managed with
the left hand.  The front wall of the vagina is  now divided and both the  side cuts
connected, i If the operation be  performed high  up, the vagina and peritonaeum may
be divided together, before and behind,- by two  transverse cuts.   If the peritonaeum
be not at the same time divided, a pharyngotome is carried deeply into one of  the
two side cuts at the back of one broad ligament through the peritonaeum, which
after having been previously stripped off as far as possible with the finger, is to be
divided with the hernial knife, first behind and afterwards before; and in doing this
the whole  left hand must be employed for using the  knife in the vagina.   A double
hook or a pair of hook forceps are now fixed in the body of the womb, which must
be drawn gently down, without bringing it into the vulva.  The whole hand  having
been passed into the vagina, is pushed into the cavity of the belly, the hernial knife
carried behind  the right ligament of the womb, which is made tense, the body of the
womb being drawn to the left  by the hook, and the broad ligament divided from
behind forward, whilst the bowels are kept back with the fingers.  The other side
is to be managed in the same way drawing the womb to the right. The womb must
now be twisted obliquely on its axis, and gradually withdrawn.


            [Excision of the  Uterus by the'Abdominal Section,

was  performed   by Heath  (a)  of Manchester,  with the long incision
"from a  little below the  ensiform  cartilage to within an inch and a half
of the symphysis pubis," under the supposition, that the  disease was  an
ovarian tumour.   The opening of the peritoneum, however, immediately
showed  its true character, and  its removal was  determined  on.   Two
double ligatures were passed, by means  of  a sharp-pointed  aneurysm-
needle, through  the cervix uteri, immediately below the  circumference of
the tumour.   Each ligature was then  firmly  tied, so as to include one
half  of the neck  of the womb and broad ligaments.  The parts were then
 excised and removed.   No bleeding  ensued  from the cut surface;  in-
 deed, throughout the  operation not more  than three ounces of blood were
 lost; and after the division of the skin, few complaints  of suffering were
 made by the patient herself."  Soon after the operation vomiting came on
 with severe pain about the umbilicus, to relieve which, two grains of opium
               (a) London Medical Gazette, vol. xxxiii. p. 309.  1844. 
       EXCISION OF WOMB BY THE ABDOMfNAL SECTION.     575

with five grains of carbonate of ammonia were  first given, and three
hours after a starch clyster with two grains of acetate of morphia.  She
became more comfortable afterwards, had some sleep, and the pain in
the belly subsided.  Twelve hours after the operation, she began to com-
plain of the heat of the room; two  hours  after  she began  to sink, and
continued to do so till seventeen hours from the operation, when she died.
Fourteen ounces of blood were found in the cavity of the belly.   This
operation was commenced under the notion of the disease being an ova-
rean tumour, and the large cut having been made, it was thought advisa-
ble to remove the tumour though belonging to the womb.] 
I   w   1
SIXTH  DIVISION.
                   LOSS  OF ORGANIC PARTS.

  2530. The loss of organic parts is either the consequence of external
injury, of  operations, or of destroying ulceration; or it is a  congenital
misformation.   The means for the removal of such misformations, or for
restoring the functions  of  lost parts {Chirurgia  Anaplastica) are of two
kinds,
  Organic Restoration, or
  Mechanical. Apparatus.
          I.—OF ORGANIC RESTORATION OF LOST PARTS.

  Tagliacotius, De Curtorum Chirurgia per institionem.  Venet., 1597.
  Rosenstein, De Chirurgiae Curtorum possibilitate.  Upsal, 1742.
  Dubois et Boyer, Dissert. Quaest., An curiae Nares exbrachio reficiendae1?  Paris,
1742.
  C arpue, J. C, An Account of Two successful Operations for restoring a lost Nose
from the integuments of the forehead ; with Remarks  on the Nasal Operation.  Lon-
don, 1816.   4to.
  Graefe, C, Rhinoplastik, oder die  Kunst, den Verlust der Nase. organisch zu
ersetzen.  Berlin, 1818; mit sechs Kupfertaf.
  Sprengel, W., Geschichte der chirurgischen Operationen, vol. ii. p. 185.  Halle,
1819.  8vo.
  Grakfe, C, Neue Beitrage sur Kunst, Theile des Angesiehtes organisch zu
Ersetzen; in Journal fur Chirurgie und Augenheilkunde, vol. ii. p. i.
  Delpech, Chirurgie Clinique de Montpellier, vol.  ii.
  Dieffenbach, Chirurgische  Erfahrungen, besonders iiber die Wiederherstellung
zerstorter Theile des menschl. Korpers nach neuen Methoden.  Berlin, 1829-38.
  Labat, De la Rhinoplastie, Art de restaurer ou de refaire  completement le Nez.
Paris, 1834.
  Blandin, Autoplastic, ou Restauration des parties du Corps, qui ont ete detruites,
k la faveur d'un Emprunt fait k d'autres parties plus ou mpins eloignees.   Paris,
1836.
  Zeis,  Handbuch der plastischen Chirurgie.   Berlin, 1838..
  Serre, Traite sur l'Art de restaurer les Difformites de la Face selon la Methode
par^deplacement ou Methode francaise.  Montpellier, 1841; avec un Atlas.
  Dieffenbach, Operativ Chirurgie, vol. i. p. 312.
  von Ammon und Baumgarten, Die plastische Chirurgie nach  ihren bisherigen
Leistungen.  Berlin,  1842.
  Liston,  Robert, Practical Surgery.   London. Fourth  Edition, 1846.  8vo.
  Mutter; Thomas D., M.D., Cases of Deformity from Burns successfully treated
by Plastic Operations.   Philadelphia, 1843.  8vo.
i---------------•--------, Cases of Deformity of various kinds successfully
treated by Plastic Operations.  Philadelphia,  1844.  8vo.
  [Warren, J. M., On the Autoplastic methods usually adapted for the
Restoration of Parts, lost by Accident or. Disease.   Boston^. 184P,  8v.q.. 
HISTORY OF NOSE-MAKING.               577
    Pancoast, J., A Treatise on Operative Surgery.  Philadelphia, 1844.
 4t0.—G. W. N.]
    Ferguson, William, A System of Practical Surgery.  London, 1846.  8vo.
 Second Edition.
    2531. History points out the methods of organically restoring the lost
 parts of the face, especially of the nose, the mutilations of which disfigure
 most horribly, under three distinct classes.  Either the neighbouring
 skin, especially that  of  a forehead, is made use of;  or the  skin  of the
 arm,  whilst still remaining connected with its original seat, till it has be-
 come organically connected with the part on to which it has been trans-
 planted ; or the transplantation of a completely detached piece of skin upon
 the part to be supplied.
    The ancient bad practice of restoring old divisions  and  clefts of the nose by
 drawing together their  edges fresh pared and  detached, to some extent, or by
 encouraging granulation must be distinguished from restoration by transplanting.
    2532. The origin of organic restoration is lost in the earliest periods of
 Indian  history, and appears to have been  preserved  from age to  age in
 certain castes, especially the Koomas or Potters.   In India, where many
 criminals  are punished  by cutting off the nose, ears, and lips, the  fre-
 quency  of  such mutilations has manifestly led to  this operation.  The
 peculiarity of the Indian Method is, that the flaps of skin necessary  for the
 restoration are formed from the skin of the forehead.
    About the middle of the fifteenth century, the art of restoring lost noses
 was found  in Sicily, in possession of the family of Branca, from whom it
 passed  into Calabria, to the family of Bojani, but with the end  of the
 sixteenth century it was entirely lost.   About the same time it was prac-
 tised  by Caspar Tagliacozzi, of Bologna; he wrote a special  work on
 the subject, and brought it  into great repute.  It is doubtful whether this
 operation was brought from India to Italy, perhaps by the Arabs or by the
 missionaries, or whether it originated in Italy itself.  The characteristic of
 the Tagliacozzian or Italian Method, is the  formation, of the  restoring
 flaps from  the skin  of the  arm, which, after a  preparatory management,
 are attached to the seat of transplantation.  Tagliacozzi had  but  few
 followers; his scholar Cortesi described his master's and his own  some-
 what modified operation in 1625;  Griffon performed it twice, Moli-
 netti once,  and Thobias  Fienus  gave  an extract relating  to  it from
 Tagliacozzi's work.  For a long while after, this operation sunk into
 disuse, since by most people it was held to be  inapplicable or fabulous,
 and many no longer thought about  it.   Yet in India it was still practised,
 even  by an English Surgeon named Lucas, who  had' learnt  it from  the
 Indian operators, and. was successful;  and in England it was performed
 by Lynn, in 1803, and by Sutcliffe (a), though by both unsuccessfully.
 In  1814, however, it was first  performed wTith  good' result by Carpue,
 in two cases which he has described in his paper.   In Germany,-Graefe
 made  use of the Italian  method in 1816,  but  subsequently the Indian
 mode; he  also modified  the Tagliacozzian operation, as had been pre-
viously proposed in  1721 by Reneaulme de la Garanne (b), in which
he  connected the flap, formed from the skin of the arm, without waiting
for the complete skinning over of the inner edge, to the refreshed stump-

  (p) Carpue, above cited, p. 41..     <b) Histoire de l'Academie des Sciences- 1721.
                                 49* 
578
METHOD OF REPAIRING;
of the nose;  and this was distinguished as the German Method'of "Rhino-
plasty.   Although  Graefe has introduced many niceties and complica-
tions, he has, however, contributed much to the real improvement of this
operation, and must be considered as the actual creator of Plastic Surgery
in Germany.   His example had  quickly numerous followers.   Reiner,
Textor, myself,  Rust, von Walther, Beck,  Dzondi, Fricke,  and
others.   Rhinoplasty was not alone actually improved and, simplified, but
Plastic  Surgery was extended to  the  restoration  of eyelids, lips, and the
like.   The most important services in this respect have been rendered by
Dieffenbach, who has devoted himself-to this branch of Surgery, with
peculiar zeal,  and has contributed, by  numerous  clever operations for
various mutilations, to the establishment of Plastic Surgery.   In England,
since  Carpue's time, Plastic Surgery  has found little  sympathy (1).
Hutchison  only,  in 1818,  and  Davies in  1823  (a), have  performed
Rhinoplasty.   In, France,  Delpech,  in 1818,  had performed plastic
operations for the restoration of the scrotum, of the lips, and of the-nose,
at first according to the Italian, and subsequently  after the Indian manner.
After him  followed Mouleau and Thomain, but  by Dupuytren, Lis-
franc, Martinet, Velpeau, Jobert, Labat and Blandin, numerous
operations were performed for the restoration  of the nose  and  other
missing parts,  and-new methods were described.
   It is, however, remarkable, that in the greater extension of Plastic Sur-
gery, from it beinglhus generally taken up, the restoration by means of a
detached piece of skin, the Itafian method has been rather avoided, and
that by flaps from  the neighbouring skin, the Indian method, generally
preferred.
   In Germany, Graefe (6), Dzondi  (c), Bunger  (d),,and others,  have
performed that, described as the second Indian method,  in which,  after
beating a portion of the skin of the rump w-ith a wooden shoe till it has
swollen considerably, a triangular piece with the cellular tissue is cut out,
placed on the stump of the nose, the edges of which have been  previously
refreshed,  and there fixed {e); Bunger's operation, however,  was the
only one which succeeded.   This operation is very rarely performed, as
the  completely detached* skin, has rarely sufficient life for organic con-
nexion,  (f).
   [(1) CheliusJs in error on this point;  Plasttc Surgery has not been so  much
neglected in England ?as he seems to imagine, and there are few Hospital  Surgeons
who have not more or less frequently made new, or mended old noses, made new-
lips, and inserted pieces into eyelids, attempted the restoration of urethrae, in which
large portions of the canal have been  exposed, either by original misformation, or
from disease, and transplanted pieces of skin to supply,the place of scars from burns.
Iii but few instances, however, have the operators thought them of sufficient import-
ance to give to the public, which may account for foreigners being unaware of Plastic
 Surgery-being much practised  in England, though  probably not so many rhino-
plastic operations at*least, are  performsd here as abroad, perhaps for the reason
that loss, of nose is.with us of not very common occurrence, since our syphilitic

   (a) London Medical Repository, vol. xxi.   (d) Journal von Graefe und  von W»l-
 p, 39.  18:24.  ,                        ther, vol. iv. p. 559.
   (6) Rhinoplastik, p., 8.— Jahresbericht    (e) Gazette de Sante, No. IX. 1817.—
 uber das chirurgische und  augenarzbeliche.  Hufeland's Journal, vol. xxxvii. part v.  p..
 Jpstitut zu Berlin.  1819;. p. 411.          106.  1817.
   (<*) Rust's Magazin, vol. i. p 8..           (/) For the complete history  of Plastic
                                     Surgery, see Zeis,.above cit,ed. 
OR RESTORING  THE" NOSE.
579
treatment has been improved.  To which may be added  as another reason, that our
young men are not in the habit of amusing themselves with slicing off each other's
noses in sword duels (a).—j. f. s.].
  2533. The following may be generally distinguished as the methods of
reparation by a fold of skin from, the neighbourhood, either fixed only by
its edges, or by contact of its inner surface* which have been proposed in
modern times (6):—
   «& Formation-of a flap with a neck, upon which it is-twisted round.
   /3 In-healing of a  bridge of skin, in which the cut forming the bridge
is carried uninterruptedly in  the wound formed by its removal, and the
flap twisted upon the-whole thickness of its stem.
   y Removal of the flap, in which one of its edges is attached to the
edge of the part to be supplied, the loosened flap being carried  over the
lost part.
   ^ Drawing over the skin.
   t Lifting up sunken parts,  as of the nose.
   £ Implanting, for the restoration  of a partially destroyed part, for in-
stance, the bridge of the nose, and  the like.
   «j Overplanting, by which a nose rendered; irregular and jagged by some
destroying disease, is covered1 or overlapped by a flap  from the skin of
the forehead:.
   6 Underplanting, for the purpose  of supporting the sunken  parts, when
the bridge  of the  nose  has  quite dropped in,  by undersetting a flap of
skin from the forehead..
   » Rolling together a flap, with the  object of filling up  deep and wide
fistulous passages.
   a Unrolling rolled-up flaps for the purpose of  closing openings which
have been made by their separation.
   n Sewing over with mucous membrane, of parts disposed to  unite, to
prevent their union.                                   ■
   v Doubling the edges of the skin  to prevent the crumpling of trans-
planted; flaps.
   | Fixure by  holding.
   o Removal of the skin, in which a flap of skin is again fixed in its place
by holding, especially for: the better formation of noses which have been
attached1.
   *■ Transplantation by gradually moving the flap onwards.
   P Transplantation by removal of  the flap.
   2534. The value of  plastic operations  must in general be considered
very great, especially as  regards the numerous effectual improvements,
which have been recently practised, and as by them not merely is a con-
genital defect  provided  for, but even the restoration  of any important
function, and the removal of any very serious  inconvenience is effected,
as for instance, in the restoration of  eyelids, and of wanting lips, in the
closure of vesico-vaginal fistula? and the like.  In those plastic operations,
however, in  which the removal  of deformity is  the  principal object, as
for example, the formation of a  nose, the danger of the operation, the
possibility of complete failure, or an imperfect result, and the probability

   (a) Dieffenbach, above cited,,part u p.   (b) Cbmpare on these subjects Dieffen-
22;,part ii. pp. 84, 85.  1845..             bach, Blandin, Zeis, and others. 
580         VARIOUS MODES OF REPARATION COMPARED.

of the restoration being always imperfect, and very unlike the original
organ, must be well considered.
  Rhinoplasty is always a very painful operation ; it may cause a violent
attack of erysipelas, nervous symptoms, and  even death.  The healing
of the flaps can only be expected with good  state of the general health,
with the removal of every dyscrasy, with proper condition and vitality of
the skin, where  it is not very thin,  very lax, very  sensitive,  and the
part upon which it is implanted  is not very tough, hard, or altered by
scars, or in any other diseased manner.   Scrofulous  subjects  generally
afford the most unfavourable prognosis; but  according  to  Blasius, this
does not apply to lupus, as he has  performed rhinoplasty with the best
result, whilst that disease has still existed on  other parts of the face.   I
have, however., seen a case belonging  to  another practitioner, in which
the lupus spread to the restored nose, and produced horrible deformity.
In defects from accident, and in syphilitic destruction of the nose, when
the disease is completely extinguished, the prognosis is most favourable.
Death of the flap  may result from deficient nutrition, and also  from ex-
cessive influx and congestion of blood.
  Although the cure of the nose  be completed', yet in progress of time
very considerable changes  may take  place  in it which  will materially
change its previous form and condition.   If the nose have at first a tolera-
ble shape, yet it  may gradually shrivel, especially on its two sides and
upper  part, the  granulations which  were  developed on  its interior be-
coming at last connected on both sides, so  that  the two halves of the'
nose grow into one solid mass, by which its root shrinks, whilst its fore
part thickens, the  nostrils contract, and are almost entirely closed at the
end.   Such shrivelled noses in. no respect resemble the engravings which
have been given of them soon  after the operation, and are as remarkable
in their  form, as  they are disfiguring.  All  endeavours by subsequent
attempts, to improve the shape of the nose, are  generally fruitless, although
experience proves that wounds in such, new noses are easily  cured by
adhesion, but union with the neighbouring skin usually cannot be effected,
and commonly takes place only after long-continued'suppuration.  These
circumstances require serious consideration in settling the value of many .
plastic operations, and specially  that  of rhinoplasty, in order to guard
against the excessive enthusiasm which this operation has excited among
many of late ; and these are the circumstances which have led some prac-
titioners, as Klein (1), to prefer mechanical to organic restoration of the
nose.
  (1) Klein (a) considers an- artificial" nose of lime wood  preferable to  one made
from the skin of the  forehead.
  2535.  As regards preference of the various modes of organic restora*
tion, and specially of the nose, putting aside the totally ineffectual trans-
plantation of a completely separated portion of skin (1), and the employ-
ment of the skin of  another individual, that  method is  to  be  generally
preferred  in  which  the  restorative  flaps are  obtained from the neigh-
bourhood rather than .that by which they are  obtained from a distance.
The Indian mode  is for the patient  far less painful  and  its result more
certain than the Italian method, and if the nose-bones be  deficient, the-
vault of the nose may be tolerably supplied with a pad formed by turning;
       (a) Ueber Rhinoplaslick ; in Heidelb. klinisch. Annalen, vol. ii. p. 103. 
UNION OF  COMPLETELY-SEPARATED PARTS.        581
in the flaps.   The scar remaining on the forehead, which has  been  ob-
jected to in this method, generally disappears, so that  little or no defor-
mity is produced.   Only when the skin of the forehead cannot be used
may the restorative flaps be made from  the skin of the temples, which,
although it  be  more  substantial, and its connecting strip be longer, and
usually sufficient for nourishment, yet is a much more considerable injury,
and the hairs growing upon the nose cannot always be completely eradi-
cated, as is supposed, by repeatedly pulling them out.   The skin of the
cheeks and upper lip  can only be used in partial  defects of the sides of
the  nose.   The German  method  as  given by Graefe, is indeed less
tedious than the Italian, but succeeds only in very healthy persons with
very healthy skin.   But the cure by fastening the arm to the head subjects.
the  patient to the  same annoyance, the  flaps  die more readily, and if
suppuration ensue  on  its cellular surface, the difficulty is further increased
by its spreading over the surface.
   (1) Simply paring the edges of a destroyed nose and transferring a detached por-
tion of skin from some other part of the body, is probably not very likely to succeed,
as the mere edges of  the wounds can hardly be expected to afford sufficient surface
for the shooting of vessels speedily enough to nourish the whole flap.  But there
is no doubt that if two tolerably large wounded surfaces, one of which belongs to a
detached part, can be closely applied, union will take place, and ugly scars, no less
than tedious sores, will be prevented.  The following are curious examples of  this-
fact:—
   Balfour (a) has given two interesting cases, in one of which, parts all but com-
pletely, and  in the other, parts completely divided, were reunited by simple re-
placement; and hence he  thinks, " that the practice of  attempting the  reunion of
separated parts, may be carried farther than has ever yet been done."  (p. 425.)   In
the first case, a boy had  " the joints of three of  his fingers completely separated,
with the exception of a slight attachment of skin, which barely suspended the parts,
in consequence of having had  them shut into the groove of a  door."  The points
hung at right angles when the fingers were extended.  The point of the index was
cut off at the middle of the nail, the next finger a  little above the nail, and the ring-
finger at the root of the nail.  The wounded surfaces were necessarily much bruised*
but cut perpendicularly."  *  *  #  On  the sixth day after the accident, I removed
the bandages, when I found adhesion had taken place.  The skin and nails came off
all the three  fingers, but  were afterwards renewed ; and  the cure was  so complete,
that  a narrow inspection was necessary to discover any difference between  the-
fingers of the one hand and those of the other.  There was, indeed, no difference to
be perceived, but a slight scar on the left side of  the ring-finger at the root of the
nail." (p. 426.)   The second and most  remarkable case is that in which by  one-
stroke of" a hatchet, half the index was cut off: " the wound began near the upper
end  of the second phalanx on the thumb side, and terminated about the third pha-
lanx on  the opposite side.  The amputated piece, as measured by the  patient him-
self, (a carpenter,) was an inch and a half long on the thumb side, and an inch on
the other."  The amputated portion was fetched  from the shop where it had been
left; was white and cold, and looked and felt like a bit of candle.  *   *   *  "I
poured a stream of cold water," says Balfour, "on both wounded surfaces, to wash
away the blood from the  one and any dirt that might be  adhering from the other.
I then applied, with as much accuracy as possible, the wounded surfaces to each
other, expressing a confident expectation that reunion would take place." (pp. 426,
27.)   This was done  twenty-five minutes after the accident.  Two days afterwards
the man insisted on having the bandages removed, and "adhesion had taken place."
Since that time the finger " recovered both heat and sensation.  In the progress of
the cure, the skin was changed and soon after the accident, the nail fell off."
(p. 428.)
  (a) Two Cases, with Observations demon-  separated from the Animal System; in Edin-
strative of the Powers of Nature to reunite  burgh Medical and Surgical Journal, vol. x.
parts which have been, by accident, totally  p. 421.  1814. 
582
NOSE-MAKING FROM
  Braid (a) also mentions a case in which (on 13th June, 1816) "a hatchet cut off
a portion of the forefingei of the left hand in an oblique direction, carrying off all
the nail, except a small portion of its root on the ulnar side, together with the soft
parts on the anconal and  radial aspect, to a  little above the first joint.  The bone
was denuded, but not divided.  He came from a  considerable distance.   Finding
on inquiry, that he had left the detached piece, I returned with him, and found it
covered with  dust.  After having washed it with warm water, I applied and
retained the divided part in  its former situation by straps of adhesive plaster, &c.
*  *  *  On the 17th adhesion had  taken  place completely.  *   *  *  On the
20th he had the sense of feeling even from a small pointed instrument applied gently
to the  part which  had been detached."  The skin and nail  separated, " and in a
month  from the time he met with  the accident,  he was able to follow his work as a
miner,  and in five weeks could use his finger in tying threads whilst weaving.  The
nail has made considerable advance in growth."
  The  truth of these statements I  had the opportunity of verifying about the time of
Braid's case.   A lad came  to St. Thomas's Hospital during my dressership, with
a slice  cut off from the front of the top of his thumb, to about the middle of the last
phalanx.  As  the  cut was  very clean, and the part detached ready to hand,  as he
had brought it with him, it was too good an opportunity to  miss making the  expe-
riment. The piece was  therefore  cleansed, carefully applied, and  fastened with
straps  of plaster.   A few  days after, how many I do not recollect, the dressing was
removed, and the greater part of the detached piece had adhered.  The cuticle sepa-
rated, and a part of the thin edge sloughed, but at least two-thirds  of the whole
piece remained  firmly united.
  Barthelemy (b) mentions instances in which portions of skin sliced off accident-
ally from  the toe and finger, adhered readily.  In another case, the tip of the nose
cut off by a sabre stroke,  also  united.   But he relates  a still more remarkable in-
stance, on the authority of Regnault, principal physician to the Military Hospital
at  Gros-Caillou, in which during a fight between two prisoners at Niort, a  large
piece of the nose of one was bitten off by the other;  five hours after, it was replaced
by the surgeon  of the prison, and  in about ten days  it was firmly united.
  I am not quite so sanguine as  Balfour was, who thought such treatment might
be advantageously employed in many wounds or rather  slicings received in the field
of battle ;  but still I should feel disposed to make the attempt again,  under similar
circumstances, as even if  a portion only of the detached part adhered, there would
be  less of the granulating process required, and therefore the  cure would be more
quickly effected.—j. f. s..]
    OF NOSE-MAKING FROM  THE SKIN OF THE FOREHEAD.

   2536.   In the Indian method  of Rhinoplasty, which premises, that the
skin of the  forehead should  be  healthy, perfectly moveable, sufficiently
thick, and free from scars and eruptions ; a model of wax or fine clay is
required which should fit accurately, be  handsome, and  correspond  to
the form of  the person's face.  This is  to be placed immediately on the
stump of the  nose, and  held there firmly, whilst with a  fine miniature
brush, dipped in some not very soluble varnish, the base to which the
artificial nose is to  be attached is carefully marked with a  line.   In this
way are mapped the longitudinal cuts on the sides of the  nose, and the
transverse one for the septum.    The longitudinal cut,  for  refreshing the
edge, should be begun at the upper part of the stump of the nose, close-
to where,  after twisting round the flap of skin, the fixing of its side edge
must begin; the two side cuts  must not unite at top.   All the  dimen-
sions of the  model  having been  sketched on a piece of paper, so that its

  (a) Case of Reunion of a separated Finger;    (6) De la Reunion des parties entierement
in Edinburgh Medical and Surgical Journal,  separees du Corps;  in Journal Hebdoma-
vol. xii. p. 428.  1816.                    daire de Medecine, vol. v. p. 15.  1831. 
THE SKIN OF THE FOREHEAD.
583
entire surface be obtained, the shape is to be cut out of paper and placed
upon the forehead, the septum above and the  root of the nose below, be-
tween the eyebrows, but less low down, and with the coloured varnish
a line marked round it.   If the forehead be  low, and the figure would
fall upon the hairy part of the head, it must be placed obliquely.   Where
at bottom the side cuts are about five lines apart, they must be continued
straight down to the root of the nose, to mark the bridge of skin.  The
suture points are now to be marked, first round the nose-stump,  two on
the upper point of the side  cuts, a line and a half outwards, two on the
lower end of both side cuts, and opposite each  other; between these the
spaces for the other suture points are easily found.   All these have been
marked upon the paper model, and  from it transferred to the  forehead.
  As in the directions above given by Graefe, the lines and points marked with
coloured varnish are easily obliterated during the operation, a model of the flap of
skin should be cut out of sticking plaster,.fixed on the forehead, and the flap made
by cutting round it, but a quarter or third  of an inch larger (Dieffenbach.)   As the
flap always shrinks considerably, care must be taken that it be not made too small;
the septum especially must be broad, because, during the scarring process, its edges
draw back and it easily becomes  too narrow.   A model for comparison  may be
found in Zeis (a), from Graefe, which also lets the septum run into a triangle, for
the purpose of assisting the  union of the wound in the forehead.  Delpech's recom-
mendation, to allow the flap to run into three long points, so as to render the union
of the wound on the forehead more easy,  does not answer the purpose, and can only
be sufficient for supplying the deficient tip of the nose.  In some cases Dieffen-
bach has formed on oval flap of skin from the forehead, which method will be pre-
sently more particularly described.  That the skin of the forehead should be rubbed
in with some aromatic spirits daily for six or eight days before the operation, unless
tension and pain ensue, (Graefe,) is superfluous.
   2537. The operation  is to be now begun by paring the  edges of the
stump of the nose ; or,  if there be  no stump, by making grooves in the
skin close to the opening of the nose.   In the first  case, the edges are to
be cut sore, whilst held  with hook  forceps, and the  cut  is to  be  carried
through the whole thickness of the nose-stump.   As much  as possible of
its substance is to  be preserved; but both sides must be made as near
alike as can be.   If  a part  of the wing of the nose remain, but dropped
in, it must be first separated from its adhesions and raised.   If the nose
be still  whole, but curtailed and%dropped  in, it must not be removed, but,
according to Dieffenbach, covered by planting upon it a flap of skin,
for the reception of which, as  well  as when the whole nose  is wanting,
a strip of skin,  a line and a half wide, must be cut out, and thus a suffi-
ciently deep groove formed.   Lastly, a broad transverse groove must be
cut out to receive the septum; or the upper  lip being drawn well from
the  upper jaw, and  the scalpel  thrust through  where the lip is attached
to the  jaw, competely separates it to  the  breadth of an  inch  and more,
according to the thickness of the septum (Zeis.)   The bleeding must be
stanched with cold water, and only  when this is insufficient, by tying the
vessels.   The preliminary stitches may now be made at the points marked
around  the  stump of the nose, and  the threads held by an assistant; or
they may be made afterwards, when the flap is turned down and properly
applied.
   2538. The separation of the frontal flap is  now  to be proceeded with.
The convex scalpel  being inserted rectangularly at  the topmost  point,
                          (a) A'ove  ci'ed, p. 267. 
584
NOSE-MAKING FROM
  divides, with a sharp, bold stroke, along the marked line, or at the edge
  of the sticking plaster, the skin of the forehead through its  entire thick-
  ness, avoiding the  bridge, which still remains on the root of the nose.
  The upper part of  the flap is  now grasped with hook forceps, and care-
  fully dissected off'from the galea aponeurotica, which  is preferable to re-
  moving it with the galea itself, to render the flap as thick as possible,
  and the division  is to  be  carried to  the  very extent  of the  line which
  marks the bridge of skin;  or the one  end of the cut, circumscribing the
  flap, is  carried on till it reach that for its attachment.   The bleeding from
  the wound in the forehead must be stanched with cold water or ligatures,
  and carefully covered with a piece of  soft German tinder.
    The continuance of one cut into the wound on the stump of the nose is advanta-
  geous, as then  twisting round the flap is  easier, and the swelling arising from this
 twist is much less, and more points of attachment for the transplanted flap can be ob-
  tained, because the suture may be continued along the bridge of skin.
    Labat endeavours to prevent the narrowing of the nostrils, and  the alteration of
  the nose dependent on the granulations developed within, by covering the inner sur-
 face with skin at the operations.  For this purpose he bounds the frontal flap above
 with a curved cut, extending from the wing of the nose above  the septum, and after
 separating, divides it  by two vertical cuts into  three pieces, of which  the middle
 folded together lengthways forms the septum, and the two side pieces also folded in,
 and with a thread passed with a needle from without inwards, and from within out-
 wards, and having its end knotted, are kept in  this position, that the wings of the
 nose may be formed of a doubled  skin.  Blasius had previously operated in this
 way with success, and Dieffenbach, also,  by forming an oval flap from the fore-
 head, the lower end of which he twice cut into.   This mode of practice  is specially
 advantageous if the skin of  the forehead  be very thin, as the  otherwise shrivelled
 end of the nose gains thickness, and the openings of the nostrils easily narrow.
    2539. The flap of the  skin  from the forehead is now dropped  down,
 and twisted half round on its  axis, so  that its epidermal side is outmost,
 and it is observed whether its edges can be applied to  those of the nose-
 stump, or into the groove prepared  for it, without  any  dragging.  If the
 flap be tort, the bridge of the skin must be loosened still more, and the
 side cuts lengthened some lines  lower.  If the flap fit  at every part, as
 soon as  the bleeding ceases, its attachment by the interrupted suture must
 be proceeded  with, the threads previously introduced  in  the  stump of
 the nose being passed through the  corresponding edge of the flap, and
 finishing with that  on the septum..   After  the wound has been cleansed
 of the blood that hangs  about, the threads are tied in knots from ^above
 downwards, so as to produce the closest  application of the  edges, and
 when at any  part these gape asunder, another stitch must be introduced.
   Union with the interrupted suture is the most convenient, as the twisted suture
 with thin insect-pins, according to Dieffenbach's plan, is  in many parts very diffi-
 cult to apply, and in withdrawing them, the easy tearing asunder of the edges of the
 wound is to be feared.   Graefe's ligature-stem, which after its application may be
 so separated on the face, and each part fixed with plaster, that no tension is produced,
 is useless, aad not to be recommended.   And equally so are his pieces of ivory
 placed beneath the ligature (a).
   2540. The wound in the forehead is now to be brought together, where
 the nature of the wound  and the yielding of its edges permit, with insect-
 pins and the twisted suture, and the middle of the remaining open space

  (a) Beck; in  Heidelb. klinisch. Annalen, vol. iii. part ii.—Chelius, Gelungener Fall
einer Lippen und Nasenbildung an einem Subjccte; in aamej vol. vi.—Textor ; in Neue
Chiron, vol. i. part iii. 
                                         t
                   THE SKIN OF THE FOfcEHEAD.               585

 covered with a piece of soft German tinder, and with  lint and sticking
 plaster.
  Advantageous as it is to draw the wound in the forehead together by uniting some
 of its points, for the purpose of shortening the time of cure and lessening the scar,
 yet, however,  drawing the wounded  edges forcibly together should be cautioned
 against.  Also, when the frontal wound is healed merely by suppuration, as proposed
 by Graefe, and properly brought together with sticking plaster, with good manage-
 ment there will not be any scar, as is commonly stated.
   2541. Into the apertures of the attached nose, quills, covered with lint
 and oiled, should be introduced; or, according to Zeis, tubes made of
 plates of caoutchouc, which have  recently come into use.  Plugs smeared
 with rose ointment (Graefe) inconvenience the patient, because they pre-
 vent the passage of the air through the nostrils.   The patient should be
 kept in bed  in rather a sitting posture, with  his head sufficiently bowed
 forwards; he must be kept quiet, and his diet should be antiphlogistic.
1  When the nose first becomes discoloured and seems fallen together, it
 must not be considered a bad omen ; turgor usually soon sets in, the nose
 swells, reddens, becomes shiny  and moderately tense.  If these symp-
 toms  become severe, if the nose  be bluish and hot, it must.be treated
 strictly antiphlogistically, cold applications  are to be  made to  it,  and
 general  and   local blood-letting  by leeches  or  by scarification.   If, as
 often  happens under these  circumstances, there  be bleeding from the
 edges of the  nasal apertures, it must be kept  up for the due depletion of
 the flap.  In one case I saw this bleeding continue  twenty-four hours,
 and with the best result.  Only when the bleeding is considerable, must
 it be  stanched by the application  of German tinder.  It is more common
 that the nose is  endangered by overloading than by want of blood ; but
 if due turgor do  not come on, if the flap  remain cold  and discoloured,
 light aromatic applications must be made.  If gangrene ensue, it is either
 partial, and then in general attacks only a straw's breadth of the edges of
 the flap, or if union come to a stop, pus presses out along the whole cleft
 of the wound, and the entire flap dies.
   Besides the above-mentioned causes, the occurrence of gangrene may
 depend  on the tough, callous nature of the edges of the nose-stump, or
 from  constitutional dyscrasic symptoms, or from  improper irritating treat-
 ment, whilst  there is increased turgor of the flap; then  the  gangrene
 usually appears from the third to  the fifth day after preceding symptoms
 of increased  turgor.   It is  well worthy of notice, that the surface of the
 nose has frequently a gangrenous appearance, and  after throwing  off' a
 superficial slough, good  granulations appear, and  the  flap remains per-
 fect.  (Walther.)
   The best sign is when the united edges of the wound  are covered with
 a crust of dried  lymph, from whence  speedy union may be safely con-
 cluded.
  The removal of the stitches or of the pins should in general be effected
 on the third or fourth day, and the union is to be preserved by strips of
 court-plaster laid across.  Other matters, as nervous symptoms, erysipelas,
and the like,  must be treated according to the ordinary rules.
  2542. When  the nose  has completely united at all points, and the
lower part of  the wound on  the forehead has scarred,  if the flap have
been twisted  round, a narrow bistoury must be passed  under the fold of
  Vol. hi.—50 
586
NOSE-MAKING FROM
skin formed by the twist  of the flap, which  should be cut through ob-
liquely upwards so that a small flap is formed ; and this is to be applied to
the raw made upper part of the stump of the nose, for which purpose a
suture is only sometimes proper, but the application  of sticking plaster
is generally sufficient.   If  there still  remain any puffiness of the frontal
flap, it must be got rid of.
•  If the bridge of skin have been formed  by continuing the cut into the
wound on  the  nose-stump, and  the bridge heal  in, a myrtleleaf-shaped
piece must be cut out of it, and the edges united with  insect-pins and
the twisted suture.   But if there be too much  skin on the back of the
nose, it must be completely removed.
  2543.  For the purpose of perfecting the form of the nose  after  union
is complete, various modes of after-operation may be requisite, which,
however, dare only be first undertaken when the  skin has recovered its
natural condition.   A puffy scar, when not expected gradually to diminish
and disappear, should be cut  out with two parallel cuts, and  the  edges
of the wound closed with  the twisted  suture.   Deep scars  must also
be  cut  out, and  if  the edges of the wound be also  somewhat loose,  a
little more skin must be removed from the bottom than from the surface,
and the woUnd brought together with the twisted suture.   If the nose be
very puffy and misshapen,  an almond-or myrtle-shape  piece  should, ac-
cording to Dieffenbach, be  cut out, and the edge of the wound united
vertically.   If the tip of the nose project too little, a  flap from  the new
nose should be made,  according to Dieffenbach, by two slightly curved
cuts meeting in an angle above, and diverging below towards-the septum.
If now the upper angle of the Wound be  united  with a  twisted suture,
and thus the space for the inhealing of the flap be restricted, the flap must
be compressed from side to side, and fixed by some retaining apparatus,
so that the tip of the nose shall project.
  For the proper formation of  the nostrils Graefe recommends the introduction of
tubes fastened With a peculiar  apparatus, and  afterwards furnished with superficial
plates.  An  eductor which fits into  this and draws  it  forwards, thereby shaping
the tip of the nose, is fastened on a compressing instrument which can act on various
parts of the  nose and give it the  proper form.  This apparatus is to  be worn the
whole of the first winter,  and only laid aside in the following summer, that the nose
may be exposed to the hot rays of" the sun!
  2544.  With the restoration of the whole nose must also be classed those
cases in  which there  are  only single defects, to wit, of the wTings and
sides of the nose, of the ridge and septum, which must be managed by
transplanting the  skin from the neighbouring parts.
  2545.  Attempts  to  supply defects of the wings of the nose from the
skin of the cheek had  no satisfactory result; hence Dieffenbach prefers
the skin of  the forehead.  After paring the edges of the  stump of the
nose, a sufficient flap of skin  is separated from  the forehead, the side of
the nose cleft, the flap twisted to that side, and fixed with twisted sutures.
The neck of the flap is for a  time healed into the  cleft on the side of the
nose ; but after the  scarring is complete, it is removed.  The wound on
the forehead is brought together with the twisted  suture.
  When only a narrow portion of the wing of the  nose is deficient, Dieffenbach
cuts off the edges,  as in  ffie operation for hare lip, and  brings them together with
insect-pins.  If a large piece be wanting, he cuts out a corresponding portion from
the healthy side so as to make both sides of the noSe alike,and then fastens up both 
THE SKIN OF THE FOREHEAD.                587
 wounds.  If the cleft be pretty broad and high, Dieffenbach lengthens the cut from
 the point of the triangle through the wing to the bridge of the nose, and cuts out a
 piece from it and the septum.  If the wound heal by the  first union, he cuts out a
 corresponding piece from the other side of the nose.
   2546. If the side edge be wanting as well as the wing of the nose, a
 flap corresponding to its extent  must be cut out of a piece of paper, and
 a like  flap  cut out of the skin of the forehead.  Care  must be taken that
 the part of the flap, which is to  be put into the upper part of the defect,
 should correspond to it, but the lower  part of the flap which corresponds
 to the  opening of the nostril must be made rather  broader, and so much
 longer, that its edge may be folded in, to prevent the contraction of  its
 edge and the narrowing of the nasal aperture (a).
   2547. If the bridge of the nose have sunk in, by  the destruction  of the
 bones, but the tip  still stand up, a scalpel should be thrust between  the
 eyebrows,  and the nose cleft throughout its middle to the tip.   The adhe-
 sions which draw down the sides of the nose to the skin of the cheek must
 then be divided, so that the sides can  be  drawn up.  An oval piece  of
 sticking plaster must be fitted  between the edges of the wound to give the
 model of a good bridge.   The plaster is then fixed on the lowTer part of
 the forehead,.and cut round in such way that one cut shall pass into  the
 cleft made in the nose, but the other only to  the left eyebrow, and here
 a strip is left for nutrition.  The flap  is now separated, twisted round,
 fitted into the  cleft, and fastened with  the twisted suture.  As this flap,
 after healing has a  misshapen form, Dieffenbach has proposed  overr
 planting, or underhealing the frontal flap; in doing this, the  operation is
 at first performed  precisely as in inhealing, and when this is  done and
 the scarring complete, pieces of the transplanted skin must be cut out, and
 the edges of the wound brought together by the  twisted suture.  The
 excision must be  repeated till the whole of the inserted piece of  corion
 has been removed, and the edges of the original nose-stump united over
 the remaining thickened cellular tissue.
   2548. The  deficient columna  narium may be variously replaced.   If
 when the column be wanting, the nose itself be  very large, so that  by
 removal of a  portion it will not be disfigured, and the  upper lip from
 being too shallow or beset with scars, is unfit for making the reparation,
 then a piece four or  five lines broad and  about an inch long, must be
 cut out of  the thickness of the nose, and with its neck attached to the
 tip, turned round,  and fastened  to the  upper lip in a groove previously
 made there:  the wound on the  nose  is to be united with  the twisted
 suture.
   In the so-called bottle-nose,  or in that form in which the nose is turned
 up and the  bridge resembles a saddle, the cuts should be  made, according
 to Dieffenbach, as in the former case, only that both outs should equally
 descend to the free edge of the wide nostril.  The lower edge of this flap
 should be made raw, the upper and middle part separated from the under-
 lying cellular tissue, so that its undermost part alone remains connected,
 and serves for nutrition.  The flap thus separated, is usually so moveable
 that it  may be drawn down to the upper  lip, where it must be fastened
with the interrupted suture to the  part  made raw, and the cleft on  the
middle of the nose must be united with the twisted suture.   If the flap
                        (a) Zeis, above cited, p. 316. 
5S8
OF FORMING THE NOSE.
cannot be brought sufficiently down to the lip, the cartilaginous part of
the tip and of the column of the nose must be so far cut transversely till
the lowest part  of the flap can be united to the corresponding part of the
upper lip.  The upper part  of the  flap must be  attached also  on  both
sides with  insect-pins to the tip  of the nose.  When  it has  perfectly
healed, the tip of the nose must be kept down towards the upper lip  with
pieces of sticking plaster put across it, so that the newT septum be not very
much stretched.  If the deficient column cannot be supplied by the pre-
ceding method, a corresponding piece must be formed by two cuts  from
the whole thickness of the upper lip, of which the red part has been cut
off', the entire piece turned up, fixed to the tip of the nose, and the wound
in the lip brought together with the twisted suture.   This turning up of
the flap  by which its mucous surface becomes outermost is better  than
twisting the flap, which  is  always violent; and the mucous  membrane
soon assumes the  appearance of the external skin (Fricke, Dieffen-
bach, Liston and:  others).   If the  condition of  the  upper  lip do not
admit the formation of a flap of its whole  thickness, a corresponding
strip of skin  must be cut out of it in a horizontal or  oblique direction,
turned round and fixed into the  nose.  The wound in the lip must be
united with the twisted suture.
  [Sometimes by the retraction of the parts, after making the column from the lip,
the lip and nose become approximated, and the movements of the former are im-
peded.  This happened to Dupuvtren, who did not choose to do any  thing more.
Gensoul of Lyons, (a), however, corrected this inconvenience in the following  way.
He  '* plunged the point of a very sharp bistoury obliquely  to the right of the base of
the flap attached to the lip, and divided it in nearly its entire depth and height;  then
did the same on the left, and these two oblique incisions meeting at their summit in
the  thickness of the lips, the flap was detached.   It represented the figure of a
wedge; he removed it, and having thus reduced  the wound of the lip to a simple
incision, by this loss of substance, reunited it by means of a pin and waxed thread.
The nose, which had been much'pulled down, being no longer fixed, was elevated by
the elasticity of its cartilage.  The advantage thus gained has since continued.
  In a case in which a large portion of both jaws  were exposed by gangrene of the
left cheek, and  the teeth and alveolar processes were much, thrown out during the
healing process, Gensoul (/>) cutaway all the attachments of the scar and integu-
ments, chiselled off the projecting part of the jaws, dissected up about two inches of
the skin of the upper part of the neck, and one inch of that  of the cheek, and brought
the  edges together with sutures and  adhesive straps.   The  deformity was  thus
removed, leaving a small salivary fistula which was easily covered.]
     OF  FORMING THE  NOSE FROM THE SKIN  OF THE ARM.

   2549. The formation  of the nose by a  piece  of detached skin,  for
which the  skin on the inside of the arm immediately over the m<. biceps
is best suited, is for both  patient and operator a very much more trouble-
some operation  than the  Indian rhinoplasty; it is more uncertain in its
result, and  better fitted for the reparation  of a part than of the whole
nose.  The transplantation performed is either immediately after detach-
ing the flap (Graefe's German method,) or  after previous preparation of
the part (Tagliacozzi's Italian method.)

  (a) Journal Clinique desHdpitaux de Lyons, No. I.—Journal Hebdomadaire de Medecine,
^ol(,viJ%p..442,  l£3Pf>                              (6) Ibid.,.p. 442. 
FROM THE  SKIN OF THE ARM.               589
   2550. In the German Mode of Rhinoplasty^ which can only be under-
taken in persons who are very healthy, and whose skin is quite sound,
the  necessary bandages are  to be applied nightly for some time, eight
days, previous to the operation, so that the person may get accustomed
to them ;  and every day, the part of the skin of the arm to be used in the
reparation is to be rubbed with spirit, when the waistcoat must be drawn
together,  but the hood  thrown back.  The measurements for the flap of
skin, and the markings on the nose-stump are to be made  as described
in the Indian method, excepting  that the part of the  flap corresponding
to the septum, which runs downwards, should be about twro-fifths narrower
than the wings of the nose,  and  should  be marked of such length,  that
the whole flap  should be one-fourth  longer than the paper model.  The
edges of  the nose-stump are to be so refreshed that  the side cuts meet
above ; the notch for the septum is not yet to be made.   The threads for the
stitches are to be introduced at the determined  points.  A  piece of the
skin of the arm is now to be separated, with  as. much cellular tissue as
possible,  on both sides and at the upper end, and the arm  having been
raised close to the face,  the parts, are brought together  by  drawing the
threads through the points marked on the skin of the arm.  Lint is to be
put  into the nostrils, and upon  the under surface of the flap of skin  and
on the wound in the arm a pledget, spread with? rose ointment, which
must be fastened with strips of sticking plaster.   The  arm is now to be
kept in the  proper nearness to  the face by  the connecting  bandages.
The general and  local treatment must  be conducted according to the
rules laid  down for the Indian method, and  more especially must  the
patient keep his head and arm perfectly still.   As often, as the lint is
sopped with  the pus  and fluids  it must be  removed, and the nostrils
cleansed by injecting lukewarm water.  If union take place, the stitches
maybe removed, though not earlier than seventy-two hours.   When,the
union has acquired sufficient firmness, the division of the skin fr-ora the
arm  must be  made;  and this is done, after removing the bandages, and
whilst an  assistant supports the arm, by making a transverse  cut between
the  lower angles of the  longitudinal  cuts with  a  rather long, convex
bistoury;  after  which the skin flap is kept in its proper place  by the in-
troduction of pledgets spread with zinc ointment and strips of plaster^ and
must be covered with a layer of aromatic cotton to  protect  it.  After
about  fourteen days the formation  of the nostrils and  septum must be
undertaken, for which purpose, with the  aid  of the model,  the  position
and  form  of the nostrils and septum is to be  marked with varnish, and
cut out with a narrow scalpel and Cooper's scissors, and  the septum
fixed into the  wound made  for it with,  two stitches.   In from three to
five days, when the septum has healed,  the stitches must be taken out,
and  the further treatment, in reference to dressing and improving  the
form of the nose, managed according to the Indian method.
  Benedict (a) has specially endeavoared to further the preference of the German
method by  his  successful practice, and has  proposed an  alteration of the binding
apparatus, by which it is rendered easier to change the dressings; he putsplugs  into
the apertures of the nostrils.

  (a)  Beitrage zu den Erfahrungen iiber die-Rhinoplastik nuch der deutschen Methode,
Breslau, 1828; with four plates.
                                50* 
390'
RAISING A SUNKEN NOSE.
  According to Galenzowski, the septum should be formed immediately after the
separation of the flap from the arm, and fixed, at once.
  2551.  In the  Italian  Method  of Rhinoplasty, the piece for the flap is
marked upon the corresponding part of the arm, which, on account of its
shrivelling up afterwards,  should always be  six inches  long and  four
broad.  Instead of the trellis forceps used by Tagliacozzi, it is better,
according to Graefe, first to make  the two side cuts with a scalpel, and
then divide the skin from the  underlying cellular tissue, with a very blunt
director,  a gum fleam, or even with the  finger, from  one side cut to the
other.  A piece of linen spread  with rose ointment is then to be drawn by
a thread  fastened to its side,  under  the flap; the side cuts are  covered
with lint spread with- rose ointment, with a compress,  and the  whole
fastened  with a circular bandage.   This dressing is to be first removed
after three or four days, but  a. fresh piece of linen is to be previously
introduced beneath the  flap,  if  suppuration be properly established.   In
this way, with  proper modifications, according to  the condition  of the
suppuration, and so on, the case is to be proceeded with, and then the
division  of the flap, at the upper  end of the side cuts, must be made upon
a director introduced for the purpose.   The flap should not, according to
Graefe, be turned baGk as  recommended by Tagliacozzi,. but merely
supported  by a wad  of charpie and  oiled, pasteboard;  and  afterwards
dressed  with  lead wash or  decoction  of elm bark.  The flap always
shrivels up, but gains in thickness proportionally ; and towards the sixth
or eighth week, sometimes still  later, though according to Tagliacozzi,
in a month, becomes completely fixed.   The  mode of fixing the flap, and
the further, treatment, corresponds with that of the German method.
                  OF RAISING A SUNKEN, NOSE.,

  2552.  When the bones and cartilages of the nose have been destroyed,
and the soft parts remain, though sunken, according to Dieffenbach, the
remains of the  old. nose must  be dissected in  several parts, drawn up,
and fixedun such way that the nose is raised up.   The head of the patient
must be  steadied by an assistant, a  narrow pointed scalpel passed into
the left nostril, and the soft parts divided with a stroke  in the side of the
ridge of the nose up to the nasal process of the frontal bone.  The same
ig to be done on the  right side, so that there is a strip of skin from the
ridge  and tip of the old nose remaining between the  two side cuts,
becoming narrow above, and connected with the  skin of the forehead,
and attached  below by the shrivelled septum to  the upper lip.  If this be
destroyed^ the flap can be raised;  if the septum be shortened, it may be
oasily lengthened by a cut on either  side downwards through the upper
lip.  Some lines below the end of the first cut,  the knife  must be thrust,
at the junction of the right nostril with the cheek, down, to the bone, and'
c?arriecf through the whole of the  soft parts obliquely  down to the line
where  the floor of the  nose terminates on the skin of the cheeks.  The
same cut is continued to the left side, and thus makes two semilunar cuts
at the  insertion  of the wings of the  nose, whieh pass  round their.lower
part outwards  and upwards  into the former- cut.  These side flaps- are 
RAISING A SUNKEN NOSE.
591
now carefully divided from  the bone, so  that  they may be raised and
turned backwards.   The skin of the cheek next the nose is then to be
separated to the extent of three or four lines from the bone, so that it can
be slipped towards the middle.  The edges of the middle flap are now
cut with scissors, in such  way that its inner surface will be narrower than,
but not separated from the epidermal side, for the purpose of giving the flap
the form of a keystone of an arch.   The edges of the wings of the nose are
to be cut in the  contrary  direction, so that  a strip as thick as a straw may
be removed from the  upper surface, leaving the inner surface untouched.
  After carefully cleansing the wound from, blood, the parts are  brought
together with twisted  sutures, of which the lowest should be by  the side
of the tip of the ndse.  Around that part of the upper lip from which the
septum has been taken, a: ligature must be passedj and so placed behind
it as to draw it and the tip  of the nose forwards, and prevent its reunion
in the old groove.   The  junction of the side edges of the nose with the
skin of the cheeks is  effected with four interrupted sutures.  Lastly,  two
long pins are carried  through the edge of the separated skin of the cheeks
behind (on each side of) the nose, through strips of stiff leather,  which
are pressed together on the one side by the heads of the pins,  and  on the
other, by twisting their points spirally with  the forceps,  by which the
nose is permanently projected.  The after-treatment is conducted accord-
ing to the rules laid down for the Indian Rhinoplasty.
   This  exceedingly  troublesome  and very painful operation  rarely
answers expectation,  as  according-to my  own  experience, although the
nose  remains for a time after the operation pretty well, yet subsequently,
it again shrinks.   For this reason, Dieffenbach^ thinks  it preferable, in
most cases of flattened-nose, to insert  a strip of skin, which may after-
wards be partially removed (a).
  [Liston's treatment of this deformity is much more simple.  He  observes:—
" Sometimes the cartilaginous portions of the nose fall a prey to abscess andulceration,
while the integument remains intact, excepting the column, which usually shares
the fate of the cartilages.  The consequence is a  sinking down into the nasal cavity.
The depression  may be obviated by simply raising the parts after dividing any ad~
hesions that may have formed in their new situation.  By stuffing the nose carefully
and neatly, the integument is retained of a proper shape until the disposition to fall
in is in part overcome, and firmness and stability obtained.  Then a new columna is
raised and fixed, and careful stuffing of the nostrils is continued until all has become
consolidated." (p. 264.)
  Fergusson's- (b) method differs from Liston's, in not making use of stuffing and
in supporting the cheeks. He "introduced a scalpel into the opening in  the nose,
and dissected the sunken alae from their attachments underneath, then raised  the
cheeks for more  than half an inch from the  surface of each upper maxillary bone,
and cut to such an extent as to allow, when the finger was introduced-under the
nose,  to raise and  put it  into a shape somewhat like the original.  He then passed
two silver needles, armed with steel points, and provided with small round heads,
from the left cheek to the right, under the  nose, and through those parts which had
been dissected from the  bones.  By means of two pieces of firm leather, two inches

  (a)  Dieffenbach, above  cited.—Rust,  Michaelis, Ueber die Herstellung der nor-
Neu;: Methode, verstUmmelte und durchbro-  malen Form  eingefallener Nasen  mittelst
chene Nas n auszubessern; in his Magazin,  des Vorziehens  ihres  flbrig  gebljebenen
vol. ii. part iii.—.Wattmann, Ueber vefkrup- Theiles; in von Graefe und von Walther's
pelte Nlsen und deren Fonnverbesserung;  Journal, vol. xii. p. 291.
in Beobachtungen  und Abhandlungen von   (6)  Edinburgh  Medical  and  Surgjcal
dem Dir.u. Prof, des Studiums der Heilkuude  Journal, voL xTiii. p, 363.  1835*
an der Universitat.zu Wien, vol. vi. p. 433.-— 
592
RAISING A SUNKEN NOSE.
long by one-half broad, through which the pins were also passed, he was enabled
on twisting the extremity of each pin spirally, after having cut off the steel points,
to bring the cheeks near to one another, and in this way to cause the nose to become
prominent.  On  the eleventh day he withdrew the pins, and introduced two others
at different points from those first  used; and in eight days more, on these being
removed, the nose stood quite prominent."]                               ,
   2553.  If the bridge  of the nose drop in, as consequence of destruction
of a part of the septum,  but the bony frame still remain  perfect,  accord-
ing to Dieffenbach, a wedge-shaped piece should be cut out of the pre-
viously long and down-hanging nose.  The tip of the nose being stretched,
the straight edge of a  knife is  placed  upon  the ridge of the nose below
the nasal bone, and the nose is cut through at a stroke, with  the  blade
turned a little  upwards, to  the skin of the cheek.   A  like cut is then
made obliquely upwards beneath  the  depression, so that both  cuts meet
at an  angle, and cut out a wedge-shaped piece.  When the usual  smart
bleeding has ceased, and the secretion of lymph into the wound  has be-
gun, two interrupted sutures are passed  with round needles through the
septum, one end of each thread cut off, and the other carried to the nos-
tril.  The  edges of the wounds on the sides and ridge of the nose are to
be united by six or eight twisted sutures.
   With a  small, straight-pointed nose,  which  by cutting out  a  wedge-
shaped piece, would be drawn too much upwards, on each side two  semi-
circular cuts must be made, so that the  one point of the oval turn to the
ridge and the other to the base of the nose.   The union of the  septum
and of the outer edges of the wound are made  as in the  former  case.
After the operation a little bump is formed on the ridge of the nose, which
at a later period becomes level.  In other cases the ridge of the nose may
be  preserved,  and merely an oval piece cut out of both side walls, so that
one point of the oval turn towards the cheek, and the other to the  ridge
of the nose.   The union is  managed as  before.
  Here also must be mentioned the inhealing of metallic frames and plates of gold
or platina, for putting to rights sunken noses, as has been attempted by Rust, Klein,
Galenzowski, and Tyrrell.  Although the  inhealing readily take place, yet the
plate must most commonly be removed afterwards.
   [I recollect Tyrrell's  operation with  a silver frame, which consisted of a long
narrow silver stem for the ridge, terminating below in three prongs, which were
bent so'as to support the column and wings of the nose, to which it at once gave an
excellent form.   Its subsequent removal, for what reason I do not recollect, was at-
tended with much difficulty; and, if my memory be correct, the nose  which had
been made with a flap, dropped  down and was not very ornamental.—j. f. s.]
   2554.  If the tip of the  nose be  turned too much downwards,  as in
double hare-lip and wolf s-jaw, and depend on a folding of the cartilagi-
nous  septum,  the  nose  may, according to Dieffenbach, be raised  by
cutting through this fold.  The skinny septum is to be taken hold of and
drawn aside till the fold appears, which is then to  be pierced with the
point of a small scalpel, and cut through to the root of the bony septum.
The tip of the nose immediately rises  of itself, and still more if  it  be
raised.   Compression  of the sides of the nose is to be made with leathern
or leaden splints, through which long insect-pins are to  be  thrust across
the nose, and  pressed together by rolling up their ends;  or  a  saddle-
shaped plate of lead is to worn on the nose. 
[   593   ]
 II.—OF THE MECHANICAL COMPENSATION FOR LOST PARTS.

  2555. The compensation for lost parts by mechanical contrivances is
either  merely with the  object of removing or  diminishing deformity, or
for  restoring the functions of lost, parts ;  the former is the object of artifi-
cial noses and eyes, the latter of artificial legs and the like.
                      A.—OF ARTIFICIAL LEGS.

   2556.  The oldest and most  simple contrivance for the purpose, after
 the loss of the thigh or leg, of rendering the mutilated  person capable of
 walking without crutches, is the  wooden leg,  {die Stelzen, Germ.; jambe
 de bois, Fr.,) which, though it do not hide the deformity, still, especially
 with some practice by the cripple, answers its object tolerably well.  For
 the purpose of not merely supplying the lost function of walking, but also
 of giving, as far  as possible, the form  of  the lost  limb, a  multitude of
 contrivances have been proposed, from Pare  up to the present time.
   2557.  Pare {a) gave  an engraving of  a machine for the amputated
 thigh which was furnished with a knee-joint,  and with joints in the fore
 part  of the tarsus, and with an  elastic spring.   Ravaton (b) invented
 artificial  legs  for  those who had lost their leg immediately above  the
 ankle..  White (c) describes artificial tin legs covered  with thin leather.
 Addison {d) invented an  instrument with motion at the knee, and ankle-
 joints.   Wilson (e) formed legs of stiff leather.   In  Germany  Brun-
 ninghausen {f) made known an artificial foot, which  wTas  far more
 perfect than the old  ones,  and  gave  pattern to those of StAh (g),
 Berrens  (h), Heine  (i),  Graefe  (k), Ruhl  (I), Palm>  (m), Dorn-
 bluth {n), and Schuruchat, for the thigh, and Wals (o), Miles, Serre,
 and others,  for the leg.
   2558.  In making choice  among the different kinds of artificial legs,
 the following points are to be attended to ;—Besides the correspondence
 of the artificial with the whole leg as to form, for the purpose of removing
 the deformity, it  must be made as light as possible, but proportionally
 strong;  it must allow the natural movements; and afford  a convenient

  (a)  QSuvres, p. 904.  Paris, 1798*        Fusses, fur den Ober.  und Unterschenkel.
  (b)  Chirurgie d'Armee, &c.  Paris, 1T68.  Wurzburg, 181-1.
 8vo.                                    (k) Nonnen  fur die Ablflsung  grosserer
  (c)  Bfll, B., System of Surgery, vol. vi, p.  Gliedrnassen, p. 1"47.  Berlin, 181.1.
 512.                                    (.1) Ueber die Ersetzungs Chirurgie im
  (d)  Bromfield, William, Chrurgical Ob-  Allgemeinen, nebst Abbildung und Besch-
 servations and Cases. 2 vols. 8vo.  London^  reibung eines kiinstlichen  Unterschenkels;
 1773.                                 in Hufeland's Journal, vol. xl. part iv. p. 1,
  (e)  Bell, B.,above cited.               fig. i.-viii. 1818.
  (/) Ricrter's Chirurgische Bibliothek^    (m) Dissert. (Pries. Autenrjeth) de pedi-
 vol. xv. p. 568, fig. i.-iv.                  bus artificialibus.  Tubings 1818.
  (g)  Anweisuny zuai verbesserten chirury.    (n) Ueber den Mechanischen Wiederer-
 Verbande, p. 498, pi.  xxiv. fig. 2^27,  228.  satz der verlorenen unteren Gliedmaasen
 Berlin, 1802.                           durch  eigene  Apparate.   Rostock, 1831;
  (h)  Langenbeck^  Bibliothek  der  Chi-  with two plates.
rurgie, vol. iv. p. 173, pi.  i.  fig. i.-iv., pi. ii.    (o) Rust's Magazin, vol. kii. part hi.—
fig. i. ii.                              Riss winkler, A., Ueber kunstliche Fiisse.
  (j)  Beschreibung eines neuen kiinstlichen  Wien,  1836, fol.—Frorieps  Chirurgische
                                     Kupfcrtafeln pi. ccccli. 
594
ARTIFICIAL LEGS.
and safe rest for the stump which it surrounds, avoiding, however, all
painful pressure on it, and especially on the amputated surface.  Simpli-
city of construction and lowness of price are, at least for the greater num-
ber of maimed persons, important advantages.   Of all the artificial legs
proposed, those which best answer these acquirements, according to my
experience, are Ruhl's for the leg and Stark's for the thigh.
  2559. Ruhl's leg has the peculiarity of well-stretched Russia leather,
two inches broad  around the  stump,  to which two strong  brass hooks
are attached;  with this the stump received into the socket of the leg is
suspended, and so fastened that the amputated surface is not subject to
any pressure.   The leg is connected by a joint to the foot-piece, and  this
in like manner to the toe-piece.  At the upper part of the leg, on both
sides, are two wings fixed with hinges, which are applied on both sides
of the thigh, and drawn to with a strap.   The whole leg is made of lime-
wood, properly hollowed, having been previously sawn through for that
purpose, afterwards glued up, surrounded with a bandage dipped in glue,
and afterwards lacquered.
   2560. Stark's thigh consists of a thigh-piece, made of copper or  tin,
for the reception of the  stump;  of a knee-piece and  leg, composed of
soft but tough wood, and connected by a hinge;  and lastly, of a foot-
and toe-pieces.   The fastening of this  artificial limb is by means of an
iron rod passing up from the thigh-piece to the hip-bone, by which it is
attached with a strap  around  the pelvis.   Over both shoulders strong
straps, like breeches braces descend, and  are fastened behind and before
to knobs with elastic springs.  The weight of the whole body rests on
the padded edge of the thigh-piece, so that the  end of the stump lies in
the cavity of the thigh-piece, softly, upon an elastic leather pad.
   2561. When, after amputation of the  leg, the  stump becomes per-
manently bent, or where  it  has been so bent by anchylosis of the knee-
joint, then, only, a wooden leg can be used.   This consists of a lower
portion turned cylindrically, upon which  an upper piece  hollowed in an
oval or semicircular shape rests, from which two splints  an  inch and a
half wide rise up  on the thigh, the outer  to the hip-joint, and the inner
to the middle of  the thigh.  These splints are  fastened by straps to the
thigh, and from the upper end of the outer another strap passes round
the pelvis.  I have  in many instances  extended the long splint  only to
the middle of the thigh,  making it, however, so elastic, that  by means of
straps it may be  brought quite close to the thigh, by which the leg is
rendered much lighter and more convenient (a).
   Ruhl (b) has made a  wooden leg, in which with motion  at the knee-joint, the
stump is fastened in the same way as with artificial legs, and the maimed person is
capable of moving the knee-joint.
   2562.   For the  thigh, that wooden  leg is best in which  Stark's
 socket for the  stump of  the thigh is fixed upon  the cylindrical lower
 piece, and its  firm application is in  this way as in an  artificial leg ef-
 fected.
   2563.  The wooden leg has always the advantage of simplicity, less
 price, firmer application, and  greater lightness.  In  the leg, the back-

              Co) Brunninghausen's Wooden Leg, above cited, pi. iii.
              (b) Abqve cited, part v. p. 108, fig. i.—iv. 
ARTIFICIAL UPPER-ARMS.
595
ward bent stump, if not too long, rests easily, hidden with a rather wide
stocking.   For poor persons, especially of the labouring class, a wooden
leg always answers  best.  I have often seen rich persons, after  trying
various kinds of artificial legs, given  them up for a mere wrooden leg.
   2564. After amputation between the astralagus and os calcis and na-
vicular and cuneiform bones,  the supply of the mutilation is readiest; as
in most artificial  feet, two  foot pieces,' properly hollowed  and padded
behind, so that the scar of the stump cannot be pressed, are  made use of.
The whole is put into a boot or leathern  stocking, which  is drawn to-
gether  and fixed to the knee {a).   When in this case the calf has consi-
derably shrunk above, it is necessary that the foot-piece should be so
fastened to the  heel, that in walking  the heel should be a little  pulled
down.
                    B.—OF ARTIFICIAL HANDS.

  2565.  In Pliny (6) is found an  example of the replacement of a lost
hand by an iron one.   The artificial hand of Gotz von Berlichingen is
well known, and  its mechanism has been  described  and engraved by
von Mechlin (c).   Pare {d) has given plates of artificial hands made of
iron and  boiled leather.   Wilson  (e) also manufactured  them from
leather.   Ballif {f) of Berlin devised a contrivance more simple than
von Berlichingen's, by means  of which without the  assistance of the
other hand, flexion and extension could be  performed at will, so that
objects could be held firmly, and even a pen taken up and written with.
Bending  the fingers is effected with  elastic springs, and  straightening
with catgut, by bending and straightening the arm.  For the application
of such artifical hands, it is  always necessary that there should be a suf-
ficient stump of the fore-arm.
                C—OF ARTIFICIAL UPPER-ARMS.

  2566.  When  sufficient stump is left after  amputation, Graefe {g)
thinks that it  may perhaps be supplied, as well as in  lost fore-arm, by
an artificial  hand, which must also have an artificial elbow-joint.   The
upper-arm must be surrounded with a sheath,  from whence spiral springs
pass to the fore-arm to effect the bending of the  elbow-joint.  Catguts
fixed upon  the opposite side, pass from the upper and hinder edge of
the fore-arm to the  arm-pit  pieces of the chest-strap.  If the arm, by
bending  the stump, be brought towards  the  chest, the fingers also by
means of the springs, remain so.   If the stump be carried away from the
chest by  means of the stretching  of  the catguts, the elbow-joint, and
also the fingers, are straightened.

  (a) Graefe, above cited, p. 155.           (e)  Bell, Benj., above cited, vol. vi. p. 513.
  (6) Historia Naturalis, lib. vii. cap. xxix.     (/) Graefe, above cited, p. 156-164, pL
  (c) Die eiserne Hand des  tapfern Ritters vi. fig. i. ii.—Geissler, Beschreibung und
Gotz von Berlichingen, u.s. w., beschreiben Abbildung  kiinstlicher Hande und Arme,
und abgebildet von Ch. v. MecheLn. Berlin  nebst einer Vorrede von Joerg.  Leipzig,
1814.                               1817-
  (d) OZuvres, pp 902, 903.                (g) Above cited, p. 164. 
[   596   ]
               D.—OF ARTIFICIAL NOSES AND EARS.

   2567. If the organic reparation of the nose be  impossible, or be not
eff'ected, there remains only its replacement by one made of silver plate,
of lime wood, papier mache, and the like, to hide the deformity.  It is
evident that such nose should be made to correspond as well as possible
to the form of the face, and should be coloured externally to match.  The
fixing of this kind of nose, if only a small part of the original one be lost,
is effected by smearing sticking plaster on its inner surface, or by springs
in the nostrils, or by little bandages drawn through the nostrils into the
mouth, and attached to the  teeth, or what is  best by  a spring passing
from the root of  the  nose over the temples to the back of the head.  If
the mutilated person wear spectacles with his artificial  nose, the decep-
tion is very complete (a).
   2568.  Artificial ears are best made of silver,  and fastened by a tube
passing into the ear passage, and a spring passing round the head.
E.—OF THE SUPPLY OF LOST PORTIONS OF THE HARD PALATE.

  2569. Openings  in the hard palate are either vices of the first forma-
tion, as in wolf's jaw, or they are consequence of destroying ulcerations,
specially those from  syphilis.  A piece  of sponge, corresponding to the
opening in the palate, attached to a  silver plate, fills up the space, and
thus the loss of speech and difficulty of eating and drinking are  got rid
of.   Such instruments are called obturators;  and it must be remarked,
that there should not be too great hurry in having recourse to them, as
both congenital  clefts of the hard palate, as well as  those  produced by
ulceration frequently contract and close  of themselves, which process is
prevented by the introduction of a foreign body.   The obturator must be
occasionally removed, cleansed, and replaced with another.
             F.—OF REPLACEMENT OF THE TEETH.

  2570. It has been already remarked {par. 896) that a tooth which has
been drawn, if it be at once replaced in  its socket, and the  jaw kept
quiet, most  commonly becomes fixed, hence  in former  time  arose the
objectionable and inhuman practice of transplanting teeth.
  2571. For the supply of lost teeth, others taken from the dead body,
and properly cleaned, are  used; these are inserted into the gaps of the
teeth which have been drawn, and are fixed with silken or golden thread,
to the neighbouring teeth.   Or artificial teeth are manufactured  from hip-
potamus' teeth, from ivory or  bone, and  from  enamel.   If the tooth-
socket be already Closed, or very much narrowed, the crown only of an
artificial tooth can be fixed upon the gum, and fastened to  the neighbour-
ing teeth.  When the crown of a tooth is bad, but  its root still remains
firm, the crown must be filed off and another attached on the remaining
root  by means of a stem; or an  artificial tooth may  be fastened with
springs td the neighbouring teeth.
           (a)  Klein; in Heidelberg, klinisch Annalen, vol. ii. p. 103. 
[  597   ]
     SEVENTH  DIVISION.

SUPERFLUITY OF ORGANIC PARTS.
  2572.  To this division belong few subjects, to wit, first, supernumerary
fingers and  toes; secondly, supernumerary teeth;  and, thirdly, doubled
teeth.
          I.—OF SUPERNUMERARY FINGERS AND TOES.

   2573.  Supernumerary Fingers occur under two different forms.  The
supernumerary finger  is either articulated with the  metacarpal bone of
the thumb, of the fore, or of the  little finger; it resembles the other
fingers in form, but is  not provided with proper motive organs ;  and by
its growth interferes with the  motions of the  neighbouring fingers.  Or,
it is not merely a supernumerary finger, but there is also a supernumerary
metacarpal bone, and the finger has its perfect organization and mobility.
The same applies to supernumerary toes.
   2574.  In the first case the removal of the supernumerary finger by dis-
jointing it from its connexion with the  metacarpal bone is indicated.   In
the second, disjointing the finger is of no use as regards the deformity;
the metacarpal bone must also be removed.  Such finger may be useful
by its free motion and perfect organization.
                II.—OF SUPERNUMERARY TEETH.

   2575. Two conditions are observed with respect to these.  Either a
 milk-tooth remains firm, and that which should have its place grows in
 some other direction, and penetrates through either the outer or inner
 surface of the alveolar process;  or, in consequence of  disproportion
 between the extension of  the alveolar process and the breadth of the
 teeth,  single teeth project,  either obliquely  or thrust through the fore or
 hind surface of the alveolar process.   In the former case the unnatural
 direction of the second tooth does not seem to depend always upon the
 obstruction of the milk-tooth, as it is often observed when the milk-teeth
 loosen.
   2576. Teeth standing irregularly, cause, intheir further  growth, con-
 siderable deformity, thrust out the lips, or irritate the tongue, and pro-
 duce  ulceration.   It is usually advised to draw those  milk-teeth which
prevent the proper development of the second teeth and to bring the latter
into their place by pressure.  But that this should succeed, the partition
which  separates the milk-tooth from the other must not be very thick, the
unnatural direction  not very great, and the  breadth of the  second tooth
not excessive in proportion  to that of the first.  If this be the case, and
   Vol. hi.—=-51 
598
DOUBLE NOSE.
the first tooth be quite firm, it  is better to pull out the wrong standing
tooth, and to retain the milk-tooth.
   2577. When  the teeth stand  obliquely from want of space in the alve-
olar process, it  is necessary to  draw the oblique teeth, in which case, if
this be done early, the other teeth usually take a  proper  direction, and
fill up the  socket of the tooth that has been drawn.
                         III.—OF DOUBLE  NOSE.

    2578.  Cases  are mentioned  as  examples of  double  nose, in which
 tumours developed from the root of the nose, have the form of a second
 nose; or where the nose has been cleft in the middle.   The former is
 either congenital  or arising afterwards.   Stout persons who  live very
 well and drink  much spirits  are not very unfrequently subject to such
 swelling and degeneration of the noser which often  acquires so  great a
 size that  the enlarged nose overhangs the mouth and covers it (1).  The
 single remedy here consists in the  removal of the swelling by tying, or
 by the knife, which is best.   The cut must be made  according to  the
 condition of the swelling.   The  bleeding may be  very considerable, and
 the  actual  cautery may be necessary to stanch  it.   In cleft nose,  the
 parts should be  attempted to be brought together with sutures and stick-
 ing plaster, after previously paring the edges.
    [(1) Hey (a) has given  an account of a case of this kind, in which " the tumour
 extended to the lower part of the under lip; and compressed the patient's mouth  and
 nostrils so much when he laid down to sleep, that he was obliged lo keep a tin tube
 within one of his nostrils that he might be enabled to breathe.   He also generally
 wore this tube in the day time, as the pressure which his mouth and nostrils suffered
^ at all times from the bulk of his nose, rendered  breathing without this  instrument
 somewhat troublesome.  *  *  * The disease appeared to Hey, to be nothing more
 than in enlargement of the  common integuments of the nose.   For though the latter
 were buried  in the large mass of morbid integuments,  yet when the  tumour was
 supported he could distinctly trace with his finger the border of the cartilages."
   Dalrymple (b)  observes:—"This disease cannot be called simple hypertrophy,
 since this tissue has lost its natural pliancy and natural colour ; but rather approaches
 to a state of elephantiasis, in which the cellularity is partially  deslroyed,and a fibro-
 cellular structure substituted.  The mass presents externally a nodulated surface of
 a purple, or deep-red  colour, traversed by numerous  minute  and tortuous vessels.
 The larger separated  portions are frequently divided from each  other by deep  fissures,
 occupying in many cases the convexities of the or/* and extremity of the nose.   "Where
 the disease has been of long standing, the altered state of skin advances as high as
 the junction of the frontal with the nasal integuments, seldom encroaching much on
 the palpebral furrows laterally, but accompanied  in the  majority of  instances by a
 wattled state of the skin of the cheek, corresponding in colour and general appearance
 with the tumour of the nose.  The sebacious follicles are greatly enlarged, and their
 secretion ir not only increased in quantity, but unless extreme cleanliness is attended
 to, it is offensive in smell and excoriates the surrounding skin." (p. 396)]
   Upon this subject may be further consulted—
   Bartholin, Thomas,  Historia Anatom., cent. i. hist. xxv.
   Borel, Historia et  Observationes Medico-Physicae, cent. iii. obs.  lxiii.
   Bidault de Villiers; in Journal Complementaire du  Dictionnaire des Sciences
 Medicales, cah. xxxiii. p. 183.
   Klein, Ausrottung einer ungewohnlich grossen Nase; in Harless rheinischen
 Jahrbiichern der Medicin und Chirurgie, vol. v. part i.

   (a) Practical Observations  on Surgery,    (b) On the Removal of Morbid  Enlarge-
 illustrated by Cases, p. 355.   London, 1810.  ment of the Integuments of the Nose ; in
 8vo. Second Edition.                    Medical Quarterly Review,vol.i. p. 395. 1834. 
[   599   ]
EIGHTH  DIVISION.
L—OF  THE  ELEMENTARY  PROCEEDINGS  OF SURGICAL
                          OPERATIONS.

  2579.  There is scarcely a Surgical Operation which  can be  fully per-
fected on a diseased body by one  single, simple act.  All rather consist
of several manoeuvres following, according to determined rules, and dis-
tinguished by the name of Steps of the Operation (Operationsacte, Germ.)
One of these is the special object of the operation, and the  others must
necessarily precede  or follow, to effect this object,  and bring about
the restoration of the patient.  The object of the operation is always the
same, but the manner and way of attaining it may be very different, and
this difference may consist either in the difference of the several steps of
the operation, or of the entire way by which the attainment of the object
of the proposed operation maybe effected.   Hence arises the distinction
between  Operative proceedings and Methods of Operating.
  2580.  The Method of Operating is the compass of the regulated modes
of proceeding, by which the  object of an operation in any peculiar way is
attained.  In the various methods of operating, therefore, not merely are
different  parts cut through and in very different directions, but the prac-
tice of the methods of operating is so peculiar, that the one method does
not exclude the other.
  2581.  Upon the choice of the method of operating depends  for the
most part the successful or  unsuccessful result of the operation, just as
upon the choice of the operative proceedings rests the facility of its exe-
cution.   The choice of the mode of proceeding is therefore of little con-
sequence, and  depends commonly  upon the operator himself.  Hence
also, the  variety of opinions as to the preference of the mode of proceed-
ing in general is greater than upon that of the method.
  2582.  In deciding upon the preference of the various methods of opera-
tion the following circumstances must be attended  to.   First.  The least
important organs must be injured, consequently the loss or destruction of
organic parts caused by the operation, the pain, and the traumatic reaction
depending thereon is least.  Second. The better method must always be
most fitting for the greater number of cases.  Third.  This must'consist
in the manoeuvres, which do not make the operator dependent on acci-
dental circumstances, but which rest completely on the will of the operator.
Hereon and  upon the nature  of the parts  to be wounded, are founded
safety and facility in  the execution of the method of operating.  Fourth.
The quickest cure which can be effected by the operation.
  2583.  Many operations  are  subject to certain and general rules, and 
600
ELEMENTARY PROCEEDINGS.
but few cases require any variation in the way of their execution ; to these
belong, for instance, all amputations, the operation for the stone, laying
bare arteries, and so on.  Such operations  may therefore be perfectly
learnt by due practice upon the dead body.   There are, however, on the
contrary, other operations, and their  number  is  the more  considerable,
which cannot be subjected to such definite rules, and of which the  con-
duct must necessarily rest on the special  difference of  the case, and of
the existing circumstances.  These operations are the most difficult and
require the closest knowledge of pathology, in order to be at the moment
in a condition properly to comprehend and decide  on the circumstances
which present.   Here belong, for instance, the operation for strangulated
rupture, disjointing, cutting off  the ends of bones, removal of tumours
which are of considerable size, and seated in the neighbourhood of parts
that dare  not be wounded without the greatest  danger to the patient.
The difficulty of  the operation in other respects depends on many par-
ticular  circumstances, and is  not always connected with one  and the
same act of the operation.
   2584. Operations are specially called for, when the  cure of the  case
cannot be  effected by any other mode of treatment.  But as  whatever
acts upon the material side of the constitution also effects the dynamic
side and influences the reaction, and as the disease^ which is hoped to be
removed by the operation, is in  many cases,  merely the  result  of general
persistent  causes, hence  must  be borne in mind the  various circum-
stances in reference  to the successful result of the operation, which
depend on the method of operation, the circumstances affecting the opera-
tion which relate to the condition of  the patient, to the  external circum-
stances under which the operation  has  been  determined, and to  the
possibility of good previous and after treatment..
   2585. That the operation should have  the probability of a successful
result, the following circumstances must be attended to:
   Firsts The disease to be removed  by  the operation, must  not be so
connected with any general ailment, that may act on it as a cause to keep
it up continually.  In such case the operation would remove  merely the
product of the general disease, not the  producing and sustaining cause.
But not unfrequently a general disease terminates in a local disease, and
the operation then has the happiest result, because it gets rid of the  resi-
duum  morbi.  In these cases  a careful discrimination is necessary in
order to determine which of the general symptoms are to  be ascribed to
the reaction of the local disease, or to a persistent general cause.
   Second. The patient's weakness must not be great, nor the  sensibility
so excessive that the effect upon life resulting from the  operation should
bring it into very great danger.
   Third.  The local disease, to be removed by operation, must not by its
long continuance or other circumstances, be so related to the constitution,
that it have acquired the rank of a secreting organ,.©)? have removed any
previously existing disease, or  have checked  it in its earlier develop-
ment.
   Although the above circumstances generally contraindicate an opera-
tion, there may be still some cases where in spite  of the decided pros-
pect that no cure can be effected by operation, yet it may be  employed 
OF  SURGICAL OPERATIONS.                601
 as a palliative, if it be possible thereby to mitigate the sufferings of the
 patient, and lengthen his existence.
   2586. In regard to the  patient's condition it must be observed, that
 operations on persons who can bear pain  quietly and patiently, are less
 dangerous than in those who are much excited by the least pain.   Those
 patients who have suffered severely for a long while, have become accus-
 tomed  to pain and  are enfeebled, generally  bear  operations best, which
 depends partly on  the moral  influence of their  earnest desire  for the
 operation, and partly on the less degree  of traumatic reaction.  Persons
 of sanguineous temperament who  seem  to superabound with health, are
 unfavourable  subjects  for important  operations.   In like manner also,
 very stout persons of tall  and strong  make.  Among nervous subjects a
 distinction must be  made  between  those who  are  very sensitive and
 excitable, and those who  on the slightest  cause drop into  moral des-
 pondency and  nervous stupidity.   The former are much affected by the
 pain of an operation, but on account of their easy excitability, they quickly
 again  perk up, and are  influenced  by encouragement and  comforting
 hopes, so that their spirit is again  aroused; but such is not the case with
 the latter, who writh dull despondency and nervous stupidity allow every
 thing to affect them, and without a murmur give themselves up.   Young
 persons bear operations better than old ones;  but even  much advanced
 age  does not contraindicate  them;  operations oftentimes  do so much the
 better on account of the less degree of traumatic reaction.   In  gouty sub-
jects operations ard always dangerous; preparatory treatment, especially
 purging, is necessary in such cases.   It must be noted especially in scro-
 falous subjects, whether there  be not any particular  organ as the lungs
 for  example affected with that  disease.   Not  unfrequently; after the
 removal of a diseased part, scrofula breaks forth in the internal organs (a),
   2587. From the circumstances  already referred to* it may  be for the
 most part ascertained u.ider what circumstances it is necessary to prepare
 a patient specially for an operation, as according to his different condition
 such remedies must be previously employed, as either counteract the
 general  disease, raise  the  patient's powers,  or  lower the increased
 sensibility, or by artificial evacuations, by issues and'the like, render the
 result  of the  operation more  safe.  Very robust, fulKblooded  persons
 should  for some time previously be put  on spare diet; and bloodletting
 had recourse to if the general condition should seem to require it.
   2588. The practitioner  must  determine,  according  to the patient's
 character, whether he  may venture  to make him acquainted with the
 more immediate circumstances of the operation, or  conceal  them from
 him.  With  sensitive  persons he must  go- very  cautiously to work;  a
 kind and sympathizing carriage  and encouragement, are often  exceed-
 ingly advantageous.  Great sensibility must  be somewhat repressed by
 opiates, and in such persons-small doses-of opium before and  early after
 the operation are required.
  [As a general rule, the administration of bpiirnvor any other sedative, either before
 er after an operation should be carefully avoided, as it is difficult and often impossi-
 ble to distinguish between the effects of the medicine and the symptoms springing
out of constitutional excitement.  Persons who have been long in the habit of taking

      (a) WARimorTLectures on Surgery; in-Lancet. 1932-33; vol. ii. pu51T;
                                  51* 
602!
ELEMENTARY" PROCEEDINGS
opium to alleviate their pain, should not be deprived of it either before or after the
operation, but great care  should  be  taken to watch  the  period  when it  can be
diminished, or  completely withdrawn without  disadvantage to the patient;  and
beyond  all doubt this  may frequently be  done  greatly to  his benefit  much more
speedily than is in general believed.   Many persons who have for a length of time
suffered the excruciating tortures of ulceration of the  cartilages of  a  joint, and not
known an hour's rest for weeks, will enjoy quiet tranquil sleep the first night after
the removal of the limb, without any other opiate than relieffromthe horrible pain  that
they had previously suffered, and will need no sedative during the whole course of
their cure.  The  same also happens frequently with  hectic cases  after compound
fracture.  I have  witnessed this state o£ things  so frequently, that even  if opiates
have been  previpusly, taken, I endeavor* to do without them; and  if towards night
the patient drop off to sleep, none  is given; but if he be restless and uneasy, opium
must be given, and in such dose as shall ensure sleep, and if one  be insufficient, a
second should be  given a  few hours  after, which is- asually effective.  Also if, on
the evening after the operation, the patient  should be restless or even only wakeful,
although he have  not been accustomed to opium, it should not-be spared,  as it is of
the utmost importance  to his well-doing that he should get- sleep  for the first few
nights after the infliction of so severe-an injury as an  amputation.  As  to the seda-
tive to be employed, opium is, I am  sure,  the most effective; in ordinary cases, its-
tincture, from thirty to forty drops at a dose, as may be, is sufficient; but some-
times, especially to free livers and sottish persons, it will ba advantageous to give it
in form of muriate of morphia, a third on half a grain at a dose, and  such persons not
unfrequently require it twice or three times a day during the  whole course of their
cure.  Care, however,  must be taken that the bowels  should not be blocked up and
loaded, as not unfrequently happens,  and is best  corrected by a dose of three or  four
grains of calomel, which  in general answers sufficiently,  without disturbing the
alimentary canal, andioxciting diarrhoea, as other purgative remedies  too frequently do.
   Another very important point in the treatment of operations, is the use  of porter,
wine, or spirituous liquors; even where the  patient has  been prudent  and temperate, it
is occasionally necessary that one or other of these should be given soon after an ope-
ration.  But  for persons who have been accustomed to take large quantities cf  por-
ter or spirits, or both, and  who, in consequence of severe accidents, are  subjected to
the amputation of a  limb, or who have severe  lacerations, which, however, do not
require operation, it is absolutely necessary for their safety that the  stimulant should
not only be not entirely withdrawn, but even somewhat very near the quantity they
have been accustomed to, must be allowed, or they either sink at once, are attacked
with erysipelas, or are violently affected with delirium tremens, in  which condition
they speedily die.  The quantity taken may often seem enormous under the circum-
stances.; three or four glasses of gin or brandy, and as much or more wine, and some-
times porter besides, in the course  of the twenty-four hours, is by no means an unfre-
quent allowance; and I have just the  recollection of one of the younger  Glixe's pa-
tients, a porter at the Royal Exchange, who required a  pint of brandy daily alter
having suffered amputation of his  leg for an accident.   This man was saved by  this
treatment, and lived many years after, doubtless  following the  same free course of
living which had required  treatment, at  that period  thought  exceedingly bold  and
almost marvellous in  its  result,  although ati present every  day's practice and no
wonder at allow*, f. s.]
   2589.  In regard to the time of year when an operation  should be un-
dertaken,  there is no  longer any restriction,  as  was formerly the case
with many operations.   If spring have any preference over.olher seasons,
it depends  only on  the steadiness of the  weather.   In  other respects, it
the circumstances of the case allow the operation to be deferred, in those
operations, which, on  account of their precision  require bright light for
their performance, and in persons who are subject to rheumatic and gouty
affections, and  are very sensible  to changes of  temperature, a bright day,
and a  season when steady weather may be expected, should be preferred.
 The time of very oppressive heat should be, if possible, avoided.
   2590.  In order to lessen the pain in operations, besides moderate doses 
OF  SURGICAL OPERATIONS.
603
of opium previous to the operation, it has also been advised to warm the
instruments (a).  Wardrop (6) has  even proposed bleeding the patient
to faintness previous to any important operation, and during the swoon
to perform the operation ?!
  [It is scarcely possible to imagine any one could have made so precious a propo-
sition as that last referred to, unless the operator's object were to finish his patient.
Another more recent foolery, with the same intent, is mesmerism, which, however,
does not endanger the patient as- Waadrop's  proposal most certainly would.—
j. f. s.]
   2591. Among the most  serious occurrences during an operation, be-
sides severe bleeding, the following  must be notieed ::—
   First. Faintings and convulsions,, wrhich depend either on loss of blood,
on  want of blood: in the brain from irregularity of the circulation, on from
reflected activity of the spinal marsow, consequent on the severity of the
pain.  In all  these  cases the operation must be suspended, the patient
placed in the  horizontal postune, and roused by sprinkling the face-with.
cold water, by scents, especially liquor of caustic  ammonia, or naphtha,
and according to eircumstances, reviving remedies, as Hoffman's spirit
©f aether, wine, brandy, and the like, or some laudanum should be given.
   Second.—Sudden death, which may indeed be the result of very severe-
gain, or of loss of  blood, and especially of the entrance of air  into the
veins.  This last accident  is moce frequent,  and more especially occurs
when  large veins, particularly those of the neck and armpit, are  much;
pulled and dragged before being eompletely cut through.  There is then
heard at the moment the vein is cut through, a whizzing as on  opening
the air-tube,  {gfiick-gluck geramch,)  and immediately after-, shivering,.
swooning, convulsions and death.   The cause of the sudden death is the
entrance of the ai»  into  the right side of the hea-rt,  by  which its move-
ments are suddenly stopped.  The wounded vein must be dicectly pressed
with the finger, and according to  Amussat, the  chest and. belly quickly
and forcibly compressed during expiration, and at every interval of such
compression,  the finger applied? to the opening of the vein, and  then the
vein tied or twisted.   Others have recommended blood-letting by opening,
the temporal  artery, sprinkling with  cold water, applications-of ammonia
and camphorto the nostrils, andlpfessure on the abdominal aorta and both
axillary arteries, as well as drawing out  the air which has entered the
vein through, a pipe with the mouth, or by means of a syringe and flexi-
ble catheter (Magendie.)  In but few instances has  the patient been re-
covered.    It must not, however, be forgotten that many cases-which have
been ascribed' to the entrance of air into the  veins, are  very problemati-
cal, and that death must be attributed to other causes.
   Bichat asoribed death from the entrance of air  into the veins, to its-effeot upon the
 brain; Nisten and Magendie to the extension of the heart; and Piedagnel (c)  to
emphysema of the lungs.
   Amussat (d)'att9mpted to restore several animals destroyed by the entrance of air
into the veins, aa already described;  Ji Warren (e) relates two cases, in the first of

   (a) Faust  und Heinolo, Ueber die An.    (d)  Mem.de l'Acad.. Roy..de  Medecine,
wenrlung und den Nutzen  des Oels und  vol. v. p. 82.
der Warme bei  chirurgischen Operationen,    (e) American Journal of Medical Science,
Leipzig-, 1806.                         and article Air,-.in the American Medica!
   (/>) Lancet, just quoted, p. 597.         Cyclopedia, vol. i. Pbilad. 1834.
            (c) Magendie, Journal de Physiologic, vol. ix. p. 60.   1829. 
604
DIVISION OF ORGANIZED PARTS.
which, the patient was restored bybleeding from the temporal artery.  Mussev (a)
brouo-ht the patient to himself by the application of ammonia and  camphor to the
nostrils.  Mercier (b), who attributes-death from admission of air into a vein to the
same cause which produces syncope, namely, the deficient  supply of blood to the
brain, recommends, that the small quantity of blood which—in spite of the obstacle
offered by the admitted air to the transmission of the Mood from the right to the left
side of the heart and thence to the body—is, nevertheless, transmitted into the arte-
rial system, should be directed towards  the brain, and this  by compression of the
abdominal aorta, and of the two axillary arteries.
  [Bransbv Cooper (c) relates a case  in which this alarming syncope occurred,
after an amputation at the shoulder-joint, and whilst he was removinga small gland.
Whilst recovering, the patient " uttered a continual whining cry, and  maintained a
constant motion of alternate flexion and extension of the right leg, whilst the left
remained perfectly quiet."  This movement continued for about nine days and then
ceased.
  2592. All  kinds of  operations, according to  their nature,  must be
referred to the following principal acts, which, at the same  time, must be
considered as the elements of every operation, and of which every single
act consists:—They  are, first, Division ;  second,  Apposition;  third,
Dilatation.
           A.—OF  THE DIVISION OF ORGANIZED PARTS.

  2593. The division of the connexion of organized parts, is that one of
the elementary acts of an operation most frequently brought into use, and
m most operations constitutes their principal circumstance.
  2594. The division of organic parts may be effected by mechanical ot
chemical means; though the latter is less employed in reference to division
than to other objects, on whieh  account division by mechanical  means
will now alone be considered.
  2595. The parts of our body may  be divided—
  First, By  a cut or incision.         Third, By tearing asunder.
  Sacond,  By a stab or penetration.    Fourth, By tying or ligature.
  2596. All instruments employed for the division of soft parts by cutting
must be placed in  two classes; to the former belong those which  have a
single cutting edge, knives, bistouries, and  scalpels; to the latter, those
consisting  of two cutting edges, connected crosswise in their middle, and
terminating in handles ;  such are scissors.
  2597. Knives are distinguished from each other, to wit, by the fixing
of the blade to its handle, and by the form of the blade itself
  2598. The blade is either attached firmly to the handle, as a scalpel, or
it drops into the scales of the handle andean be opened, as a bistoury.
In bistouries the connexion of the blade is either such, that when opened,
the blade is  not fixed steady, but only cannot fall back, or the open blade
may be fixed firmly.  The mechanism for this purpose consists either of
a metallic ring, which  can  be pushed up  on the  laid-back end of the

  (a) Schmidt's Jahrbiicher.  No. 9; p. 332.  Edinburgh, 1837—von Wattmann, Sicheres
1339.                                Heilveifahren bei dem schnell  gefahrhches
  (6) Revue Medicale, vol. iii. p. 294. 1837.  Lu teintritt in die  Venen und dessen ge-
—Amussat,  Recherches sur l'lntrodnction  richtsarztliche Wichtigkeit.   Wien, 1843.
nccidentelle de  l'Air dans les Veines. Paris,    (c) Med.-Chir. Transactions,  voLxxviup-
1839.—Cor mack, F. C, Dissertation on the   4L  1844.
presence of Air in the Organs-of Circulation. 
DIVISION OF ORGANIZED PARTS.
605
blade, or in  a particular  form of connecting stem and catch, through
which it passes, so that when the bistoury is opened; the blade is^ thrust
up, (Percy's bistoury,) or in a spring, like the  common  clasp-knife.
The latter kind of bistoury is the most convenient.
   2599. The utility of the bistoury depends specially on the form of its
blade; the length and breadth  are of less  importance.  The following
are their distinction  according to  form:—*. The  straight  bistoury, of
which the edge runs straight to the tip, which is formed by its narrowing
from the back.  /3. The pyramidal bistoury, in which the edge and back
narrow to the point,  y.  The convex bistoury, of which the blade is con-
vex,   h  The pyramidal  bistoury,  with  a double-edged point,   t. The
bistoury curved, and having  a button at its tip (Pott's bistoury.)  The
choice of these different bistouries depends upon the special use to which
they are applied.
   2600. In general the straight-edged bistoury is most  convenient in all
cases, and with it alone can a regular cut be made.
   A regular  cut must have the same depth from its beginning to its end ;
it must not have any bridges, the  angles must not be  cut more shallow than
the middle and the edges must not be jagged.
   This cut is to be made in the following manner:—The ulnar edge of
the left hand must be placed on the part where the cut is  to be made,
pressed firmly on it, and  the  skin tightened from  above or below, and
with  the  thumb and forefinger stretched on either side.  The bistoury
held in the right hand with the thumb,  middle, and ring-finger, and the
forefinger laid on its back, or held as  a pen, has its point thrust directly
down to the  depth the cut is to be made, then the handle is sunk, and
the whole edge is drawn  with equal pressure over the parts to be cut
through.  When the cut  has been made, the bistoury is  again  raised
perpendicular, and cuts through every thing which still remains undivided
in the angle.   This is the most common kind of cut.
   2601. In many cases, where  the skin is  easily  displaced, or an im-
portant part  beneath may be injured, a fold of skin may be cautiously
made, the one end of which is given to an  assistant, the other held by
the operator, and the knife drawn across its middle.  Sometimes the cut
is made from within outwards; the bistoury is then thrust in to  a certain
depth, and  its edge, drawn  out to or  from the operator, enlarges the
opening.   This kind of cut has no  necessary cause for its employment.
It is most commonly made when the bistoury is introduced on a director.
If the latter  instrument be passed beneath  the skin, or  into a canal, it
must be held with the left hand and in such direction that its end presses
towards the  skin, which  an assistant tightens on either side, whilst the
straight bistoury is rung  along  the groove  of the director, at an acute
angle with it, up to its end, when the bistoury is raised upright to divide
every thing up to its tip.
   2602. The convex bistoury is specially employed for making semicir-
cular cuts, and for the removal of tumours, where a larger extent of blade
can be made use of than with the  straight-edged bistoury.   The button-
ended bistoury is only used when parts are cut at a depth; the bistoury may
then be introduced on the finger of the left hand alone, or on a director
to prevent the point doing mischief. 
606  DIVISON OF  ORGANIZED PARTS  BY VARIOUS INSTRUMENTS.

  2603. The mode of holding the knife has an important influence on
its use; in this respect, four  postures, or positions of the knife may be
distinguished.  First. The knife is  held like  a  pen, the handle being
taken hold of with  the thumb and middle finger near the blade, and the
forefinger laid on its back.  Herewith the knife can be used with ease,
and  employed  in every direction; it is  specially suitable where small
cuts are to be made with great care.   Second. The knife  is held with the
thumb on one, and the  middle and ring finger  on the other side of its
handle, and the forefinger laid on the back of the blade,  as in holding a
violin-bow.  Third. The handle is placed upon the inside of the ball of the
thumb, with the thumb on one side, and the middle, ring, and little finger
on the other, whilst the forefinger is extended upon the back of the blade.
Fourth. The knife is  grasped with the whole hand, the thumb on one and
the fingers on the  other side of the handle;  this is only applicable to
large or amputating knives.
  2604. Scissors effect the division of parts, like the bistoury, by drawing
and  pressure ; but the pressure is greater, and therefore the scissor edge
is not generally so fine  as  that of the knife; neither are the  edges set
directly opposite, but lie beside each other, so that ordinarily, a cut with
scissors, is not so clean as that with  a bistoury; the parts must also be
pressed and squeezed before they are divided.  On this account the use
of scissors is by many entirely rejected.  The objections, however, to
the use of scissors may be  done away with by the  proper fineness of their
edge, and by the greater power with which they can be employed.
  It  has been  hitherto supposed that the due degree of fineness, Tike that of a bis-
toury, cannot be  given to scissors without impairing  their  strength.  I, however,
possess scissors made by our clever, instrument-maker, Gorck, which have the per-
fect edge of a bistoury, and with, proper strength.
  2605. Scissors are specially employed to a certain extent for  cutting
off disorganized parts, for instance, in torn or bruised wounds, to remove
the loose  flesh in misshapen flaps ; in gangrene,  to  take away the half-
separated sloughs and  the like; in very luxuriant fungous growths of
flesh ; but especially for cutting off very soft or yielding parts which have
no supporting point, as in cutting the frenum lingue, cutting  off excre-
scences from the  mouth, refreshing the edges of harelip, for cutting out a
portion of the thickened vaginal  tissue in operating  on hydrocele by in-
cision, and the like.
  2606. Scissors are distinguished according to their form.   u. Straight
Scissois, of which the blades are  made pyramidal and run to a point; the
point of one blade being pretty  sharp, and  that of the other  somewhat
rounded.   /3. Scissors curved towards the surface of their blades, (Cooper's
scissors,) or  the blades curved at an angle.  These are used for removing
growths with necks,  luxuriant granulations  and  the  like, or when they
have to act in a cavity,   y. Scissors curved towards  their edge in an arch
or at an angle.   The use of the  latter (kneed scissors, or  Richter's scis-
sors) have the advantage of being used with more power, and their blades
are not so very much drawn back  in cutting (a).
  Besides these, there are also scissors  which have a double curve, that is, towards
their blades and their edges, (Daviel's Scissors,) which are used for enlarging the cut
(a) Percv, Memoire sur les Ciseaux a incision.  Paris, 1784. 
SEPARATION OF DIVIDED PARTS.
607
in the cornea in the extraction of cataract,   Levret and Percy's scissors for shorten-
ing the uvula have been already mentioned,  (par. 133.)
  2607. In using scissors, the thumb and ring-finger are to be passed
into the rings of their handles, and  that handle held with the fore and
middle finger, in the ring of which is the ring-finger.  In this way more
power is gained than if the middle instead of the ring-finger  be  put in
one ring.   The blades of the scissors having  been opened, and passed
several times between the fingers of the left hand, the parts to be divided
are made  tense, and then whilst the blades are brought together, the
escape of the part from  them must be prevented.
  2608. As regards the division of soft parts by stabbing, it must be ob-
served,  that all the  instruments employed for that purpose, are formed to
penetrate  the parts in a  peculiar way; consequently the wounds made by
them  are to be considered and treated as clean cuts.  The object of a stab
is the discharge of an  unnatural  collection  of diseasedly produced or
natural fluids.  The instruments for this  purpose are the trocar and the
lancet.
  The trocar consists of a steel stem with a wooden or horn handle, and
which runs  to a point with  three cutting  edges, and of a silver canula
which ensheaths the stem, behind the part where the three-cutting edge
begins,  and so ranging with it that there is not the least elevation.  Two-
edged trocars are inconvenient.   The lancet consists of a narrow  blade,
with a cutting edge on  either side to its tip and so connected with the
two scales of its handle that it can be moved backwards or forwards.
  2609.  Tearing presupposes  with the division  of connexion,  also a
tearing and bruising of  the part; such wounds there do not heal like a
clean cut  or stab.   This proceeding has only the  advantage  of the con-
sequent bleeding being  less than in dividing with a cut.   Hence, it is
specially used for polyps.
  2610. The division of parts by tying or the ligature is a slow cutting in
by its firm tying, in which the divided parts heal, proportionally  as the
ligature cuts deeper in.  This  method is always tedious, painful, and
should  be only employed where the neighbourhood of important parts
render the use  of the knife dangerous, for instance, in fistulous passages
and tumours of various  kinds.
  2611.  The division of a bone requires, on account of its hardness and
firmness peculiar instruments.   Such are performed.  «. After the manner
of a ad with the saw ; with the circular saw, the trepan ; with the chissel
and hammer ;  with the bone-knife, and with the nippers.  /3. After the
manner of a stab with the perforating trepan ; and y. By scraping, either
with the bonescraper or the exfoliation-trepan.
          B.—OF THE SEPARATION OF DIVIDED PARTS.

  2612.  This operative proceeding in many cases, although not the prin-
cipal object, yet however is one of the principal acts of the proposed ope-
ration.  The division of parts happens in most operations, and the indica-
tion is to bring them together again.   In  how many ways this may, and
in certain cases should be done, has been already mentioned in consider-
ing the treatment of wounds in general. 
T_   603   ]
               C—OF THE DILATATION  OF PARTS.

  2613. The object of enlarging is either simply to obtain a free entrance
into natural, unnarrowed  openings,  as for example, enlarging the mouth,
the vagina and the like by dilators and specula ; or it applies to the un-
natural  narrowings of natural passages, and is then effected by the intro-
duction of tents, or elastic bougies, which are gradually selected of larger
size ; or by such substances, as by attracting  fluid, increase in bulk, like
sponge  tent, catgut, and  the  like.  These remedies  are also often em-
ployed, after previous cutting, to prevent reunion.
Second Section.—OF  GENERAL SURGICAL OPERATIONS.
                       I.—Of Bloodletting.
     (Mstraclio Sanguinis, Lat.; die Blullassen, Germ.; la Saignce, Fr.)
2614.  Blood-letting may be performed
First,b>.opening a vein      ) ^^ Bloodletti
Second, By opening an artery, )
Third  By the application of leeches, j Local BloodIetti
fourth, By scarification or cupping.   )
                      A.—OF OPENING VEINS.
   (Veneseetio, Phlebotomia, Lat.; Eroffnung der Venen, Germ.; Ouverture de la
                               Veine, Fr.)
  Gyer, N., The English Phlebotomy, or Method and Way of healing by Blood-
letting.  London, 1592.   12mo.
  Butler, R., M.D., An Essay concerning Blood-letting, &c.  London, 1731. 8vo.
  Wallbaum, Dissert, de Venesectione.  Gotting., 1749.
  Dickson, Thomas, M. D., A Treatise on Bloodletting, &c.  London, 1765.  4to.
  Bucking, Anleitung zum Aderlassen.   Stendal,  1781.
  Wardrop, James, M.D., On  Bloodletting; an account of the curative effects of
the abstraction of blood, &c.  London, 1825.  8vo.
  Hoppe, F., Die Eroffnung der Blutadern.  Neisse und Leipzig, 1835.
  Abernethy, On the 111 Consequences  sometimes succeeding to Venesection; in
his Surgical Works, vol. ii. p. 133.   Edition of 1815.
  2615.  Opening a Vein {Breathing a Vein, in our old common language)
may be performed in any  of the  superficial veins; but usually those of
the arm,  of the hand, of the  foot,  and of the neck are preferred.
  2616.  At the bend of the elbow may be chosen the cephalic, basilic,
median-basilic, median-cephalic, and  the  upper part of the radial and ulnar
veins.
  In regard to the choice of one  or other of these veins, it must be  re-
marked, that the cephalic vein is safest,  as far as possible injury of neigh-
bouring parts is concerned, but it is frequently of sufficient size to afford
the quantity of blood required;  the  median,  median-basilic, have indeed
generally  a large diameter and project more distinctly, but they lie in  the
neighbourhood of the brachial artery, sometimes immediately upon it, and 
BLOODLETTING FROM THE VEINS.            609
only separated by the tendon of the wi.  biceps and the aponeurosis of the
arm.   It is therefore always, but especially for beginners, best to choose
the cephalic or median-cephalic, or the median and  basilic near the inner
condyle of the upper-armbone,  and to avoid the part where the artery is
felt pulsating beneath the vein.   In very stout persons the veins, although
swollen cannot be seen, but only felt.
   2617. In bloodletting from the arm the patient may either sit or lie.
The former is best when, the patient not being very weak or confined to
his bed, fainting is not to be  feared, or fainting may be produced without
much blood being drawn.  Lying-down is best when the patient is weak,
and fainting,  even when much blood is taken, is desirable to be avoided.
The patient stretches out his arm moderately, and the  operator with his
forefinger carefully ascertains the situation of the brachial artery, and of
the veins at the bend  of the arm.  A bandage about a yard and a  half
long  and two inches wide, usually of red cloth, is now applied around
the arm,  a few fingers' breadth above the bend, its middle placed on
the front, its ends carried behind the arm, where  passing over  each
other, they  are again brought  forwards  and tied there so tightly with
a  knot that the  return of the venous  blood, but  not the  inflowing of
the arterial blood,  is prevented.  If the  vein do not then become  suffi-
ciently swollen, the  skin at the bend of the arm may be rubbed with  a
sponge dipped in warm water, or the arm may be allowed to hang down
for a time.
   2618. The surgeon  nowplaces himself  on the inside of the arm, and
the patient rests his hand on his hip.   He  then opens the lancet, the point
of which  should  be neither very narrow nor very suddenly broad, places
its blade at a right angle with its scales, and puts it  by them between his
hips, and  with its point directed to the opposite side, so that he may take
it  again with his hand.   He next places his left or right hand, according
as he has to bleed in the right or left arm  of the patient, upon the elbow-
joint, so that  he can  steady the  vein which he has  to  open, with his
thumb.  This being done, and the blood  stroked down a few times with
the unoccupied hand,  he takes the lancet  with the thumb and  forefinger
in such way that only  so much of the point  should project as is sufficient
for the depth of the opening.  The middle, ring- and  little finger of the
hand holding the lancet, are now placed upon  the arm, and the thumb
and forefinger brought  to and so dropped on it, that when they are stretched
out, the point of the lancet may penetrate obliquely into the vein, imme-
diately on which the blood  shows on the lancet-blade, and the fingers
being raised, the opening in the vein is enlarged, and the spouting blood
is^to  be caught by an assistant in a  proper vessel.   The operator now
passes to the outer side of the arm, supports it, the one  hand being
applied to the fore- and  the  other to the  upper-arm without altering its
position;  or he allows the patient to  grasp the end of a stick resting on
the ground.
   [This mode of bloodletting is not the best that can be employed, and the manage-
ment  of the lancet is both awkward  and bad, and if, as is occasionally absolutely
necessary,  a vein running over an artery have to be opened, the pushing the point
of the lancet obliquely into the vein  is dangerous, as  though the vein  be wide, it
may not have much thickness, and its coats both behind as well as before, together
with whatever may be behind, may  be pierced even by the most clever operator.
   Vol. hi.—52 
610
ACCIDENTS  OF BLOODLETTING.
 The readiest and best method is, after selecting the vein, to grasp the fore-arm just
 below the elbow, with one hand, the  thumb of which is to be placed firmly upon
 the vein, just below where it is to be opened, and which is quite sufficient to steady
 it.  The little finger of the hand holding the lancet is then to be rested just below
 the thumb of the other hand, with the other fingers piled upon it, in such way, how-
 ever, as to leave the thumb and forefinger with the lancet quite at liberty, and above
 the skin, so that the point of the lancet may be capable of a swinging motion from
 below upwards, and  then by sinking  the lancet point and making it perform  the
 swinging motion, the front wall only of the vein is wounded, and at the same time
 the wound in the skin being made rather larger than that in the vein, a free opening
 is afforded for the escape of the blood, and thus a thrombus, which is often the con-
 sequence of  opening the vein, as recommended  by Chelius, and  very commonly
 practised, is prevented.—j. f.  s.]
   2619. When the proper quantity of blood  has  been obtained the knot
 of the bandage is to be untied, the wound and its neighbourhood cleaned
 with a moist sponge, the wound  covered  with the thumb of one hand,
 whilst with  the other, a little compress is slipped from  the side of the arm,
 over the wound, which it presses on the removal of the  thumb.  The
 compress is then  steadied by putting the thumb upon it, and after bending
 the arm, fixed with a bandage, which is to be carried  round the elbow in
 several figure of  8 turns.   The arm is to be kept quiet.
   2620. The particular accidents which may occur during the operation
 are, «.. A faulty stab,  in  which  case  the  operation  must  be repeated.
 /3.  The formation of a too small opening;  the wound must then be en-
 larged, or   another place  chosen,  y. Stoppage of  the flow of blood,  by
 displacement of the skin when the arm is moved into some other position;
 the arm  must then be restored to its proper place, and be a little more
 bent, the blood  stroked upwards, and the  hand  moved; or  from the
 bandage being tied too tight, which  must then be slackened ; or from
 the aperture being stopped up by a little lump of fat, wThich may be brushed
 away with the sponge  or  cut off;  or from  extravasation of blood in the
 neighbourhood  of the wound, in which case the  operation must  be
 repeated elsewhere; or from fainting, when the  patient must be revived
 with fresh air, sprinkling with cold water, and  the  like.  A  Severe pain
from wounding a nerve,   e. Wounding an  artery, which may be  known
 by arterial blood  spouting  out together with the  venous, by  arterial blood
 continuing  to flow after the removal of the  bandage, and by it not being
 checked by pressure below, but  above the  wound.   The treatment  in
 this case consists of pressure and binding up  the arm as already men-
 tioned, {par. 386.)  £. Wound of a lymphatic  vessel, of a tendon, or of
 the aponeurotic expansion,  which is only rendered apparent  by symptoms
 which come on afterwards.
   2621. The bandage must remain  if it do not  slip, or  no particular
 symptoms   ensue after the  operation till the third  or  fourth day.  The
 accidents which  may occur after  the operation,  are, *. Bleeding, if the
 bandage slip ; it must be replaced.  /3.  Inflammation  and suppuration,
 in consequence of inflammation  of the aponeurosis, of too tight bandaging,
 of movement of the arm, or of the state of constitution.    Perfect quiet,
 loosened bandage, application of compresses  soaked  in lead wash,
 soothing poultices, and if collections  of pus be formed, opening them
 become necessary,  y. Inflammation of the veins or lymphatic vessel,
 which, according to its degree, requires  a more  or less active antiphlo-
 gistic  general or local treatment   Abernethy has, in inflammation  of 
        BLOODLETTING IN THE  FOOT J IN  THE NECK.       611

veins, advised the application of pressure above the wound, in order to
effect the union  of the walls of the vein, and to prevent  the spread of
the inflammation.  £  Severe pain, even convulsions in consequence of
partial division of twigs of  the external  subcutaneous nerve, when the
median-cephalic vein has been opened,  or of the internal subcutaneous
nerve when the median-basilic has  been opened.  In such case, Aber-
nethy advises complete division  a little above the wound in the  vein,
which is, however, rarely followed, and  proper antiphlogistic and anti-
spasmodic  treatment may be more fitting.
  I have not referred to the employment of the Snapper, because on account of its
uncertainty and danger, the stroke may be made too deep, too shallow, or inefficient,
and the fleam be broken off; it cannot be compared with the use of the lancet, but
may also be  very dangerous in unpractised hands.
   2622. The  veins of the fore-arm are, however, to be preferred for
opening when in very stout persons, those at the bend of the arm can-
not be opened with certainty.   But on account of the numerous plexuses
of nerves surrounding them, their opening is perilous, and it is better to
choose the vena cephalica or salvatella upon  the hand ; the former, how-
ever, has often a branch of an artery running beneath  it, and the latter is
very small.
   2623. In Bloodletting in the foot, after putting  the foot in a tub of
warm water, a bandage is to be appliad as in bleeding from the arm, a
little above the ankle, the foot put on the edge of the  tub,  and the lancet
carried as  already described, into the swollen vena saphena interna or
parva.  The foot must then again be put into the tub of  water: or if a
certain quantity  of blood be required, it  must be  caught in  a vessel.
The dressing is  to be similar to that for bloodletting in the arm.
   2624. The external jugular vein is selected for bloodletting in the neck.
An assistant standing behind the  patient, who sits  up in bed or upon a
stool, holds the head with  one hand, and with the thumb of the other
presses the external jugular vein, whilst the  operator  compresses it with
his left thumb at the part where the opening is to be made.   The jugu-
lar vein may also  be compressed  on the opposite side without the aid of
an assistant; in  doing this a compress is placed upon it above the collar-
bone, and  fastened with a  bandage carried around the chest  and back
from the armpit of the  other  side.  The vein is to  be  opened with a
lancet from below upwards, and  from within outwards, so that  it may
not be covered by the neighbouring fibres of the m. platysma myoides ;
and the blood may be  allowed to flow along a gutter-shaped piece of
pasteboard  into  a vessel.   When the dressing is applied, the compress
must be removed, the  edges of  the wound  pressed  together, sticking-
plaster and a compress put  over it, and fastened with  a bandage.
                   B.—OF OPENING ARTERIES.

   (Arleriotomia, Lat.; Schlagader-Oeffnung, Germ.;  Ouverlure de VArtere, Fr.)

  2625. Opening an artery is only performed  on the temporal; it is re-
commended in severe inflammation of important organs, as the brain the
eye, and the like, so as quickly to evacuate a large quantity of blood. 
612              OF THE APPLICATION OF LEECHES.
   This operation is best performed in  the  following way:  the pulse of
 the temporal artery, or one of its branches, is sought for in the temporal
 region:  the place is to be marked with a black streak, the skin raised in
 a fold  and cut through.   The artery is then easily found and opened in a
 rather  oblique  direction  with  a lancet.  The proper quantity of blood
 having escaped, the artery is to  be cut through, taken up with the for-
 ceps and tied, and the skin  closed with sticking plaster.   This method
 is more certain than  opening the temporal artery at  a stroke with the
 lancet, and, stanching  the bleeding by pressure.
   [Opening the temporal artery is oftentimes far less easy than might be expected,
 and inattention to its subsequent division frequently causes very serious and some-
 times fatal results.  The facility with which it is  found depends pretty much upon
 the part at which it is opened.  If this be done just before and above the tragus, it
 is managed easily on account of the size of the vessel; but if higher, after its divi-
 sion into temporo-frontal and temporo-occipital, it is  more difficult; the temporo-
 frontal branch, which is the part  of  the vessel commonly chosen, as it  runs along
 the edge of the hair, diminishes  quickly in its course, so that the  higher it is ope-
 rated on, the more difficult is it to be found.  If it be expected  that  a  single blood-
 letting from one or both temporal arteries  will alone be  required, then the artery
 may be  opened in front of the auricle, upon, or  a  little above the root of the zygo-
 matic process.   But if it is likely  that more than one bleeding from each vessel will
 be required, then it will be better  to open the artery upon the forehead, which will
 give the opportunity of repeating the operation again and again, each  time below the
 former one, till the root of the zygomatic process be reached.  The younger Cline,
used to  advise that in the performance of this operation the artery should be laid
bare lengthways to the extent of half an inch or an inch, that a  tenaculum should be
passed across and  behind it, so that the vessel could be  raised, more readily punc-
tured, and what was 'of infinitely greater importance, more certainly divided after
sufficient biood had been  obtained.   Inattention  to  the division of the temporal
artery after it has  been opened, is occasionally followed by a  spurious  aneurysm,
which cannot always be managed by compression, or even by tying the ends, and
patients  have been destroyed by after-bleeding wearing  out the powers of the con-
stitution.  In general, cutting the artery completely across, and the application of
pressure, are sufficient; but when the vessel continues bleeding, both its ends must
be tied, as the  anastomosis is so  free upon the  head, that if only one be tied the
bleeding continues.   The same practice must also  be followed  when spurious
aneurysm of this vessel occurs after arteriotomy.—j. f. s.]
              C—OF  THE APPLICATION OF  LEECHES.

   2626.  In applying leeches, they may be held with  a  piece of linen
round their hind  part, so that the  head, which is always their thinnest
part, may be directed to the spot upon which they are to be fixed.   This
spot must always be carefully cleaned.   Some  persons apply leeches in
a piece of pasteboard rolled  up,  or in  a glass cylinder.  When the part
permits, it is most convenient to put the requisite number of leeches into
a cupping-glass, and turn it  down.
  The Blood-Leech (Hirudo medicinalis, Lin,) is  distinguished  from  the horse
leech and the common leech, which are never  so  large, by six  orange-coloured
stripes running from the head along  the back and sides  to the tail.   The back and
sides of the horse leech are of  a blackish-brown or blackish-gray colour, without
any marking; the common leech is  light brown, spotted with black, and without
other marks.  The belly of the blood-leech is steel-blue, with regular yellow spots,
but the latter are often so numerous that they are mistaken  for the ground colour,
and the steel-blue  for the spots; in rare instances, the yellow spots are entirely
wanting, and the whole belly is simply steel-blue.  The belly of the horse-leech is 
OF  THE APPLICATION OF LEECHES.             613
 yellowish-gray, and that of the common leech, grayish-brown.  Leeches are best
 caught in the  spring, because  in winter they do not so  readily find food.  Rain
 water is better to preserve them than river or distilled water.  The glass in which
 they are kept should not be in the sunlight, and they should especially be put in a
 cool rather than in a warm place.  Frequently changing the water is hurtful (a).
   2627.  If the leeches will not bite, the  part on which they are to  be
 applied  must be smeared  with spittle or sugar and water, or the  skin
 cooled with cold water, or it must be slightly scratched and smeared with
 the blood.   Leeches oftentimes will not take,  because when previously
 at liberty, they had sucked freely ; their belly is then full, and such should
 rather be chosen  in which it  is  sunken.  They are generally allowed to
 remain on till they drop off';  but if necessary to get them away before,
 they must be  sprinkled with a little salt or snuff.   The after-bleeding is
 to be kept up by bathing the bleeding parts with sponges dipped in warm
 water.   The  recommendation of  cutting off the leech's tail, if it be de-
 sirable they should suck long, is absurd, as  they soon after drop off.   I
 have seen one leech which was  uninjured, remain on six-and-thirty hours,
 and the  blood flowed from its tail.
   In the application of leeches in the mouth, care must be taken that they do not
 crawl down and fix in  the throat, or be  swallowed.   In the latter case, a quantity
 of salt and water should be swallowed, and an emetic taken.   If leeches be applied
 in the neighbourhood of the anus, that should  be stopped up with a wad of lint.
   [Crampton  and Osborne (b) recommend the application  of leeches to mucous
 surfaces, having first passed a thread through the animal's tail, and then directing it3
 mouth by means of a probe, or channel made with card, to  the part desired.]
   2628.  After the leeches have dropped off, bleeding  may generally be
 kept up for some time by sponging with warm water; but if it be wished
 to stop it, this may be  done  by bathing1 with   cold water and applying
 German tinder.
   Sometimes, especially with little children, the bleeding is very severe,
 and may easily be fatal if unattended to.   The means here advised for
 stanching the blood are, strewing  the  part with styptic powders,  with
 gum tragacanth, the introduction  of a small  portion of  lint into the  little
 wound, holding the skin  in a fold and pressing it together with the fingers
 or a proper instrument, cauterization  of the part with  a red-hot  needle,
 the introduction of a common  sewing-needle on one  side through  the skin
 to the bottom of the wound, and out at the other side some distance  from
 the wound  and the needle,  the  ends of which are  covered with  wax, is
 then to have  twine twisted round so as to compress the wound firmly (c).
 Hennemann  {d) has invented a  particular  kind of forceps for this  pur-
 pose.   Lowenhardt (e) penetrates  superficially the edges of the  wound
 brought together, with a fine  needle and thread, arid after  removing the
 needle, ties the thread in a simple knot.  If no after-bleeding ensue, the
 thread in a few days drops  off of itself.
   [The employmemt of leeches in the treatment of inflammation is so commonly
  (a) Kunzmann, Ueber  die Function  der    (6) Dublin Journal  of Medieal Science,
Laugorgane des Blutigels, dessen  Anwend-  vol. iii. p. 340.
ung und Aufbewahrung; in von Graefe und    (c) Whete; in von Graefe und von Wal-
von Walther's  Journal fur chirurgie  und   ther's Journal, vol. i. p. 185.
Augenheilkunde, vol. ii. p. 262.—Schmucker.    (d) Rust's Magazin, ,vol. xvi. part  iii. p.
Hislorischpraktische Abhandlung von medi-   375.
cinischen Gebrauche der Blutigel;  in his    (e) von Graefe  und von Walther's Jour-
Vermischte Schrifte, vol.  i. sect. ii.—Otto,  nal, vol. xv. p. llli.
Der Mcdicinische Blutigel.  Weimar, 1835.
                                 52* 
614             OF THE APPLICATION OF LEECHES.
 unattended with inconvenience, that it would seem scarcely worth while to refer to
 the subject.  But frequently the bleeding from the wounds caused by them is very
 considerable, and very difficult to stop;  sometimes  threatening danger from  the
 quantity of blood lost, and occasionally destroying the  patient.  It is, therefore, well
 worthy a little  consideration.   Dangerous  bleedings from leeches occur in adults as
 well as in young children.   Of the former kind, are, the case of a stout country lad
 who died in La Charite, of bleeding from a single leech bite on the belly in twenty-
 five hours, related by Brichetau (a) ; that of an old woman in La Pitie, under Lis-
 franc (b), to whose belly leeches had been applied ; she went on well for three days,
 retired to rest at night apparently well, but  on the following morning was found
 dead in her bed in a pool  of blood.   My friend Green, some years since, had aman
 in St. Thomas's who died  of bleed ing from the temporal artery, which had been bitten
 by a leech.   Of the latter kind, the case of a child of nine months, who died in a
 night after a leech-bite, is recorded  (c).  No such fatal cases have come under my
 own care ; but I have frequently seen the bleeding continued for several days,  so as
 to render the patient pale as ashes, and weakened as under severe loss of blood under
 any circumstances.  The  cause of the bleedings is  either from an  artery being
 wounded by the bite, as in Green's case certainly, and probably also in Brichetau's,
 and in a case of bleeding  from  leech-bite on the temple, mentioned by Oliver (d);
 or from that incapacity of the  blood to coagulate  occasionally observed in peculiar
 constitutions, of  which I  have seen  many instances, and which, unless properly
 treated, as surely, though  sometimes more slowly destroy the patient, as if an artery
 had been wounded and left undivided or untied.
   The treatment recommended  for these cases is very various, and must necessarily
 vary according  to their cause and* situation.  In the more trivial  cases the applica-
 tion of rag repeatedly dipped in cold water,  so as to reduce the vascular action of
 the part is often sufficient, either with or without  pressure, which is advantageous
 when it can be  made efficiently, as on the head and chest, and also, though less ad-
 vantageously, on  the limbs ;  but upon the belly pressure is of little avail, as  from
 the yieldingness of the parts, it cannot be continuous.  If a vessel, as  for instance,
 the temporal artery, be wounded, it  is best at once treated  by division between the
 wound and the heart, as practised in arteriotomy.  This  plan will succeed if done
early;  but it will not always answer, if put off till the formation  of  spurious aneu-
 rysm, as in Green's case.  Or the vessel may be found and tied.  Or it may be
 compressed  firmly between the bone  and a piece of cork  bound tightly on, either
 with or without division of the artery, as in  common  cases of the  wound of such
 vessel.   If the  leech-bite be on a yielding part, Lowenhardt's (e) method of draw-
 ing the edges of the wound together with a  fine  needle and thread may be employed.
 But I prefer thrusting a couple of needles at right angles to each other, at a little dis-
 tance  from  the aperture below the  bottom of the wound, and out at the opposite
 side; around which, including the whole bite,  a  strong thread is to be  carried once or
 twice and tied tightly.  After two or three days the thread and pins may be removed,
 and the bleeding has generally been stopped.   Oliver has recommended, from his
 own experience, the application of plaster  of Paris (/), and particularly mentions
a case which was cured by this treatment, in  which a pint of arterial blood was lost
 from the temple (g), and  perhaps the temporal artery was wounded.  Ridalfo (h)
 of Leghorn recommends the application of  a cupping glass, which done, he says, a
 coagulum forms immediately,  and  he advises  that the glass  should be left on for
a few minutes.   On the  other  hand, Sir J.  Murray (i)  advises the employment
 of condensed air in a syringe ; but it is rather difficult  to  make out whether he has
 had practical experience on this point.  The introduction of nitrate of silver, scraped
 to a very fine point, into the bottom  of the leech-bite, is, so far  as my experience
 goes,  not so successful as related of twenty-two cases,  infants and adults (j'), after
 the plan recommended  by Donovan (k).   In slighter cases a saturated solution of
   (a) Gazette des  H6pitaux, vol. vii. p.  36.    (h) Ripertorio di  Medic, e di Chirurg. di
 1833.                                    Troino; quoted  in Lancet, 1828-9, vol. i. p.
   (6) Revue Medicale.  1897, vol. iv. p. 149.  232.
   (c) Lancet, 1829-30, vol.  ii. p. 394.          (t) On the local and general Influence on
   (d)  Ibid, 1834-5, vol. i. p. 304.           the Body of increased and diminished At-
   (e) Above cited; quoted in Lancet, 1828-9,  mospheric Pressure; in Lancet, 1834-5, vol.
 vol. ii. p. 400.                             i. p. 916.
   (/) Lancet, 1833-4, vol.  ii. p. 209.          (j) Lancet, 1829-30, vol. ii. p. 927.
   Ig)  Ibid., 1831-5, vol. i. p. 304.            (it) Annals of Pharmacy. 
OF  SCARIFICATION.—OF CUPPING.             615
German tinder may be successfully used.  Howison (a) says, that a thick layer of
flour dusted on flannel is very rapid and efficacious in stanching bleeding leech-bites.
One or other of these plans  are almost invariably used and succeed, except when
the blood  cannot coagulate,  and which is indicated by the failure of these means,
and not unfrequently by the history of the case; under  such circumstances it i3
necessary to use the actual cautery, or to express it more simply, a piece of thin iron
wife heated red-hot and thrust  down to the bottom of the wound ; and this treatment
is almost  universally successful, for it seems that  the  actual fire has some-peculiar
effect upon the wounded vessels more than other escharotics have.  I cannot explain
in what this consists, but from repeated observation, I know that a red-hot iron wire
will stop bleeding, when all other means have entirely failed.  The introduction of
small  bits of hard-rolled sponge I entirely disapprove of, on this, as well as on most
other occasions.—j.  f. s.]
  2629.  If considerable ecchymosis, inflammation and suppuration should
occur, the parts must be bathed with lead wash, or lead ointment should
be applied.
                      D.—OF SCARIFICATION.

           (Scarificaiio, Lat.; Scarificiren, Germ.; Scarification, Fr.)

  2630. Scarification consists of more or less deep cuts with a lancet or
bistoury, in any one part, whereby it is  emptied of the fluid it contains.
It  is more frequently employed  in  inflammation  of those  parts- where
leeches cannot  well be  applied, as for  instance,  inflammation  of the
tongue, of the gums, of the tonsils and the like.   In considerable  inflam-
matory swelling of such parts as are  surrounded with unyielding aponeu-
roses or very thick cellular tissue, scarification, besides the local bleeding,
produces also a lessening of the tension.   It is also employed after the
bites of rabid animals, under certain circumstances in gangrene, and in
callous ulcers.   Scarifications of the dropsical swelling of a part must be
made quite superficially, and never  then if  there be accompanying ery-
sipelatous  inflammation, or a great  degree of exhaustion, because gan-
grene  generally follows.
                          E.—OF CUPPING.

  (Applicatio cucurbitarum cum incisione, Lat.; Schropfen, Germ.;  Ventouses, Fr.)
   2631.  Cupping differs from scarification, in that before the skin is cut
into at any one part and in different directions, with  the  scarificator,  or
a  bistoury, congestion of blood is  promoted in  it, by the  application
of a cupping glass; and afterwards a suitable quantity of blood may be
drawn.
   2632.  When the part to be  cupped has been  rubbed with  a sponge
dipped in warm water, a cupping glass is held over a burning lamp  to
properly expand the contained air, and then  as quickly as possible, and
cleverly applied to the spot chosen.   After a few minutes, when the skin
has been properly drawn up into  the cupping glass, the  glass must be
removed,  whilst the forefinger is slipped under its edge.   Upon this part
the scarificator is  now  placed, after having set the lancets and drawn up
the spring, and then pressing upon  it, the lancets  wound the  skin.   A
                   (a)  Medical Gazette, vol. vi. p. 207.  1830. 
616
OF CUPPING.
lancet  or bistoury may be  used  instead of the  scarificator, with which
more or less deep cuts are made upon the part chosen.   For the purpose
of discharging the blood, a cupping glass  is to be  again  applied in the
way already mentioned ;  and when nearly  full, it must be removed, the
part cleansed and the glass put on again.  The  cut  may be repeated in
any direction with the scarificator.   When no  more blood flows, the part
must be cleaned and covered with a firm compress.

  Dry cupping consists simply in the  application of cupping glasses without scari-
fication, and is for the purpose of drawing the blood to any one part.
  [As occasionally scarificators and cupping glasses are not at hand, the following
substitutes, which I recollect having heard a friend in the military service mention,
may be employed.  Some short incisions near each  other are to be made through
the skin, and over them is to be whelmed a  tumbler, wineglass or teacup, the air in
which is to be exhausted or rarified by burning within a piece of paper.
  Instead  of a scarificator, Dr. Osborne (a) proposes his poly tome, which consists of
several lancets with circular edges fixed parallel  in a frame, with a handle.  It is
drawn quickly along the skin, so as to  make incisions an inch in length, and one-
sixteenth or one-eighth of an inch deep.  He  supposes a better flow of blood will
be procured by this instrument than by the scarificator.
  Cupping is sometimes attended  with danger  and  even loss of life, either from
wounding an artery, or from inability of the blood to coagulate.  Of the latter kind
it has been several times noticed, when cupping has been employed during an attack
of jaundice, that very tiresome and dangerous haemorrhage ensued from the want of
coagulability of the blood.  In one case which  came  under my care a few years
since, all kinds of styptics and escharotics were used in  vain, at last I employed the
actual cautery, which stopped the bleeding, and  the  patient did well.  In another
case, in which a girl had been taking for some time nitrate of silver on account of
epilepsy, and for some cause or other she was cupped  on  the loins, continued
haemorrhage from the wounds ensued, which nothing could stop, not even the actual
cautery, and the patient bled to death.—j. f. s.]

  2633.  In regard to the preference  of leeches, or  cupping for  local
blood-letting, it may be observed, that  in  general  the former are more
convenient as they can be applied on every part, and their effect is not
attended  with so much irritation as from cupping.  But the latter circum-
stance gives an undeniable  preference  to cupping over leeching in many
cases of chronic, deep-seated, especially rheumatic or arthritic inflamma-
tion, as not  merely is  the bloodletting, but also powerful derivation to
the skin effected, as for example in  sciatica, lumbago, and many affections
of the joints and  the like (1).

  Sarlandiere's (£Q bdellometre corresponds to cupping.
  For  the  purpose of effecting a powerful  derivation of blood, without an actual
bloodletting, Junod (c) has invented an apparatus consisting of a  glass cylinder to
enclose the whole limb, around which it closely and air-tightly fits at the upper end.
At the lower end  is a cock, connected with an  elastic tube  and an air-pump, by
means of which the air  is drawn out of the cylinder.  As this  is done, the skin
expands and reddens, the size of the limb is increased, the  temperature raised, and
transpiration becomes so profuse, that  it collects- on the walls  of the cylinder.  At
the same time the head becomes light, the countenance pales, the pulse in the tem-
poral artery slow, thready and faint; swooning ensues and  sometimes nausea.   By
this apparatus, severe pressure with air  can also  be effected ;  by which the limb is
rendered pale, the superficial veins are emptied, the bulk of the part diminished, and
the  circulation interrupted.  After  the operation the limb remains considerably

  (a) Observations on Local Bloodletting; in   (c) Bourgery, Traite complet de l'Anato-
Dublin Journal of Medical Science, vol. iii. mie de  l'Homme, comprenant la Medecine
p. 334.   1833.                          Op(5ratoire,  vol. vi. pi. 83.—Froriep's Chi-
  (6) Bdellometre.  Paris, 1818.  8vo.      rurg.  Kupfertaf., cccxcvii. 
OF PUTTING IN ISSUES.
617
lighter,  and moves more  securely and easily.  Moreover, especially when it has
been used upon one of the lower limbs, dizziness, rushing in the ears, seeing sparks,
disposition to apoplexy, and difficult respiration have been produced.
  [I cannot agree with Chelius in his preference of leeches over cupping, as causing
less irritation, for I have witnessed the contrary again and again.  The leech-bites,
specially in persons with  irritable skin, often fester, and I have occasionally seen
tedious sores, and difficult  to be healed resulting from them.  They also not uncom-
monly are attacked with erysipelatous inflammation, which, though generally yield-
ing to a bread poultice, sometimes assumes a serious character.  The danger ensuing
from their occasional  disposition to bleed indefinitely has been already mentioned
(par. 2028.)  And even under the most favourable circumstances, the quantity of
blood obtained by them is very uncertain, and  the exhaustion of the  patient by
exposure, and mopping the parts with a sponge, it may be for hours together, render
their employment far  from desirable, excepting on parts where cupping cannot be
performed on account of disfigurement as on the face, or where the parts are too
yielding, so that a cupping glass would be almost filled by them, as on the belly,
or where important vessels and nerves are in the immediate neighbourhood, as in
the neck and the like,  or where there is merely a small inflamed lump, upon which
a cupping glass cannot be conveniently applied.   With these exceptions cupping is
infinitely preferable to leeches, and more especially as a determinate quantity of
blood can be obtained with little additional pain for a short time, the whole operation
being generally completed in half an hour or less without fatigue to the patient.  So
far as I have noticed, the after-irritation of cupping is very far less frequent than that
from leeching,  and therefore from all  these circumstances I should always recom-
mend cupping rather than leeches, where it can be employed.—j. f. s.]
                     II.—OF  PUTTING IN ISSUES.

               (Fonticulus, Lat.; Fontanelle, Germ.; Fonticule, Fr.)

   2634.  By the term  Issue is meant an artificially  produced, and conti-
 nually suppurating wound, which is made  either  with the knife, with
 blister plaster, with the actual cautery, or with caustic.  The latter two
 will be specially considered afterwards.
   The place for the issue is determined by that of the disease which calls
 for it, though generally a  part is chosen where much  cellular tissue  is
 beneath the skin, usually between two muscles, on  the  arm between the
 m. biceps and  the m. deltoides, omthe thigh between the m. vastus internus
 and m. gracilis,  on the calf between the m. gastrocnemius and m. soleus,
 on the breast between two ribs  and  so on.   Large vessels and nerves
 must  be avoided.
   2635.  When using  a bistoury, a  small fold of skin must be nipped up
 and cut through lengthways,  and the wound stuffed with a little wad  of
 lint, and covered with  sticking plaster.   On  the  second or third day the
 dressing should be taken off,  the  wound cleaned, and  one or more peas
 put into it  (I).   A square piece of sticking  plaster and a compress are
 put on and fastened with a  bandage.  The issue must be  dressed daily,
 once or twice, according to  the degree of suppuration, and  always pro-
 perly  cleansed.
   [(I) The best and cleanest materials for issues are little, solid, glass beads, which
 soon imbed themselves, and not swelling like peas, excite  little irritation, and may
 be worn for months, merely taking them out for washing every day,  and returning
 them to their bed.—j. f. s.]
   2636. If on account  of the patient's dread  of the knife, a blister be em-
ployed, a round piece  about half an inch in diameter, must be applied 
618                 OF  INTRODUCING A  SETON.
and kept on till vesication take place, when it is to be taken off and the
cuticle removed.   One pea is then to be put upon the exposed part, fixed
with sticking plaster and  pressed with  a  bandage, so that the pea may
sink into  the  skin.   The  after-treatment  is the same as in the former
case.
  2637. If the issue cause violent pain, the pea must be removed, or if
there be several, their number  must be diminished ; this  must also be
done if there be  much inflammation, and lead  wash applied  over.  If
there be not proper suppuration, the pea must be smeared with digestive
salve, the issue touched with lunar caustic and the like.   If the suppura-
tion be too great, the pea  must be removed.   If fungous  flesh grow up
around the issue, it must be got rid of by touching with caustic  or cut off
with scissors.   If the part  waste in which  the issue is, it must be moved
elsewhere.  The issue  must not be allowed to heal too quickly.
  The method of proceeding employed under the name of the English Issue, is, in
its application, very agreeable  to the patient.
                 Ill—OF INTRODUCING A SETON.

           (Setaceum, Lat.; Eiterband, Haarseil, Germ.; Seton, Fr.)

  2638.  The Seton consists of a strip of linen unravelled  at each edge,
or of a strand of several cotton, silk or hempen threads, which are drawn
into the skin or into any tumour, to keep up a continual discharge, and a
certain degree of inflammation, for the purpose of diminishing any tumour
by continued suppuration, and to keep up the passage through any canal.
The  introduction of a seton L> managed  in different ways.
  2639.  If the seton be passed through the  skin, a fold of skin must be
lifted up vertically in the neck, with the finger and thumb of the left hand,
and pierced at its base with the seton-needle, in the  eye of which is the
strand  of threads or strip of linen, and as the needle  is drawn out, these
follow  it.  If there be not any seton-needle at hand, the  raised fold of
skin must be pierced with a double-edged bistoury,  and an eyed probe
armed with the  seton-threads  carried through  the opening thus made.
Both openings are to be covered  with a wad  of lint, which is fastened
with sticking plaster, and the loose ends  of the seton put into a compress,
and retained with a proper bandage.
  [Of late an Indian rubber tape, about three-eighths of an inch wide, and a line
thick, has been used instead of threads or linen, for a seton.  It is much belter than
either of the latter, as it does not get loaded with matter and become offensive. It
is easily passed, after thrusting a  double-edged  bistoury through the skin, through
the opening thus made.—j. f. s.]
  2640. Passing  a seton into a cavity containing  fluid, for instance, an
abscess, is to be  managed  as already directed (par. 57); or a somewhat
curved silver canula is used, with a stilette, of which the front  end has a
trocar  point, and its hinder end  an eye, through which the strand of
threads  is threaded.   The swelling is to be pressed,  so that  it maybe
made  sufficiently prominent,  and the canula well oiled,  with  its point
projecting,  must be thrust  through its lower part into the cavity of the
swelling, then the point of the stilette drawn back,  and the end of the 
           OF THE APPLICATION OF BLISTER-PLASTER.        619

tube carried to the upper part of the cavity pressed against the skin, and
then the stilette thrust through.  The tube is now drawn out at the lower,
the stilette at the upper wound and the threads introduced into the cavity.
   2641. If the seton be  passed into  a  swelling which does  not contain
fluid, either a seton-needle or a stilette with a  trocar point  and an eye
must be used and  carried in such direction, and  so deeply through the
mass of the tumour as not to run any risk of danger from wounding any
considerable vessel or nerve.
   2642. After the seton has been introduced it may be left alone  for
some days till suppuration be set  up in its track; then, after  removing
the dressings  and washing off the crusts at the wounds with lukewarm
water, a fresh portion of the seton  may be drawn through, the part already
used cut off some distance from the wound, and the dressing renewed.
In this way  the  seton is to be managed  daily, once or twice a day,
according  to  the degree of suppuration and the  object purposed.   If
requisite, other remedies may  be smeared  upon the seton  strand, and
with it drawn into  the canal of the wound; and when the  strand has
been used  up, a new one may be attached to and drawn through with  it.
If the seton strand require thickening, more threads are to be added to it;
if it need thinning, some must be taken from it;  the strand or linen band
must be gradually thinned, and when it is drawn out, moderate pressure
applied.  If there be  bleeding in passing the seton-needle, it must be
stopped with cold water or pressure.  Severe inflammation requires the
seton to be smeared with  fresh oil, or simple cerate and soothing applica-
tions.   If the suppuration be profuse, strengthening  remedies are to be
employed, both externally and internally.
      IV.—OF THE APPLICATION OF BLISTER-PLASTER AND
                         MEZEREON BARK.

(Vesicatio, Lat.; der Setzen der Blasen-pfiaster, und der Seidelbastrinde, Germ.; le
                       Visicatoire, et le Garou, Fr.)

   2643.  The effect of Blister-plaster  is more or less severe irritation  of
a part kept up for a longer or shorter time.   For this purpose Spanish-
Fly Plaster (Emplastrum Cantharidis) is used, spread on linen or leather,
applied to the part required, and bound on with strips of sticking plaster,
a compress, and bandage, but not too tightly, or severe pain will be pro-
duced, and the  formation  of a blister prevented.  The time  a  blister
should remain on varies according to  the object of its application, the
constitution and  age of the  patient.
  [The most cleanly, and as efficient a way of producing a blister, as with a plaster,
is the use of a fold or two of lint, sopped in acelum cantharidis, and applied to  the
part with  a camel's-hair  brush to the extent required.  Recamier and Trousseau
have, for the same purpose, applied lint dipped in a strong solution of ammonia.
  When it is considered necessary to produce blistering as quickly as possible, other
remedies have been resorted to, which are  in fact only purposely-made burns and
scalds,  and will require at least some little  caution in their  use.  Pigeaux (a)  ap-
plies a  piece of lint, cloth, or paper, of the necessary size, just previously dipped
in spirits of wine, and  passing  a match rapidly over it, at once sets it a light, it is
extinguished, and then the skin may be removed, leaving the cutis perfectly dry and
                  (a) Bulletin de Therapeutique, vol. ii. p. 176* 
620         OF THE  APPLICATION OF MEZEREON BARK.
 unharmed.  (On the contrary, I should think the dryness were a tolerable proof that
 a slough had been produced.—j. f. s.]
   Boiling water has also been poured in a thin saucer upon the part to be blistered,
 or by soaking a sponge, and applying it for a few minutes, but not long enough to
 destroy the cutis.   Sir Anthony Carlisle recommended the application of a spatula
 dipped  in boiling water; in other words, a gentle burn.
   Blisters are often left, as to their mode of application  and the length of time  they
 are to be kept on, entirely to  the will and pleasure of an ignorant nurse, and the
 patient  consequently suffers much more pain  than necessary, and sometimes, also,
 has sloughing of  the cutis, which, if the patient be a female, and the blistered part
 be the neck or any other visible part, will get the medical  attendant into much trouble,
 which he deserves; though occasionally, even with the  greatest care, this tiresome
 accident will occur when the skin is irritable.
  In applying a blister, one of the greatest inconveniences arises from some  of the
 little pieces of fly sticking to the skin, or even to the cutis, if the skin break whilst
 the blister is applying; this much increases the pain and irritation, and can be very
 easily avoided,"by merely  laying a piece of tissue paper or any other thin paper be-
 tween the plaster  and the skin, and if the plaster be bound firmly on, it will operate
 as readily through the paper as if it were in immediate contact with the skin.
  A blister is  often directed to be kept on twelve or twenty-four  hours, which at
 least is  a great absurdity, and may be very inconvenient to the  patient.  It is only
 necessary to keep it on till the whole of the skin beneath it has fairly separated from
 the cutis and the serum has begun to be poured out, which in most persons will take
 place in six or eight hours.   But with children even this  will not do; the blister
 should be removed as  soon as it has  caused bright redness of  the skin, which gene-
 rally happens in two or three hours; it should then be removed  and left alone for a
 little while, as the blister very soon after rises, if it have not already.  The younger
 the child is, the more necessary it is  to attend to this point, or  sloughing will ensue,
 and death has  been known to follow  in consequence.
  Indeed with children, I am by no means sure that, in most cases, a mustard poul-
 tice is not preferable te the application of a blister.  It should be made with mustard
 and warm water, (some recommend vinegar,)  rather thinner than if for the table, as
 if made stiff it is much less active.   It should then be spread  about a quarter of an
 inch thick on fine muslin, and another layer of muslin being put upon it, applied to
 the part, and kept on ten, fifteen, or  twenty minutes, according to the redness and
 pain.  In some persons it will even blister.   When  removed, the skin should be
 carefully sponged  clean  with warm water, otherwise the irritation, which is very
 great, will continue.
  In the few persons whose skin is blistered with difficulty, it is best to apply pre-
 viously  a mustard poultice till the skin becomes reddened and painful.—j. f. s.j
   2644. When  the blister  has  risen, the plaster must  be carefully re-
 moved, the blister opened with  scissors, the water emptied, and the part
 dressed with simple  cerate, fresh  butter, or  any other mild  ointment.
 If requisite to keep up the suppuration for a time, it must be dressed with
ung. resine,  or  some digestive.ointment to which cantharides has  been
added, or with  ung. sabine, which is best of all.
  [I must confess I am no advocate for  open blisters, the only special  result of
which appears to me that of putting the patient to unnecessary pain.  All that is
desirable, to wit, derivation,,is much more effectually done by a  succession of small
blisters, about  the size of  a half-crown piece, around  the part affected, which may
be repeated ad infinitum, with scarcely any inconvenience to the patient.   They are
called flying blisters.—j. f. s.]
  2645.  When a blister is applied to a part not very sensitive, its opera-
tion may be  promoted by rubbing it with a hot flannel or with vinegar.
  If the inflammation  be very violent, it must be soothed  with some
softening and cooling  remedy.   If the  cantharides  be  absorbed, it will
produce strangury, for the relief of which, mucilaginous  drinks and emul-
sions with camphor, may be given.   Swellings of the neighbouring glands, 
OF  VACCINATION.                      621
which sometimes  arise, may be relieved by the application of soothing
ointments and poultices, and by the removal of all irritation.
  2646. For the  employment  of Mezereon  bark {Seidelbast, Germ.) a
piece of the bark an inch and a half long, and the same wide, should be
soaked eight or ten hours  in vinegar  or water, after which, it is to be
applied with its smooth surface next to the skin, generally upon the arm,
at the insertion of the m. deltoides, and covered with a piece of oiled silk
compress, and roller, to keep it close.   After ten or twelve hours, when
the bandage, is removed, if» the skin be sufficiently inflamed, a piece  of
oiled silk is to be  applied on the  inflamed part and fastened  with com-
press and bandage ; but if the first application have not been effective, a
second piece of the bark  must be applied.   About the  second or  third
day  a new piece of bark is put  on, the skin  rises, and  a serous  fluid
exudes.  The  part must be cleansed daily with warm  water or milk;
and  if the inflammation be very great, it must be rubbed  with warm milk
and  bound up with some mild ointment.  The pustules  around the irri-
tated part  in general yield to cleanliness and repeated washing  with
warm water.
  [2646.*  Another very excellent and very gentle mode of blistering is
with croton oil, ten or a dozon drops of which should be gently rubbed
over the surface with  the finger,  protected in  a  piece of oiled silk, for
two  or  three following nights.  Usually a slight  stinging is felt  accom-
panied  with puffiness of the part on the second or third day, and this is
followed by a crop of small vesicles,  which speedily maturate, in a day
or two  after dry up, and fresh cuticle is formed.  It  is  one of the best
modes  of blistering, if not required to be speedy.—j. f. s.]
   V._OF VACCINATION, OR INOCULATIOxN WITH COW-POCK.

     (Vaccinatio, Lat.; Einimpfung der Kuhpocken, Germ.; Vaccination, Fr.)

  Jenner, Eoward, M.D., An Inquiry into the Causes and Effects of the Variolas
Vaccinae, a Disease discovered iii some of the Western Counties of England, par-
ticularly  Gloucestershire, and known by the name of Cow-pox.  London, 1798.
4to.
  Ibid.,  Further Observations on the Variola? Vaccinas,  or Cow-pox.  London,
1799. '4to.
  Ibid.,  A Continuation of Facts and Observations relative to the Variolae Vaccinae,
or Cow-pox.   London, 1800.  4to.
  Bryce, James, Practical Observations  on  the Inoculation of  Cow-pox, pointing
out a new Mode of obtaining and preserving the Infection, &c.  Edinburgh, 1809.
8vo.
  Woodville, William, M.D., Reports on a Series of Inoculations for the Variolae
Vaccina?; with Remarks, &c.  London, 1799.  8vo.
  Creaser, Thomas, M.D., Evidences  of the  Utility of Vaccine Inoculation.
Bath, 1801.
  Gregory, George, M.D., Lectures on the Eruptive Fevers. London, 1843. 8vo.
   [Coxe, J. R., Practical Observations on Vaccination.  Philadelphia,
1802.   8vo.
  Fisher,  J.  D., On Small-pox,  Varioloid  Disease, Cow-pox, &c.
Boston,  1829.   4to.—g. w. n.]

  2647. Vaccination consists in the insertion of cow-pox matter under
     Vol. hi.—53 
622
OF VACCINATION.
 the skin, whereby a peculiar diseased process is set  up, which destroys
 or diminishes the susceptibility to the contagion of small-pox.   The vac-
 cination is performed  either with fresh cow-pox matter, conveyed  from
 one  individual to another, or with dry matter which has been  previously
 moistened.   Othermodes of vaccination are inadmissible, and the former
 is the best,  as it is also at present the  most common.

   Cow-pox matter comes originally from the pustules on the teats of cows in vari-
 ous countries (1).  The  matter to be  used, must  be obtained  from an  uninjured
 pellucid  pustule,  between the sixth and  ninth  day, and be clear and  transparent.
 If dry matter be used, it should have heen taken under the just-mentioned circum-
 stances, and should have been kept safe against the  effect of both light and air.  To
 effect this, various modes have been advised, as placing  between glass plates her-
 metically sealed, on threads of lint or cotton, on golden  or  bone needles, in glass
 tubes, and so on (2).
   [(1) "The earliest notice I have ever seen," says Gregory, " of cow-pox, is to
 be found  in a weekly paper  published at Gottingen, in 1769, where we learn that
 such  a complaint was  not uncommon in the neighbourhood of that town, and that
 those  who caught  it from the cows  flattered themselves they  were secure from the
 infection of small-pox.  A notion  of  the same kind had  long prevailed  in Glou-
 cestershire, a  great dairy country, and had often  been forced on the attention of the
 provincial surgeons.  But no one thought seriously  of this rural tradition, or dreamt
 of applying it to the general benefit of mankind, until  Jenner arose, (p. 184.)  It was
 not until the year 1?96 that Jenner began to experiment with  cow-pox, although he
 had been talking and inquiring about it for at least thirty year6.  The decisive ex-
 periment was made on the 17th May,  1796,  on a boy, eight years of age.   He was
 tested with  small-pox on the 1st July  of that year and found  to  be unsusceptible."
 (p. 187.)   In June, 1798, Jenner published his  paper, An Inquiry into the Causes
 and Effects  of the Variolae Vaccinae, $rc.; and  "  it  redounds to the  honour of St.
 Thomas's  Hospital,"  says  Gregory, " that its  officers were the first  persons in
 England, to put Jenner's  discovery to the test.   Mr. Cline vaccinated  a  boy here
 in  the last  week  of July, 1798, with dried lymph, which  had been  kept three
 months in a  quill.  The  boy had  diseased  hip, and  Mr. Cline proposing to con-
 vert the vaccine  pock into  a pea issue, inserted the matter on the outside of the  hip.
 Dr. Lister, formerly physician of the Small-Pox Hospital, (and also of St. Tho-
 mas's,) watched the progress of  the case.   The boy was  inoculated, almost imme-
 diately afterwards, with small-pox  in  three places, but the slight inflammation  that
 arose subsided on  the fourth  day.   The experiment, therefore, was perfectly suc-
 cessful." (p. 187.)
   (2)  According to Gregory, " vaccine virus may be preserved fluid and effective
 for two or three days in small bottles  with projecting ground  stoppers,  fitted to re-
 tain the matter.  It may  be preserved  for  a like  time in small capillary tubes,
 having a  central bulb.  This is the mode  used in France for the transmission of
 vaccine lymph to the provinces, and  which proves  very  effectual ; but if you at-
 tempt in this manner to transmit lymph to the East or West Indies, you will  fail
 utterly.  Ivory points,  when well  armed and  carefully  dried, are  very effective.
 They will retain their activity in this climate for many months, and they are found
 to be  the most certain mode of sending lymph to our colonies.   Some practitioners
 prefer glasses to points, but  they are  less certain.   The  employment of scabs for
 the propagation of cow-pox was lirst recommended by Mr. Bryce, of Edinburgh, in
 1802.   It is a very excellent mode  of transmitting  vaccine matter to distant coun-
 tries, but some nicety is required in operating with  scabs, which experience alone
 can teach."  (pp. 198, 99.)
   As regards  the period at which lymph should be taken for vaccination, Gregory
 says :—"The younger the lymph is, the greater  is  its intensity.  The  lymph of a
 fifth-day vesicle, when it can  be  obtained, never  fails.  It is, however, equally
 powerful up to the eighth  day, at which time it is also most abundant.   After the
 formation of areola, the true specific matter of cow-pox becomes mixed with vari-
able proportions of serum, the result of common  inflammation, and diluted lymph
is  always less efficacious than the concentrated virus.   After the  tenth day  the
lymph becomes mucilaginous and scarcely  fluid, in which state it is not at all to be 
OF  VACCINATION.
623
depended on.  *  *  *  Infantile lymph is more to be depended on than the lymph
obtained from adults.  The matter of primary vaccinations is more energetic than
that of secondary vaccinations."  (pp. 195,96.)]
   2648.  Vaccination is a completely dangerless operation, which may
be performed at any time of  year and in any  age.   It seems,  however,
most suitable, unless there be prevailing small-pox,  to perform it  in the
second half of the child's first year, in spring, summer, or autumn, when
the child's health is undisturbed.
   2649.  If vaccination  be performed  from  a fresh pustule, the child
must be placed on  the lap of a sitting person.  The point of a lancet is
to  be introduced into such pustule, as above described, of a person near
at hand, so as to bring away some of the clear matter  upon  it without
drawing blood.  The child's upper-arm is then grasped, the skin drawn
tight, and the charged lancet thrust in  obliquely, about  a line beneath
the epidermis, which must be gently lifted, the  point of the lancet moved
a little backwards and forwards, and  the left thumb being placed on its
point, the lancet is  then  laid flat, and  drawn out.   In  this way, three
insertions of matter are to be made  on each arm.   Dressing is  unneces-
sary.  If the wound bleed, it must be left to dry, and not be wiped off.
   [For the proper performance of vaccination, Gregory says :—" Let the lancet be
exceedingly sharp.  It should penetrate the corion to a considerable  depth.  The
notion that the subsequent effusion of blood will wash out the virus, and thus de-
feat our intention, is  quite imaginary and groundless.  Provided that  a genuine
lymph of due intensity has once  come in contact with the absorbing surface of the
cutis vera, the rest is immaterial.   The vessels of the  part have received the specific
stimulus, and  nothing can prevent the advance of the disorder, but some constitu-
tional cause.  In  making the incision, the skin  should be held perfectly tense be-
tween the forefinger and thumb of the left  hand.   The lancet should be held in a
slanting position, and the incision made from above downwards,  *  *  * I would
recommend that, with  lymph of ordinary intensity, five vesicles  should be raised,
and that these should be at such  distances  from each other as not to become con-
fluent in their advance to maturation." (pp. 197, 98.)]
   2650. If vaccination be performed  with dry matter, it must be moist-
ened with pure water, so that a part  of it may be got upon the lancet-
point.  In other respects, the proceeding is precisely the same as in the
former mode.
   2651. The  appearances which ensue after  vaccination, if it be ef-
fectual, are the following:—
   On the first and second day only a  trace of the slight stab is observed.
On the third day a blush appears at the place of  vaccination, which
becomes  more distinct on the fourth  and fifth  days, and in its  middle a
little hard knob rises, which  increases and is  surrounded with a reddish
areola.   On the sixth day the colour of the knob becomes reddish white,
it  contains some fluid,  presents a pit in its centre,  surrounded with  a
swollen edge; the  hardness  is felt  as deep beneath the skin as it is ele-
vated  above  it; the red areola becomes  more considerable.   On  the
seventh day the vesicle distinctly  contains  a transparent fluid, and  the
other appearances  are  more decided.   On the eighth  day the vesicle
has attained the size of a lentil; it  is  still most commonly filled with
clear  fluid,  and  surrounded with a more or less extensive areola.
On the   ninth  day this  areola  is  larger.    On  the  tenth  day  the
vesicle has become a pustule,  in  which  the contained  fluid  becomes
untransparent,  thick,  and  converted  into  pus,  and  the  pit  in  its 
624
OF VACCINATION.
middle  disappears.   On the  eleventh and twelfth day the  red areola
diminishes, the pustule begins to dry, is  converted into a dusky-brown,
blackish, thick and tough scab, which falls off about the four-and-twen-
tieth day, leaving a flat scar (1).  With these local symptoms, there occur,
on the seventh, or more commonly on the eighth  day, a slight attack of
fever, in which, howrever, but  few children lose their  appetite and their
usual  liveliness.   At  this  period, if  the  areola be very much inflamed,
there is often pain and swelling of the axillary glands (2).

   [(1) To  the above account may be added from Gregory,  that;  "by aid of the
microscope, the efflorescence surrounding the inflamed point will be distinctly per-
ceived, even on the second day.  On the fifth day the cuticle is elevated into a pearl-
coloured vesicle,  containing  a thin and perfectly transparent fluid in minute quantity.
The shape of the vesicle  is circular or oval according to the mode  of making the
incision.  On the eighth day the vesicle is in its greatest perfection, its margin is
tinged  and  sensibly elevated above the surrounding skin.  In colour the vesicle
may be yellowish or pearly.  The  quantity of fluid which it contains will be found
to vary much.  When closely examined, the vesicle will  exhibit a cellulated struc-
ture.  The cells  are eight or ten in number, by the flow of which the  specific matter
is secreted.   The vesicle possesses the  umbilicated form belonging to  variola.
*  *  *  On the eleventh day  the areola begins to fade, leaving in its decline, two or
three concentric  circles  of a bluish tinge. Its contents now become opaque, the
vesicle itself begins to dry up, and a scab  forms, of a circular shape, and a brown
or mahogany colour.   By degrees, this hardens, and blackens, and at length between
the eighteenth and twenty-first day, drops off, leaving behind it a cicatrix of a form
and size proportioned to the  prior inflammation.   A perfect vaccine scar should be of
small size, circular, and marked with radiations  and indentations.  These show the
character of the primary inflammation, and attest that it had not proceeded  beyond
the desirable degree of intensity.  Many of the most perfect scars disappear entirely
as life advances,  (pp. 189, 190.)
  (£) " Until  the  eighth day,"  continues Gregory, " the  constitution  seldom
sympathize^.  At that period, however, it is usual to  find  the infant somewhat rest-
less and uneasy.   The bowels are disordered.  The skin is  hot, and the night's rest
is disturbed.  These evidences of constitutional sympathy continue for two or three
days.  There is, however,  much  variety  observable here. Some  children suffer
slightly in their general health throughout the whole course of vaccination.   Others
exhibit scarce  any indication of fever,  although the areola be extensive, and  the
formation of lymph abundant." (pp. 190, 91.)]

   2652. The above named symptoms sometimes occur according  to this
order, only about two  days later, but without interfering with the effect of
the vaccination.  But if the course of the  vaccine  vesicle be irregular, if
it be formed on the first or second day,  if it  show no pit in  its middle, if
its contents be not clear and transparent, but yellow and purulent; further,
if the  inflammation  spread more widely, if the hardness on the circum-
ference of the pock be  wanting; if the vaccination spot be from the verv
first converted  into an ulcer, or a mere  slough; if instead of a dusky-
brown or blackish scab, a yellowish-green, loose scab be formed ;  if the
febrile symptoms be entirely absent, or do not  appear at the  proper time,
the vaccination must be  considered as a failure, and the security from it
of no  value.    The cause may rest on vaccinating with bad matter, if it
be  not clear, or if the lymph  employed  be putrid, if it be  inserted too
deeply, or if it be inserted with a blister-plaster.
   [On this point Gregory  remarks :—" Occasionally we meet with persons who,
from some peculiarity of habit, are wholly insensible to the vaccine poison, in what-
ever intensity, and by whatever mode it is  applied.  They receive it as they would
so much cold water.   The proportion of mankind who exhibit this idiosyncrasy is
very small.   I may have seen thirty or forty such  cases in the course of my life.
It would be very  interesting  to determine whether this constitutional inaptitude to 
OF INFUSION AND TRANSFUSION.
625
cow-pox denotes a like inaptitude to receive and develope the variolous poison.  In
the few cases which  I  have seen, where  inoculation was subsequently tried, the
insusceptibility was proved to extend to both poisons; but I have read of instances
of an opposite kind. *  *  * The insusceptibility to the vaccine poison is, in some
cases, obviously dependent on constitutional weakness, displayed in the slowness of
dentition, the imperfect ossification of the head, and the emaciated aspect of the body.
There exists here an atony of the absorbent system."  (pp.  188, 189.)]

   2653.  The after-treatment of vaccination simply requires proper regu-
lation of the health.   Care must be taken that the  child do not touch or
scratch the pock.   In  severe  inflammation cold  applications must be
made ; and if much fever, proper diet  must be  directed.  If there be
much suppuration  at the vaccination spot, lead wash  must be applied.
Eruptions of the skin,  which  sometimes occur after vaccination,  eitheE
subside of themselves under proper treatment, or by the use  of slightly^
diaphoretic remedies (1).   If the vaccination fail, it must after some time
be repeated.
   If vaccination with the lancet fail repeatedly, it  must be performed with a thread
soaked in  the cow-pox matter, after previously moistening it with warm water, and
inserted into a slight cut in the upper-arm,  over which a piece of linen spread with
cerate, is to be placed, and fastened with, a bandage, because this mode of vaccina-
tion is certainly successful.
   [(1)  "It is not uncommon," says Gregory, "to find the child's body covered,
generally or partially,  with a papulous eruption, of a  lichenous character, from the
ninth to the twelfth day, or even later.   It is seldom seen in adult vaccination; but
is frequent in children full  of blood, in whom numerous., vesicles had been raised,
which discharged freely.  Vaccine lichen, as this eruption is properly called, often-.
occasions great anxiety in the mind of the parent, from a suspicion that small-pox is
coming  out.  I have seen it in such intensity as to be followed by minute vesicles;
but this latter appearance is. very rare.  It  is an accidental occurrence, chiefly at-
tributable to the peculiar delicacy of the child's skin and fulness of habit.  Like the
constitutional irritative fever, it indicates that the  disease has taken effect on the
system; but it is not deemed essential  to. the success  of the process."  (p. 191.)].
                VI.—OF INFUSION AND TRANSFUSION.

   Denis, J., Lettre sur la Transfusion du Sang.   Paris, 1667.
   Merklin, De Ortu et Occasu Tranfusionis Sanguinis.  Nurimb., 1679.
   Major, Chirurgia Infusoria.  Kilon., 1767.
   Ettmuller, De Chirurgia. Transfusoria..   Lipsiae,  1697.
   Hemmann, Geschichte der Infusion, und  Versuch,, die sichere Anwendung dieser-
Operation zurerweisen;  in Med. Chirurg.  Aufeatze, p. 122.  Berlin, 1778.
   Scheel, Die Transfusion des Blutes und  Einspritz.ung der Arzneien in die Adern,
historisch und in Riichsicht auf die Heilkunde.  Kopenhagen,  1802-1803.
   Hufeland,  E., De Usu Transfusionis Sanguinis, praecipue in Asphyxia. Berol.,.
1815.
   Graefe, Dissert.de NovS. Infusionis.Methodo.  Berol., 1817.
   he Boer, Dissert, de Transfusione Sanguinis.   Groning., 1817.
   Percy et Laurent, Article Infusion ,• in  Diet, des Sciences Medic, vol. lxxv.
   Blundell, James, M. D., Experiments on the Transfusion of Blood by the Syrino-e; ■
in Medic.-Chir. Trans., vol.. ix. p. 56,   1818.
   Ibid., Physiological and Pathological  Researches.  London,  1825.  8vo.
   Tietzel, Dissert, de Transfusione Sanguinis.   Berol., 1824.
   Dieffenbach, J.  F., Die Transfusion des Blutes und die Infusion des Arzneien
in die Blutgefasse, vol. i.  Berlin, 1828.
   Heyken, Dissert, de Transfusione et Infusione.  Rostoch, 1830.
   Blasius, Klinisch-chirurgische Bemerkungen, p. 123.  Halle, 1832.
   Marcinkowsky ; in Hamberger Zeitschrifte, vol. i. part.iii.
                                   53* 
626
OF INFUSION.
  Berg; in Wiirtemberger Correspondenzblatt.  1838, Jan.
  Giesler; in Holscher's Annalen, vol. ii. part ii.
  Berthold; in same, vol. iii. part iv.
   2654.  Infusion consists  in opening a vein, through which opening the
pipe of a syringe may be introduced upwards, some medicated fluid in-
jected, and the wound of the vein afterwards  treated in the same way as
that made in bloodletting.   This operation, which in  the latter half of
the seventeenth century attracted great attention, was especially employed
in those cases where no  medicine could be taken by the mouth.   It has
been sometimes used successfully when foreign bodies  had stuck in the
throat, (par. 1731,)  as well also as  in cases of seeming death.
  Infusion, mentioned by Magnus Pegelius and Libavius in 1615 ;  and practised on
a dog by a Captain G. von Wahrendorff in  1642; was first subjected by Ch.
Wren, who first performed  it on a malefactor, in  1656, to philosophical examina-
tion.  The English  Physicians, Clark, Lower, and  others, made experiments with
it upon brutes; Major  in 1664, and  Elsholz in  1665, first  employed it on men;
Schmidt, Purmann, and P.  Sarpi, especially occupied themselves with it.   How-
ever, it soon sank in the estimation of physicians, and  has only of later years been
employed in a few  cases in Germany by Kohler, Hemran, Meckel, and  others.
After the early cases and his own experiments upon  this subject had been collected
by Scheel, the operation was performed in Germany by Graefe and Horn, and by
Laurent  and  Percy  in France, on men.  Bichat, Nysten,  Seiler, Magendie,
Orfila, and Dieffenbach,  instituted some exceedingly interesting, and for physi-
ology, important experiments upon  the injection of different  kinds of matters into
brutes, and have employed this operation on man, as for instance in  tetanus and
cholera.  The  most complete account of infusion and  transfusion is given by Scheel
and by Dieffenbach.
   The effect of the injection of any matter into the veins is different according to its
nature and the nature of the  disease.  The usual effects which all injections produce,
besides those peculiar to them, are, sweating, frequent vomiting, shuddering of the
whole body, and sometimes fever.  All the remedies to be injected must be dissolved
in water and be only as warm as the blood.   In  stubborn nervous diseases epilepsy,
affections of the mind,  hysteria, tetanus and trismus, in dyscrasic diseases, syphilis,
 gout, obstinate diseases of the  skin, in typhus and intermittent  fevers, infusion has
been tried, and very different  remedies have been injected.   Narcotic remedies, as
belladonna, opium, hyoscyamus, digitalis nux  vomica,  stryehnine, stramonium have
 generally dared only to be given in two-thirds of their ordinary dose;  salt is borne
 in large  quantity;  they have  the same effect as if taken into the stomach, though
their operation is mostly very irregular.   Simple warm water, which Magendie
 has injected in hydrophobia  to the  amount of two  pints, by which  quietude though
 not cure has been effected, produces great faintness, violent sweating, and increased
 secretion of urine;  sometimes when  much is injected, watery  stools;  and if it be
 thrown in  cold, severe shivering with dry cough, pale urine, faintness, and severe
 sweating.  In tetanus Percy, Laurent and Onsenoort have found good results from
 injecting extr. opii and exlr. daturas  slramonii.  In cholera Latta injected a solution
 of salt, consisting of two to three drams of nitre and two scruples of carbonate of potash
 to six pints of distilled water, at a temperature of 112- Fahrenheit,  to the amount of
 six or eight pints at once, and repeated it, so that from fifteen to forty-four pints were
 thrown in.  In Germany this was tried by Zimmermann,  Casper, Blasius and
 others, but it produced only a passing effect.  In cases of foreign bodies in the throat,
 Kohler, Balk, Kraus and Graefe have employed  with advantange an injection of
 a solution of two to six grains of tartarized antimony, in half an ounce to an ounce
 and a half of distilled water, with the result already mentioned  (par. 1731); and
 Meckel has also used it in a ease  of seeming death.

    2655.  For injection,  a  very small vein should not be chosen, the vena
 cephalica is best.  After the arm has been properly fixed, a fold of skin is
 to be made  over the vein, and  cut  through lenghways from an inch and
  a half to two inches in the course of the vein; the vein  is to be separated 
OF TRANSFUSION.
627
from the cellular tissue and two threads  carried round it;  after which it
is to be lifted a little  up and opened  lengthways with the lancet, to  an
extent  corresponding with the size of the pipe.  After having filled the
pipe with warm water, it must be passed in towards the heart, the threads
tied firmly around it so that the blood shall not escape, and  then it is to
be held by an assistant.   The syrihge heated by dipping  in  warm  water
to  the  temperature of the blood  is now filled  with the fluid warmed to
the same  degree, and its point  being directed  upwards,  some of the
fluid is squirted out,  so  that all air may be  got rid of; it is then  intro-
duced  into the pipe,  and the fluid slowly  and at intervals  injected into
the vein.   If more  fluid have to  be thrown in, the syringe  must  be
removed, the opening of the pipe covered with the finger, and the  injec-
tion repeated as before.  When the  injection has been  completed, the
threads are to be removed, the  pipe carefully withdrawn from the vein,
and the wound compressed with the thumb and  finger of the left  hand.
The wound in the  skin  is to be  brought together with slips of sticking
plaster, over which a little compress and a bandage are to be applied, as
after bloodletting.  To  prevent inflammation cold applications are  to be
 made for some days.
   The practice of opening the vein after putting on a bandage, as in bloodletting, and
 injecting after the removal of the bandage is improper, as the injection may go into
 the cellular tissue.  According  to Blasius, the vein should be laid bare by a cut
 upon the skin, compressed at the upper part of the wound,  opened in its longitudi-
 nal axis with a lancet, and into this aperture the little tube immediately inserted.
 For the injection he employs a tube with a pig's bladder;  Scheel  uses a syringe
 with an elastic tube ; others an Indian rubber bottle, Helper's funnel of transparent
 horn ; Hager uses a glass blowpipe with a silver syringe; Graefe opened the vein
 with a  thin curved  trocar which he thrust into the swollen vein, drew out the stilette,
 allowed an ounce of blood to eseape from the canula, and into it introduced a closely-
 fitting syringe, with which he injected the fluid.
    2656. Transfusion consists in opening a vein, into which blood is con-
 veyed from the artery or vein of another person, {immediate  transfusion,)
 or by  means of a syringe (mediate tranfusion, infusory transfusion.)   The
 history of this operation is connected with that of infusion.   The  notion
 of improving the juices, and of curing cachectic  and dyscrasic diseases
 by the transfusion of the blood of man or  brutes,  which was very  preva-
% lent in the  latter half of the seventeenth century, has not been confirmed
 by experience.  The operation was nearly forgotten, and only in modern
 times  has been brought into use successfully in cases of loss of  blood,
 especially after childbirth, and also in continued and irremediable vomit-
 ing, where death from inanition was dreaded (Blundell).   Only in such
 cases  can its employment be advantageous, as even in cholera, its use has
 been without any beneficial result.
    Although M. Pegelius and Paola Salvi are named as the discoverers of transfu-
 sion, Libavius, and afterwards Colle, noticed it, yet it was first performed in  France
 by Denis and  Emmerez in 1667, and by King  afterwards in England on man;  in
 Germany by Kauffmann and Purmann.  Notwithstanding the predilection of many
 practitioners for this operation, its results were not such as to keep it in sight.  Rosa
 first repeated it in 1783; Scheel in 1802 collected the experiments already made  in
 recent  times.  Blundell has successfully performed this operation in cases of loss
 of blood, and proposed  it in vomiting which could not be stopped, and the inanition
 to be feared therefrom.   Hence are the English  practitioners decided on its employ-
 ment, and it has consequently been practised by Doubleday, Uwins, Waller, Knox,
 and others.  Prevost and Dumas, as well as Dieffenbach, have made experiment*' 
628
OF TRANSFUSION.
 interesting in a physiological view, and the latter has employed it, though without
 advantage, in cholera.  Graefe has modified the apparatus for immediate transfusion.
   2657. Although  immediate tranfusion has  the important advantage,
 that the blood not being changed by  the  influence of the  air, its natural
 warmth is preserved, that it does not  coagulate, and  is even propelled by
 the action of the heart? yet, however, in recent times, mediate transfusion
 has been  preferred, because, in immediate transfusion by tubes, the blood
 alwrays  clots  in a few seconds, whereby its  passage is prevented, and
 generally, it is not known what  quantity of blood has passed ; because,
 further, the passage of blood from one vein to another  is  impossible, as
 the stream of venous  blood has  not  sufficient power, the opening of a
 small  artery is insufficient, that  of a  larger one not  admissible in  men,
 venous blood is, generally, more proper,  and human blood more suitable
 than that  of beasts.
   Various apparatus have been proposed for immediate transfusion.  Denis used
 two small silver tubes, curved at one  end, and furnished with a shoulder, and at the
 opposite end, received  into each other; he  introduced the  shouldered end of a tube
 into the artery of a beast, and that of the other }nto the patient's vein, and then con-
 nected  both by inserting their free ends.   Boehm connected them with a small piece
 of intestine, as for instance, that of a fowl, by stroking which, the passage of the
 blood might be encouraged.   Instead  of intestine, Regner de Graaf connected the
 two tubes with a piece of artery dissected from  a beast, to which there was a side
 branch, partly  to allow the escape of the air, and partly to note the constant stream
 of the outflowing blood,  von Graefe's apparatus consists of a glass cylinder filled
 with warm  water at a temperature of 29° Reaum., (97° Fahr.,) and furnished with
 a cock for the escape  and renewal of the water, and through which  a glass tube passed
 for carrying the blood, which received at one end another tube, of which that for the
 artery was curved and shouldered, and that  for the other, elastic.
   In the performance of immediate transfusion, the beast,  properly bound, is placed
 on a table near the patient, one of whose veins is opened,  and a tube passed  into it
 towards the heart; this is given to an  assistant, and below the wound a compressing
 bandage is applied.  The carotid or crural artery, according to the size of the beast,
 is then laid bare, a ligature passed around, and a director pressed upon it, and beneath
 the pressed part the vessel is opened lengthways with a lancet.   Into this opening
 the end of one  tube is inserted, arid the artery fastened around it with a ligature; the
 other end is inserted  into the tube ensheathed  in the vein,  after the  pressure has
 been removed from the artery, and  a  little  blood allowed to escape.   When the
 operation is finished  the apparatus is withdrawn, and the wound closed, as in blood-
 letting.
   2658. What has been  already  said  (par. 2654) in reference to the pos-
 sible danger  of infusion,  applies  also to transfusion.   If  too much  blood
 be injected at once, and  too quickly, overfilling and rending of the heart,
 palsy,  and death, may ensue.   Magendie has  also observed  that not
 merely the entrance of air into the  vein, but also  of clotted  blood, may
 cause  death by stopping  up  the minute vessels of the lungs.  According
 to Bickersteth (a), transfusion  should, where possible, be  undertaken
 before the circulation in the patient's arm  has entirely ceased.
   2659. The following is the  mode of proceeding in  mediate transfusion.
 A sufficiently large  superficial vein, the vena  cephalica is best, must be
laid bare,  by a cut an  inch and a half  long,  upon  a fold of skin ; the vein
 is to be cleared from the  cellular tissue, and two threads carried  round
 it, of which the one  corresponds to  the upper, and the other to the lower
 angle of the wound.  The threads are now to be  tied,  and  whilst with

 (a) Liverpool Medical Journal. 1834.   May.—London Medical Gazette, vol. xiv. p. 599. 
OF  CAUTERIZATION.
629
them the vessel is a little raised, it is opened with the lancet.  The canula
filled with warm water, is now passed into  the vein, and the upper thread
tied over it, the lower thread remaining tied.   Whilst this is doing, the
person from whom the blood is to be taken, standing close to the patient,
has a vein opened with a large wound, the  blood  is received into a warm
vessel, and the syringe, also warmed, draws  up of it about twro ounces.
The point of the syringe is now quickly directed upwards, a little blood
squirted out to get rid of the air, and it is  then fixed into the  canula in
the vein, and the blood slowly injected through it.  The syringe should
not be completely  emptied, because  the  remaining blood in  it quickly
clots.   The syringe is now to  be cleared with warm water, and  the in-
jection  repeated,  for which purpose the vein,  which in the mean while
has been compressed, must now be re-opened, and blood drawn into a
cup as already mentioned.  After the lapse of  five  minutes, more blood
may be thrown in according to  circumstances.   The dressing and after-
treament are to be managed exactly as in infusion,  (par. 2635.)
  Blundell's apparatus consists of a funnel for receiving the blood, connected by a
tube with the syringe which injects the blood into the vein through an elastic tube.
It is not proper, because the blood easily clots in  it.
  Instead of a syringe holding two ounces, Blasius thinks a  smaller one holding
not more  than half an ounce, is better, as therewith the blood loses less of its vitality,
and clots less.
  John Muller proposes, after separating the fibrous  parts from the blood by beat-
ing, to inject it warmed, as in this way it still  retains its corpuscles and living
powers.
                      VII.—OF CAUTERIZATION.

  CosT-ffius, de Igneis Medicinae Praesidiis.  Venet., 1593.
  Fienus, De Cauteriis.  Leovan, 1598.
  Severinus, PyrotechniaChirurgica; inhisDe Efficaci Medicinae, p. 143.  Francof.,
1646.
  Recueil des Pieces, qui ont concouru pour  le prix de l'Academie  de Chirurgie,
vol. iii.
  Pouteau, Memoire sur les  Avantages du Cautere Actuel; in his Melanges de
Chirurgie, p. 1.
  Loder, Ueber das kiinstliche Brennen;  in his Medic.-Chirurg.  Beobachtungen,
vol. i. p. 230.
  Pascal., Ueber die Wirkungen des Brennens  mit Moxa; in neuster Sammlung
der bester Abhandlungen fur Wundarzte, vol.  ii. p. 302.
  Percy,  Pyrotechnie Chirurgicale Pratique.  Paris, 1810.  >
  Valentin, L.,  Memoire et Observations concernant  les bons effets du Cautere
Actuel.   Nancy,  1815.
  Larrey, De l'Usage de Moxa; in Recueil de Memoires de Chirurgie,p. 1. Paris.
1821.
  Baerwinkel, Dissert, de Igniis in Arte Medicina.  Lipsiae, 1824.
  Klein, Uber die  Anwendung des gliihenden Eisens;  in von Graefe und von
Walther's Journal, vol. iii. part iv. p. 605.
  Wolff; in same, vol. v. part. iii.
  von Kern, V.,  Ueber die Anwendung des Gliiheisens bei verschiedenen Krank-
heiten.  Wien, 1828.
  2660.  Under the term Cauterization, is included the more or  less se-
vere application of escharotics or of fire on  any part of our body.  Escha-
rotics,  (Cauteria potentialis, Lat.; Aetzmittel, Germ.;  Causlique, Fr.,)
of which  those most in use  are lunar caustic, caustic  potash,  Cosme's
powder, corrosive  sublimate and butyr of antimony, are applied either in 
630     KINDS OF CAUTERIZATION ; THE ACTUAL CAUTERY.

a dry form, or as powder made into a paste with a little  fluid, or in a
fluid form,  the mode of using which on luxuriant granulations has been
already noticed (par. 2352, and frequently elsewhere.)  Fire {Ignis, Lat.;
Feuer, Germ. ;  Feu, Fr.) is applied either with the actual  cautery (Cau-
terium actuate) or by combustible substances, {Moxa, Lat.; Brenncylinder
Germ.,) which are allowed to burn on the surface of the body.
  2661. The object of cauterization  is generally very various, and may
be, first, the destruction of a part; second,  alteration, change, or excite-
ment of the living activity of any one part,  whereby a more speedy con-
version of  its substance, a more active absorption and the dispersion  of
tumours is  effected ; third, a greater degree of inflammation ; fourth,  re-
moval of a deep-seated process of disease to  the surface of the body ; fifth,
destruction of hurtful matter; sixth, stoppage of bleeding, especially that
of the so-called parenchymatous. In consequence of these various effects
of cauterization it is employed in a great many diseases, for instance,  in
fungous growths, in cancer, moist and secreting parts, in teleangiectasy,
in cold abscesses, in deep-seated, rheumatic and gouty affections,  in the
several diseases of joints, in palsy and other nervous affections, in deep-
seated suppuration and.the like.
  2662. It must be remarked, in reference  to the effect of Cauterization
by escharotics and by fire, that the former always causes destruction  of
the part on which it is applied, bu{ little alters the vitality of  the  neigh-
bouring parts, and is only specially effective from the suppuration  set up
in the cauterized part.  Hence  its use, if the  destruction of the part be not
the object of its application, is specially confined to those parts where a
discharge is to be kept up for a  long time.   The operation  of fire acts
more deeply upon the neighbouring parts, sets up greater reaction, excite-
ment of the living activity, quicker change of substance, violent contrac-
tion of muscles, and independent of those cases where its object  is the
destruction of any part or the formation of a slough, may be considered
in many other cases as a powerful remedy for the purpose, after the sepa-
ration of the slough formed by the  burn, of keeping up long-continued
suppuration.
  2663. The Actual Cautery may be employed at various  degrees  of
heat; it may either be held at a distance of five or six inches, and brought
gradually nearer and nearer to a part, or  it  may be moved  freely upon
the surface of a  part, or it may be kept in contact with it for some time.
According to these degrees in the application of the actual cautery do its
effects vary, and in the latter case is it very effectual and exciting.
   2664. Of the  various  forms  of cautery irons the following are most
useful, and if of different size  answer all  purposes, *.  conical,  £. flat.
round, y. prismatic or hatchet-shaped.   The conical iron is specially used
where one  particular small part is to be acted on, for instance in  bleed-
ings; the round, where  the effect is to be greater and a  permanent issue
is to be formed ; the prismatic  or hatchet  shaped, for  quickly passing
over any part.  If the actual cautery be used in any one cavity, or with-
out subjecting the neighbouring parts  to the effect of the fire,  either a
conical iron with a sheath must  be Employed or a red-hot trocar, which
is to be carried to the part required in its own sheath.
  2665. When the actual cautery is made use of, special  care must  be
taken that  the patient be held fast; and the part to  which it  is applied 
CAUTERIZATION BY THE MOXA.
631
must be carefully dried, and if hairy the hairs  must be  removed.   The
iron should be white-hot.   When the object is to destroy a part, to stanch
a bleeding^ or to form an  issue, it must be applied efficiently and pressed
down with requisite force.   If the iron cool and the object be yet unat-
tained,  a second white-hot iron must be  applied. If the cautery be applied
in stripes,  the stripes should be first marked, should not go from the same
point, should not  cross, should be an  inch and a half to three inches
asunder, and the white-hot prismatic or hatchet-shaped iron should  be
carried  in  the direction of  these stripes with due care over the skin, be-
cause it very  easily slips  from the proper  direction.   Klein's double
cautery iron much facilitates this operation.
  The parts to be avoided in applying either the actual cautery or the moxa are the
skull, where covered only by the pericranium and skin, at least the cautery must not
be applied here above a couple of seconds, otherwise its effect will  be propagated to
the membranes of the brain and the brain itself, the ridge of the  nose, the eyelids,
the course of the larynx and windpipe, the breast-bone, the breast-glands, the white
line of the belly, the superficial tendons, the generative organs, and those parts of
joints where, on account of the superficial situation of the capsular  ligament, injury
to it may be dreaded  (a).
   2666. After the actual cautery has been applied, the part must be co-
vered with lint,  dry and spread with some simple  ointment.   If the pain
following  be very  severe, it may be relieved with  anodyne applications.
The patient must  be  kept quiet,  and  according  to circumstances, take
antiphlogistic or narcotic  medicines.   When  the slough  separates, the
suppurating part must be dressed with  ointment which will  promote  its
healing, or the suppuration must be kept up as the case  requires.  If the
cauterization have been made on account of bleeding, the early dropping
off of the slough must  be carefully  avoided.
   2667. The Moxa is a cylinder  of cotton held  together with a linen
bandage and a few stitches, about  an inch high, and of larger or smaller
extent, according  to the condition  of the part to which it is to be applied,
and the effect it should produce.   The  cotton must not be too tightly
compressed, and the part on which the moxa is placed must be quite flat.
To fix  the moxa, a moxa-holder (b) is  best  employed, to wit,  a  metallic
ring with  wooden  feet and handle.  The neighbouring part  where the
moxa is applied must be covered with moist compresses to protect them
from the sparks  which fly about, as when lighted it must be  blown with
a pipe so  as to keep it properly burning; but if its effect be not required
to  be violent, it may be left to burn without blowing.
   A special and very convenient kind of moxa may be made with rotten phosphor-
escent wood,  properly dried and powdered, and mixed up into a paste, with alcohol,
which being forced into a mould, may be formed into a cylinder as thick as a quill;
this when dry may be cut into pieces half an inch long ;  the end of each must be
smeared with some digestive ointment to stick it to the skin, and its upper end must
be lighted.   It burns without any blowing, and its small size permits its application
at any part  and in any quantity (LarRey.)
   According to Percy, moxas are best made from the pith of the sunflower (Heli-
anthus annuus) rolled up in cotton, soaked in a solution of saltpetre, or in alternate
layers of soft  tow or  fine cotton, which have  been some time soaked in a solution of
saltpetre, two drams  to a  pint of water.  Both kinds  of moxa have the advantage,
like the former, of burning without blowing (c).

(a) Larrey,  above cited, p. 6, pi. xi. fig. 1, 2.      (b) Larrey, above cited, pi. i. fig. 3, 4.
           (c) von Grafee und von Walther's Journal, vol. iii. p. 491. 
632             DIVISION OF NERVES IN NEURALGIA.
  Very useful moxas are made of firm English blotting paper, repeatedly dipped in
a solution of chroma te of potash, one part to fifteen  parts of water, and dried. A
piece of this paper is to be rolled up, and kept together by a needle thrust through
it.  It burns quickly and regularly.
  If the part burnt with a moxa be touched with caustic ammonia, the slough is not
thrown off by suppuration, but gradually scales off (Larrey.)
  2668.  The slough thus formed is to be covered either with folds of soft
linen, or if its separation and the formation of an issue be required, with
a pledget spread with digestive  ointment;  in the latter case, after the
slough has been thrown  off, the  suppuration  is kept up, either  by fre-
quently touching with caustic, or by  inserting a pea, which is  first to be
fixed with sticking plaster and a  bandage, till it form  itself a pit.
  2669.  The difference between the effect of  a moxa and of the actual
cautery is, that in the former, the sensation of a certain warmth is gradu-
ally increased to a violent degree of pain; hence it extends its operation
to the  deeper tissues,  and  consequently is to be preferred in affections of
deep-seated organs, to the actual  cautery.   Larrey (a) also supposes that
the  moxa, besides  its relative  quantity of  heat,  communicates  to  the
neighbouring parts a volatile, very active principle, which is  produced
by  the burning of the cotton  (b).
       VIII.—OF  THE DIVISION OF NERVES IN  NEURALGIA.

  Haighton, John, M. D., A case of Tic Douloureux, or painful affection of the
Face, successfully* treated by a  division of  the affected (infraorbitar) nerve; in
Medical Records and Researches, p.  19.  London, 1798.  8vo.
  Langenbeck,  Tractatus Anatomico-Chirurgicus  de  Nervis Cerebri in dolore
Faciei consideratis.  Gotting., 1805.
  Klein, Ueber die Durchschneidung der Nerven  bei dem Gesichtsschmerze ; in
von Siebold's Chiron, vol. ii. part ii.
  Leydig, Doloris Faciei dissecto Nervo infraorbilali profligati  Historia. Heidelb.,
1807.
  van Wy, Von der Durchschneidung des unteren Augenhohlennerven; in Samm-
lung auserlesener Abhandlungen fur praktische Aerzte, vol. iii. p. 463.
  Abernethy, John, On the Tic  Douloureux;  in his Surgical  Works, vol.  ii. p-
203.  Edition of 1815.
  Murray, Essay on Neuralgia.   New York, 1816.
  Klein, Ueber die MogHchkeit  der  Zerstorung der Gesichtsnerven bei seinem
Austritte aus dem Schadel; in von Graefe  und von Walther's Journal, vol. iii.
p. 46.
  Eggert, Ueber das Wesen des Gesichtsschmerzes und die Operation desselben;
in same, vol. vii. part iv. p. 538.
  Bonnet, Traite des Sections tendineuses et musculaires, etc.; suivi d'un  Memoire
sur  la Neurotomie souscutanee, p. 622.   Paris et Lyons, 1841.
  Mayo, Herbert, Outlines of Human Pathology.   London, 1836.   8vo.
  2670. In stubborn neuralgies, which withstand all internal and external
treatment, specially those which  are seated in the branches of the nerves
of the face, the division of the  trunk  is the only remaining remedy.   The
result of this operation is generally doubtful,  as, although momentary re-
lief from pain  follows it, the disease returns, which1  is explained by the
  (a) Above cited, p. 7.                   Sch'ica, Indolent Tumours,  &c.  London,
  (6) Boyle, J., Treatise on a modified ap-   1826.   Second  Edition.—Wallace,  Wil-
plication of Moxa in the Treatment of Stiff  liam,  M.  D., A Physiological Enquiry re-
and Contracted Joints, and also in Chronic   specting the action of Moxa, tic.  Dublin,
Rheumatism, Rheumatic Gout,  Lumbago,   1827. 
DIVISION  OF  NERVES IN  NEURALGIA:            633
 numerous ramifications of the nerves spreading on the face, but is kept
 up by the union of the divided nerves, on which account it has been re-
 commended to cut out a piece of the nerve,  and to employ cauterization.
 In recent times, however, the subcutaneous division of nerves  has been
 proposed.   (Bonnet, Dieffenbach, and ofhers.)
   2671.  In frontal neuralgy where the  supraorbitar branch of the fifth
 pair of nerves is affected, the pain begins in the supraorbitar hole, spreads
 over the  forehead, the hairy part of the head, downwards into the orbit,
 to the inner corner of the eyelids, and frequently over the whole  side of
 the face.   The supraorbitar nerve should be cut through transverselv, in
 doing which the soft parts,  above the supraorbitar hole, must be divided
 down to  the bone with a bistoury, and lint thrust into the wound, which
 should heal  by suppuration and granulation.
   In the  subcutaneous division  of the inner and outer branches of the frontal nerve,
 the skin should  be pierced about an inch from  the middle line, and the third of an
 inch above the eyebrow, with the tenotome thrust in downwards and outwards, and
 carried an  inch or an inch and a half further beneath the skin; the  instrument is
 then held  steady with its cutting edge forward, and  the skin pressed several times
 with the thumb  of the other hand, so as to cut through  the parts beneath it. To
 make more sure that the nerve do not escape, the edge of the knife must be turned
 back so as to divide the soft parts  down to the bone.  If the inner branch of the
 nerve have to be divided, the knife after being withdrawn, must again be introduced
 into the wound,  turned inwards and downwards, and the division-made in the same
 way.
   2672.  In  the case of an infraorbitar neuralgy, (Fothergill's (a) Face-
 ache,) where the pain begins at the outlet for the infraorbitar  nerve, and
 spreads over the wings of the nose, the cheek and upper lip of one  side,
 the infraorbitar nerve must be divided.  This must be done by thrusting a
 pointed bistoury half an inch below the under edge of the orbit, and half
 an inch from the inner corner of the eye, directly down towards the cuspid
 tooth, to  the bone, and carried outwards, and  downwards three quarters
 of an inch towards the zygomatic process of the  upper jawbone.   The
 wound is to be treated as in the former case.
   In the subcutaneous division cf the infraorbitar nerve, that part of the skin is first
 chosen which corresponds to the infraorbitar hole; about half an inch from which
 outwards and  the same distance below the edge of the orbit, the skin is to be pierced.
 The upper lip must be drawn downwards and forwards with the left hand, to render
 the nerve tense and separate it from the cuspid pit.  The tenotome with its edge
 upwards, is introduced with the right hand, and cuts cautiously inwards and a Httle
 downwards, that it may sweep the bottom of the cuspit, till it reach the infraorbitar
 hole, and stop on the nasal eminence.  The edge is now  directed  a little forwards
 and divides the nerve by a lever-like movement, the  knife being always kept close
 to the bone.
   2673. When the face-ache spreads from the middle of the parotid gland
 towards  the wing of the nose and  lower eyelid, towrards the corner or
 the mouth and upper lip, or also even towards the chin, the teetK, and
 angle of the lower jaw, the middle branches of the infraorbitar and inferior
 maxillary nerves, or even the lower branches of the facial nerve and the
 mental nerve are affected.
   In the  former case, for the division of the middle branches of the facial
 nerve and the  infraorbitar  nerve, Klein makes  a cut from  about the

  (a) Fothergill, J„ M. D., Of a painful Affection of the Face; in Medical Observations
and Inquiries, vol. v. p. 129. London, 1776.
   Vol. iii.—54 
634
DIVISION OF  NERVES IN NEURALGIA.
middle of the nose to the middle of the cheek.  In the second case, he
makes  a cut into the cheek through the m. masseter to the under edge
of the lower jaw, and beneath it towards its angle.   The parotid duct
must be avoided.   The bleeding from the facial artery  must be stanched
by thrusting in lint and by a compressing bandage.  When the pain
extends from the hinder angle of the lower jaw to the upper lip, towards
the ear, the nose, and eyelid, when especially thelower facial nerve and
consecutively the mental and infraorbitar nerves are affected, a cut should
be made for dividing the facial nerve, which according  to Klein, should
begin below the parotid duct at the edge of the m. masseter, pass along
the under edge of the lower jaw, and run up to the corner of the mouth.
If the inferior maxillary nerve be the seat of the neuralgy, and the pain
extend from the second  molar tooth over the  lower jaw, and the teeth
towards the ear and eye, the inferior maxillary nerve must be cut through,
for which purpose the membrane of the mouth and gums is to be divided,
and the knife passed directly from the second molar tooth to the base of
the lower jaw, down to the bone.  If this  be insufficient, the nerve may
be divided at its entrance into the maxillary canal, by cutting vertically
near the coronoid  process, and  then, by scarification with  a gum-lancet
between that process and the m. pterygoideus (a).
   2674. For the subcutaneous division  of the nerves of the cheek, Dief-
fenbach passes a tenotome  in various  directions beneath the skin, and
divides the affected nerves with successive  strokes.  In mental neuralgy,
for the subcutaneous division of the nerve, at its escape from the mental
hole, the skin covering the lower jaw  must, according to  Bonnet, be
pierced half an  inch from the symphysis, and the same  distance from the
lower edge of the horizontal branch of the lower jaw.   The tenotome is
introduced with the right hand, whilst the lower lip is held with the first
three fingers of the left hand, the thumb and middle finger being placed
on the outer surface, and the forefinger on  the mucous  membrane at the
first molar  tooth, the lower lip- drawn forwards and upwards, and  the
nerve separated  a  little  from the bone.   The  tenotome,  with its edge
downwards, is passed backwards and upwards till its point which should
run along the bone, and always touch it, reach the first molar tooth, and
be felt by the forefinger beneath the mucous membrane.   The edge of
the tenotome is now pressed down, by raising  the handle, and drawn a
little  back ; and this movement is repeated  several times, whilst the edge
of the knife is carefully kept on  the upper surface of the bone.  If this
operation be performed on the right side, the left hand must be carried
round the head of the patient, and the lip held  with three fingers, whilst
the thumb  rests on the inside.
   2675. As even the repeated division of the nerves of the face, accord-
ing to these rules never affords complete relief, and the pain recurs, Klfin
was first struck with the idea of destroying the trunk of the facial nerve
at its exit from the stylo-mastoid hole.   After various experiments which
he performed on the dead body, for the division of the nerve at the part
he had thought of, he performed the operation in the following way.  He

   (a)  Klein, above cited, in the Chiron.—Lizars, Neuralgia of the Inferior Maxillary
Nerve cured by Operation; in Edinburgh Medical and SurgicalJo urnal, vol. xvii. p. 52a.
 1821. 
DIVISION  OF  NERVES  IN NEURALGIA.          635
made a deep penetrating cut with a slightly-curved bistoury, which he
thrust in, below the lobe of the auricle, well up-pulled, towards the front
edge of the  mastoid process, obliquely behind it, to its extremity.  The
divided  occipital artery bled smartly, but was  checked  by an assistant
pressing  on  the carotid.  He then made a transverse cut below the lobe
of the auricle, separating it from the beginning of the first cut to the tem-
poral artery, which  he avoided, and immediately some trifling auricular
branches spouted forth.  He then separated  the flap in the same way
deeply to the hinder edge of the  styloid process  throughout its whole
length,  at the same  time thrusting  the point of the knife deeply upwards
and backwards, and lengthening the cut also behind the mastoid process
down to the bone.  Herewith the facial nerve was cut in two.  He now
quickly pushed a hot blunt round cautery iron  as thick as a  common
quill, obliquely from below upwards  and  inwards, pressed it firmly and
for some time on the stylo-mastoid hole, and carried it in different direc-
tions for the purpose of cauterizing the occipital artery.   The  wound,
which still continued bleeding, was plugged with lint dipped in white
of egg and strewed  with gum arabic, covered with a compress, the whole
fastened with a cloth  around the head, and pressure kept up  several
hours, by an assistant
   2676. No remarkable symptoms occurred after the operation, and the
wound  healed in a  short time.  Wryness of  the mouth  and tip  of the
nose, which  occured on the destruction of the nerve, subsided, and the
face-ache completely ceased.  In  a second case, which Klein operated
on, the  result was the same, and the patient had no inconvenience beyond
a slight mark.   In both cases, however, according to positive assurances,
the result was not permanent.
   Klein considers  the  operation entirely free from  danger.   If the
division of the facial nerve be properly managed, the carotid artery and
jugular vein  cannot be  wTounded,  as the fromer lies in its  canal  too  far
from the styloid  process, and the  latter is  distant from the place of the
cut, and if wounded, can be commanded by pressure (a).
  According to Langenbeck, the division of this nerve can be performed with great
safety in the following manner.   The auricle being drawn upwards and forwards, a
cut is made from the front edge of the root of the mastoid, process, where it is con-
nected with the styloid process, and continued below the auditory passage, on the
front edge of the m. sterno-mastoideus, so that its tendinous fibres can be seen. The
parotid gland now laid  bare is carefully separated and  turned aside ; and the wounded.
posterior or occipital artery tied.  The finger is now passed to the upper part of the
wound, and feeling the junction of the bony auditory passage, and  the root of  the
styloid process as a broad bony surface, is pushed on towards the upper edge of the
mastoid process, behind it, but stopping at the hind edge of the styloid process,
without reaching its inner side, then from the inner edge of the base of that process
and the  m. sterno-mastoideus, from above downwards, and from without inwards,
towards  the styloid  process, where it  tears away the cellular tissue covering the
nerve, which then appearing as a white cord above the hinder belly of the m. digas-
tricus maxillae  inferioris, is taken hold of with the forceps, lifted up a little and cut
through, or a piece of it taken out.
  2677. On  comparing the subcutaneous  division  of nerves with the
ordinary mode  of proceeding, it  cannot  be  denied, that the complete
division of the nerve in every case is more difficult, and  the nerve may

  (a) Frieker,  Dissert, de Secundo Trunco Nervi Duri in Prosopalgia.  Tubing., 1813.—
Klein, above cited. 
636
OF  AMPUTATION  OF THE LIMBS.
even be missed.   This, however, can be avoided by careful performance
of the operation, founded on correct anatomical knowledge.   The symp-
toms are usually slight, as in all subcutaneous operations, and the blood
which has been thereby extravasated is soon absorbed.
   Bonnet has attempted to  contravert the objection, that the divided
nerve reunites, by stating, that after its division the  extravasated blood
remains between the ends of the nerve, and that,  afterwards, one part of
it  is absorbed, and the other becomes organized, and forms a connecting
intermediate substance between them.   Whether  otherwise, by the  sub-
cutaneous division of the nerve, the result  is rendered more certain, still
remains undecided by the experience hitherto  had.  It  must not, how-
ever, be overlooked, that several cases which have been related as  sub-
cutaneous neuro-myotomies, have produced painful and  spasmodic  con-
tractions of the muscles (a); or it may be  doubted whether the trunk of
the  nerve, or only some little branches of it have been divided {b).
   The following may be mentioned as examples of the division of nerves, and at
different parts. ° Delpech and Earle  have cut  directly through the ulnar nerve,
where it runs  behind the inner  condyle.   Astley Cooper cut out half an inch of
the radial nerve, after laying it  bare on the radius.  Abernethy and Wilson di-
vided, above the injured part, a nerve wounded in bloodletting.   Abernethy cut
out half an inch of the digital nerve on the middle joint of the finger.  Malagodi
cut out a semilunar piece, of a finger's breadth,  from the ischiatic nerve in the re-
gion of the knee-joint.  Swan cut through the peroneal nerve, at the inner edge of
the  outer hamstring;  Delpech divided  the  posterior tibial nerve, whilst on the
hinder edge of the shin-bone, laying it and the vessels bare, and  separating it  from
them.  Manovy divided the  same nerve behind the  inner condyle, in  a case of
traumatic trismus.   Bujalsky cut off both from the outer branches of both the acces-
sory nerves of Willis, at their exit from the m. sterno-mastoideus, a piece  three
inches lono-, but without any  satisfactory result.  In pains in  the heel,  accord-
ing to Lentin, deep cuts have been made into the heel, and suppuration kept up in
them for a long time.   From the energetic application of the  actual  cautery in
plantar neuralgy, I have seen the most satisfactory result.
               IX—OF AMPUTATION OF THE LIMBS.

  (Amputatio Membrorum, Lat.; Ablosung der Gleider, Germ.; Amputation, Fr.)

  Sharp, Samuel, A Treatise of the Operations of Surgery, &c.   London, 1761.
Eighth Edition.
  Ibid., A  Critical Inquiry into the present state of Surgery.   London, l/ol.
Fourth Edition.                                    ,  .  ,   .
  Louis, Memoire sur l'Amputation des grandes  Extremites; in Memoires  de
l'Acad. de Chirurgie, vol. ii. p. 268, p. 355.  Paris, 1761-74.  4to.
  Bromfield, William, Chirurgical Observations and Cases, vol. l. p. 38.  Lon-
don, 1773.  8vo.
  Pezold, De Amputatione Membrorum.  Gotting., 17/8.
  Larrey, Memoire sur les Amputations des Membres.  Paris, an  v.
  Alanson, Edward, Practical Observations  upon Amputation, and the After-
Treatment.  London, 1779.  8vo.
  Kirkland, T., Thoughts on Amputation, &c.  London, 1780.  Svo.
  Mynors, R., Practical Thoughts  on Amputations.   Birmingham, 1783.  12mo.
  Pott, Percival, Remarks on the necessity and propriety of Amputation, &c; in
his Chirurgical Works, vol. iii. p. 351.  Edition of 1783.
  (a) Sperino. Casimirino, Neuralgie  grave in Gazette Medicale de Paris, voLix. p. 205.
de  plusieurs rameaux du plexus cervical,  1843.
gueri par la Neuro-Myotomie souscutanee;  (b) Rivieri, above quoted, p. 496. 
KINDS OF AMPUTATIONS.
637
  Bell, Benjamin", A System of Surgery, vol. vi. p. 301.  Edinburgh, 1783..
  van Hoorn, Spec, de iis, quae in partibus membri, praesertim osseis, amputations
vulneratis notanda sunt.   Lugd. Batav., 1803.
  Schreiner,  Ueber die  Amputation grosser Gliedmassen nach  Schusswunden.
Leipzig, 1807.
  Desault, Sur I1 Amputations des Membres ; in  his GSuvres  Chirurgicales, vol.
ii. p. 531.  Edition of 1812.
  Graefe, Normen fur die Ablosung grosserer Gliedmassen.  Berlin, 1812.
  Larrey, Memoires de Chirurgie Militaire  et Campao-ne, vol. ii. p. 451.  Paris,
1812-17.   8vo. "
  Benedict, Einige Worte uber die Amputation in Kreigspitalern.   Berlin, 1814.
  Roux, Memoire et Observations sur la reunion immediate de Ja Plaie apres l'Am-
putation circulaire des Membres dans leur continuite; suivis du Rapport fait a l'In-
stitut par M. M. Percy et Deschamps.   Paris, 1814.
  Ibid., Relation d'un Voyage fait a Londres, p. 336.  Paris, 1814.  8vo.
  Guthrie, G. J., On Gunshot  Wounds of the Extremities requiring the different
Operations of Amputation; with  their After-Treatment.   London, 1815.   8vo.
  Klein,  Praktische Ansichten  der  bedeutendsten chirurgischen  Operationen.
Part I.  Stuttgart, 1816.
  Hutchison,  A. Copeland, Practical  Observations  in  Surgery.   London, 1816.
8vo.
  Ibid., Some further Observations on the subject of the proper period  for ampu-
tating in  Gunshot Wounds, &c.  London, 1817.  8vo.
  Brunninghausen, Erfahrungen und Bemerkungen iiber die Amputation.  Wurz-
burg,  1818.
  Maingault, Medecine Operatoire ; Traite  des diverses Amputations qui se pra-
tiquent sur le  Corps Humain, representees par des figures dessinees d'apres nature
et Jithographiees.  Paris,  1822.  fol.
  Averill, Charles, A short Treatise on  Operative Surgery, p. 107.   London,
1823.  sm. 8vo.   First Edition.
  Kern,  Ueber die Handlungweise bei Absetzung der Glieder.  Wien, 1826.  Se-
cond Edition.
  Hennen, John, Principles of Military Surgery.   London, 1829.  Third Edition.
  Dupuytren, le Baron, Lecons Orales de Clinique Chirurgicale, vol. iv. p. 233.
Paris, 1834.  8vo.
  Sedillot, De l'Amputation des Membres dans la continuite et la contiguite, ses
avantages et ses  inconveniens.  Paris, 1836.
  Syme,  James,  Principles of Surgery.   Edinburgh, 1837.  Second Edition.
  Liston, Robert, Elements of Surgery, p. 760, part. ii.  London, 1840.  Second
Edition.
  Alcock, Rutherford,  Lectures on Amputation; in  Lancet.  1840-41;  vol.  i.
and ii.
  Schaeffer, H. J., Dissert, de Cultris Amputatoriis.   Bonnae, 1842.
  Fergusson, William, A System of Practical Surgery.  London, 1846.  Second
Edition.
  Pelletan, Memoire sur 1'Amputation des  Membres;  in Clinique  Chirurgicale,
vol. iii. p.  183.
  Chelius, Ueber Amputationen ;  in Heidelb. klinischen Annalen, vol. i. part i.
  Jaeger, Article Amputatio; in  Handworterbuch der Chirurgie, vol. i. p. 157.
  Malgaigne, Manuel de  Medecine Operatoire, fondee sur 1'Anatomie  pathologique,
et 1'Anatomie  normale.  Paris, 1843.   Fourth Edition.

   [Mann, J., Observations on Amputation  at the Joints, in New York
Med.  Repository, vol.  7, 1822; and  in Sketches of the  Campaigns of
1812, 13, 14,  in Canada, &c.   Dedhara, 1816.
  Hubbard, On Amputation at the Joints, in the same  Journal, vol. 7.
  Davidge, Physical Sketches.  Baltimore.   8vo.
  Smith, N. R., Surgical Memoirs.   Baltimore, 1831.   8vo.
  Geddings, E., Article Amputation, in the American Medical Cyclo-
pedia, vol. i.   Philadelphia, 1834.  8vo.—g. w. n.]
                                   54* 
638    COMPRESSION OF ARTERIES WITH THE TOURNIQUET.

   2678.  Amputation is the last and most  grievous  remedy to which art
can have recourse, for the purpose of saving the life of a patient by the
loss of a  limb.  The  cases which  make it necessary have been already
mentioned in treating of gunshot wounds, {par. 346,) compound frac-
tures,  (par. 590,) white swelling,{par. 254,) carious ulcers,  {par. 886,)
and elsewhere.
  2679. Amputations may be  distinguished into those which  are  per-
formed in the continuity of the limbs, {Amputationes,) and those at joints
(Exarticulationes.)
  2680. The following points must be considered of amputations in ge-
neral ; first, the precaution against bleeding ;  second,  the formation of
such  wound  that the  bone  may be  properly  covered  with  soft  parts;
third,  the sawing off the bone ; fourth, the stanching the bleeding from
the divided vessels; and fifth, the proper treatment  of the wound formed
by amputation.
  268.1. Precaution against bleeding consists in  the compression of the
principal artery of the limb to be amputated, either by the application of
the tourniquet, (par. 283,) or by the  fingers  of an  assistant, or with a
proper compressor.
  The application of the  tourniquet is  accompanied with many incon-
veniences, as if it be placed in  the neighbourhood of the part where the
amputation is to be performed the muscles  will not retract properly ;  it is
often  inconvenient to the operator, and prevents the return of the blood
through the veins.   For these reasons compression of the principal artery
by a capable  assistant, at  least in amputation of the  upper limbs  and
thigh,  is  preferable  to  the tourniquet.  In  amputation of the leg the
tourniquet is used, because here tying the ligatures is often difficult,  and
the assistant  compressing the vessel becomes exhausted.   Compression
must  always  be made at  a spot where the artery is superficial, and the
neighbouring bone affords a point of support (par. 284.)
  In patients who are weak and have little blood, Bru\nninghausen recommends, that
before  the operation the limb should be swathed in a flannel bandage nearly up to
the place of the cut, in order to diminish the loss of blood.
  [The only real advantage derived from the use of a tourniquet at an amputation,
except  in cases of compound fracture or wounds, where it had been previously ap-
plied to check bleeding, is, that the operator has no dread of a gush of arterial blood
when he cuts through the large vessels, if he have any doubt of the capability and
firmness of the assistant, to whom compression of the principal artery is intrusted.
But if he be trustworthy, the  compression is  more certainly made with the fingers
than with the tourniquet, the pad of which, however  well adjusted, will often slip
from the vessel if the patient struggle, and become quite useless.  One would think
compression could scarcely be objected to, in amputations of the  smaller parts of the
limbs, when it is invariably and necessarily employed in amputations high up through
the thigh and upper arm and at the hip and shoulder, and  no difficulty is found in
practising it at  either of those parts.
  Chelius has justly objected to the tourniquet, that it prevents the  return of the
blood by the veins, a circumstance too little remembered in amputation.  Bleeding
from the arteries is, in general, cautiously guarded against; but bleeding from the
veins is thought of no importance, and  by some indeed actually advantageous, which
is however a most serious mistake.  It must not  be supposed that when the tourni-
quet is applied, all flow of blood to  the part of the limb below is stopped, for such
is not the case, as is decidedly proved  by the filling almost  to bursting of the super-
ficial veins, and the  generally congested state of the whole part, in consequence,of
which directly the knife begins to cut, the blood streams forth in torrents, frequently
with the observation that it  is only venous blood, forgetting that this  venous blood 
AMPUTATION BY THE CIRCULAR CUT.            639
must be so much withdrawn from the general circulation, of which the patient not
unfrequently soon feels the effect, becomes pallid and covered with cold sweat and
now and then swoons.   All this depends  on the tourniquet bandage which has
dammed up the current from below, without any possible benefit.
  But admitting for argument's sake, that a free flow of venous blood at an amputa-
tion is generally advantageous, which, however, I agree with many others in deny-
ing, yet there are occasions and those not unfrequent, where it is positively danger-
ous and occasionally fatal to the  patient.  A  healthy person who, by wound of, or
from severe tearing or compound  fracture of a limb, has lost a considerable quantity
of blood, and has been so completely pulled down by it, that it is often necessary to
administer stimulants and  wait for hours till his circulation have recovered, and the
immediate effect of the bleeding have gone off, such person cannot bear to lose any
blood, and  the operator must take every precaution, and it may be  even  tie the
principal artery before amputating, for the purpose of guarding against loss of blood.
Neither can a patient who is on the very verge of hectic, the result of any local dis-
ease or excited during the  progress of a severe injury, bear any loss of blood during
an amputation; three or four ounces of venous blood suddenly escaping may be fatal,
or endanger him very considerably.  For these reasons bleeding from  the veins is
not to be thought lightly of, and therefore compression by the thumbs is better than
the tourniquet, as*it checks the great flow of blood to the limb, and does not prevent
the leturn, by the veins, of that blood which has made its way by the side channels,
which cannot be closed more by the tourniquet than they are by the thumbs.   Some
surgeons advise  tying the -principal artery first before amputating, if  the limb be
removed near the trunk, and it cannot be doubted this is the safest method; I have
done this on two or three  occasions; but at  other times have taken up the artery
directly it was cut through and afterwards finished the operation, and upon the whole
I think this is the better practice  of the two, when there seems to be a  necessity for
either.—j. f. s.]
   2682.  The formation of  such  wound that the bone  can be properly
covered with soft parts, it has, in general, been attempted to effect in two
ways,  a. by  cutting circularly into the  soft parts down  to the  bone, or
Amputation  by the circular  cut {Amputation  durch der Zirkelschnitt,
Germ.; Amputation circulaire, Fr.); and j3. by separating the soft parts
from the bone  in  shape of a flap, or Amputation with a flap (Lappen-
amputation, Germ. ; Amputation a lambeaux, Fr.)
   2683.  History presents many  modes  of meeting the  just-mentioned
requirements  by the  circular  cut.  Celsus (a)  had already  expressly
directed that the skin and muscles should at one  stroke be cut into down
to  the bone, that  they should be wrell drawn up, and be again divided
from the bone higher up, so that the bone might be covered and union of
the parts, drawn over  it, might be effected.  At a later period, however,
this direction was so  considerably departed from, that  the  skin and
muscles  being merely drawn up,  were divided down to  the bone with
one circular  cut, and the bone sawn off.
   2684.  The impossibility, by this method, of drawing the divided parts
over the  bone  and covering it, necessarily rendered this a violent pro-
ceeding, the suppuration was always considerable, the bone stuck out, or
was  only  partially covered, and  a bad  scar  was formed.   For these
reasons,  various modes were tried to save as much skin and muscular
substance as would be sufficient for the due and  perfect covering of the
 stump.
   2685.  Here belong  the various methods of  dividing the skin and
muscles in different steps and with several cuts.   Petit {b)  divided the
skin with a circular cut down to the muscles, separated it a  little more,

(a) De Medicind*, lib. vii. cap. xxxiiL  (6)  Traite des Maladies Chirurgicales, vol. iii. p. 150* 
640
AMPUTATION BY THE CIRCULAR CUT.
drew it back, cut through the muscles at the edge of the skin so drawn
back, and after  sawing through the bone, covered the  surface of the
wound with the  skin which had been saved.   With this agreed the latter
practice of Mynors (a), who  considered a pad of flesh unnecessary; he
divided the  skin with a circular cut, dissected it off to a proper distance,
and cut through the mass of muscle vertically down to the bone.  Very
recently, Brunninghausen (6) has followed a similar practice, except
that he  does not divide the skin by one  circular, but by two semicircular
cuts,  and dissects  them back so as to form two semilunar flaps; the
muscles are then cut through vertically to the bone.
  2686. For the purpose of making a wound with a  conical surface in
the upper part  of which  is  the  bone, Louis (c) has directed cutting
through the skin and superficial muscles with the first  cut, to draw them
back, and at their edge  to  cut through the deep muscles down to the
bone.
  Alanson {d)  proposed a particular mode of forming a. conical wound
surface, to make which when the skin is divided by a  circular cut, sepa-
rated from the muscles and turned back, the knife must be so placed that
its edge is directed obliquely upwards and inwards, and whilst carrying
it round the whole limb in  this direction, all the muscles are cut through
to the bone, so that a  hollow wound is formed, at  the top of  which the
bone is sawn off.   In  practice, however, it is found impossible to  carry
the knife in  a circle round the limb as directed, as it cannot travel except
in a spiral line (e).  This method, therefore, found but few adherents (/),
and was set aside by other manoeuvres, by which a conical wound surface
could be formed in the muscular substance.
  2687.  According to Gooch and Bell {g), .he skin  and muscle should
be divided  with one circular cut down to the bone, then  the knife thrust
in about an inch higher between  the muscle and  the bone and carried
round, and lastly, the bone sawn through still higher than the cut through
the muscles.
   Desault {Ii)  cut through the muscles layer by layer, always allowing
one to  retract before he cut  through another, and so   proceeded till he
reached the bone.
   Richter {i) practised  a similar method with his fourfold circular cut,
in which, with the first circular cut he divided the skin, which he allowed
to retract, and at its retracted edge, with three several circular cuts  he
reached the bone ;  in doing this, the divided layer of  muscles retracted,
and  those still remaining were cut through higher up.
   Boyer (j ) divides the skin with the  first circular cut, and by a second
half through the superficial muscles, and on  their retraction cut  through
the deep  layer,  and finishes by dividing with a  bistoury the remaining
fibres attached to the bone, together with the periosteum.

  (a) Above cited, p. 19.                  (g) Above cited, p. 340.
  (b) Above cited.                       (h) Above cited, p. 276.
  (c) Above cited, p. 358.                  (t) Medicinisch und chirurgische Bemer-
  (d) Above cited,  p. 12.                kungen, vol. i. p. 284.
  (e) Wandenberg, Briefe, vol. ii. part i. p.    (j) Traite des  Maladies Chirurgicales et
21.                                 les Operations qui leur conviennent,  vol. xi.
  (/) Loder, Programm. De nova Amputa-  p. 156.  Paris, 1822-26.   Third Edition.
tione Alansoni. Jenae, 1784. 
FLAP-AMPUTATIONS.                    641
   2688. Graefe (a) again takes up Alanson's notion of a funnel-shaped
 cut  with one  stroke of the knife, and manages it with a  sort of leaf-
 shaped knife, {Blattmesser,) the blade of which  is bellied in front, and
 becomes narrower and narroweriowards the handle.   When the skin has
 been divided with one circular cut  and drawn back, the  bellied part of
 the knife is placed on its edge with the  cutting part obliquely upwards
 carried with a single stroke in this direction around the whole limb, and
 the muscles are thus cut through to the bone.
   2689. Dupuytren (6), for the purpose of diminishing the pain in the
 division of the skin and muscles, employed Celsus's method (par. 2683.)
 An assistant drew the skin well back, and he then divided the skin and
 muscles at one stroke to the bone ; the muscles hereupon retract, and those
 still remaining attached are  cut through higher, so that in  this way a
 conical wound is produced.
   Wilhelm operates in like manner (c).
   2690. In the history of the circular cut the proposals of Valentin and
 Portal to prevent the projection  of the bone must also be mentioned;
 according to the former, the muscles should each time be cut through in
 their greatest degree of extension, according to the latter, just the con-
 trary.
   2691. Flap-Amputations were first  invented by  Lowdham {d) in the
 seventeenth century ; in amputating the leg, he made, from the calf a pil-
 low in shape of a flap, for the purpose of covering the stump.   Verduin (e)
 and Sabourin {f) afterwards arrogated this discovery. Flap amputations,
 restricted by their inventor to the leg, were applied to the thigh also by
 Ravaton {g) and Vermale (h), and with them commenced Amputation
 with two flaps.   They always made use of flaps, in doing which, the knife
 was thrust through the whole  mass  of limb to  the bone, carried some dis-
 tance beyond it,  and then the parts divided outwards.   Langenbeck {i)
 forms flaps,  either one or  two, by  a deep  cut from without,  inwards
 towards the bone.
   Upon flap amputations may further be consulted
   Salzmann, De novo Amputationis Methodo.   Argent., 1722.
   La Faye, Historie de l'Amputation suivant la Methode de Verduin et Sabourin;
 in Memoires de l'Acad. de Chirurg., vol. ii. p. 243.
   Garengeot ; in same, p. 261.
   O'Halloran, A Complete Treatise on Gangrene and Sphacelus; with a new Me-
 thod of Amputation.  London, 1765.  8vo.
   Siebold, Dissert, de Amputatione Femoris cum relictis duobus carnis segmentis.
 Wirceb., 1782.
   2692. Pott's {k)  method  must be considered as a compound of the
 circular and  flap operations, he cut into the muscle  first on the one, and
 then on the other side obliquely from below upwards and thus formed a

  (a) Above cited, pi. vii. fig. 6, 7.           (/)  Mangetti, Bibliotheca Chirurgica,
  (b) Sabatier, Medicine Operatoire, vol. iv.  vol. ii. p. 255.
p. 471.  1824.  New Edition.—Dupuytren,    (g) Le  Dran, Traite des Operations de
above cited, vol. iii. p. 233.              Chirurgie, p. 564.  Paris, 1742.
  (c) Klinische Chirurgie, vol. i. Munchen,    (h) Observations de Chirurgie pratique,
 1830.                                precedees d'une Nouvelle Methode d'Ampu-
  (d) Young's Currus triumphalis e terebin.  tation.  Mannheim, 1767.
thina.  London, 1679.                     (i) Bibliothek far die Chirurgie, vol. iii.
  (e) Epistola de nova Artuum decurtando-  part  ii. vol. iv. part iii.
rum ratione.  Amstel., 1696.               (k) Above cited. 
642             VARIOUS MODES OF AMPUTATION.
wedge-like wound.   Siebold's (a) proposal corresponds to  it, and con-
sists, after cutting through and drawing back the skin, in making the cut
through the muscles obliquely upwards, first on  the outer, and then on
the inner side,  by which a wound is formed as in Pott's method.   Here
also belongs Schreiner's {b) plan of dividing the skin and muscles with
one circular cut down to the bone, and then by cutting upwards on each
side with a bistoury to the bone, forming  two flaps, which he separated
from the bone, and sawed the latter off in the angle.
   Herewith must also be placed the modes of proceeding which, by Lan-
genbeck  and Scoutetten, are confined to  disarticulations, the oval cut
also used in amputating the continuity of  the limb, the oblique  cut of
Sedillot, Baudens,  and Malgaigne, the sloping cut of Blasius  (c) ; in
making which, the soft parts are divided in an oblique surface, or in form
of the  mouth-piece of a clarionet, or in the form, of A, so that the point
of the  cut is on the front of the limb, a  little above  the part where the
bone is sawn through, and the rather rounded base  is behind and  below.
Sedillot, Baudens, and Malgaigne, divide in this way, the skin  alone,
separate it, and divide the muscles higher with a circular cut.  Blasius,
with a peculiar knife makes two cuts through the  soft parts, which both
pass obliquely to the  long and thick diameter of the limb, and unite at
their end, by which  a wound is made, presenting an obliquely cut out
funnel or cornet, and has close below the place of  division of the bone,
a re-entering /\ shaped angle to the wound, and two-thirds or the whole
of the  diameter of the limb lower, a projecting V  shaped lip to the wound,
which in closing the wound,  drops into each corner, but  can never be
brought directly opposite.
   2693.  When the muscles have been thus divided down to the bone,
they are held back by an assistant wTith a cleft  cloth (1), at the edge of
which the muscular fibres connected  with  and also projecting from the
bone,  and  the periosteum, are divided with a circular cut.  The left
thumb-nail is now placed close to  the face of the stump, for the purpose
of guiding the saw, which at first and towards the last, when the  bone is
nearly sawn through, must be  moved more slowly, and with  shorter
strokes (2).   Whilst the sawing is in  progress, the assistant who holds
the limb must not move it either up or down, because in the former case
he fixes the saw, and in the latter, breaks the bone.  If any bony points
 remain, they must be cut off with bone nippers, or  removed with a file or
 a fine saw.
   The cleft cloth to keep the muscles back, is better than the retractors of Bell and
 Klein. Scraping off  the periosteum  is superfluous.  Walther and Brunning-
 hausen divide the periosteum by a circular cut  about half  an inch below where the
 bone is to be sawn through, and turn it up, so that after the sawing, the end of the
 bone may be covered by it. They imagine that it promotes union!
   The saw commonly in use is the bone-saw, or Pott's plate-saw.
    [(1) 1 do not think there is any great advantage gained by using the cleft cloth,
 and very rarely employ it; as, by passing the thumb and forefinger on either side of
 the bone or bones, and pressing the palm of the hand and ball of the thumb against
 the surface of the stump, the soft parts can be pressed well back, and out of the

    (a)  Salzburar.  Med.-Chirurg.  Zeitung,  tations Methode, u. s. w.  Berlin, 1838.—
  vol. ii. p. 44. " 1812.                   Handbuch der Chirurgie, vol. in. p. 3i7.
    (6)  Above cited, p. 162.               Second Edition.—OprENHEiM'sZeitschriftfur
    (c)  Der Schragschnitt, Eine neue Ampu-  die gesammte Medecin. Jan., 1843; p. 10. 
TYING  OF  ARTERIES.
643
way of the saw, which should be applied as closely as possible, to the cut ends of
the muscles.
   (2)  It will not be superfluous to say a few words about the use of the saw, which
is probably one of the worst-used surgical  instruments.  A good saw should have
its teeth well set off, as the carpenter's expression is, that it  may neither clog nor
hang in its track; and it should have, proportionally to its size,a heavy back, which
renders its steadying more easy, and  affords all the weight the saw requires to be
loaded with.  The too frequent mode  of using the saw, is to drop its end, whilst the
handle is raised, so that when moved  it works obliquely ; the operator, at the same
time, throwing  as much of his own weight as he can conveniently spare upon the
handle, as if with the intention of forcing the blade of the saw at one or two strokes
through the bone, and then driving it downwards and upwards, as violently and
quickly as he can, and often using about as much of the toothed edge as a young
violinist does of his fiddle-bow.  The consequence is, that the saw works badly, is
continually jumping out of its track, makes another, and finishes by splintering the
bone, and often cutting through it below where it was proposed.  To use a saw pro-
perly,  it should always, where possible, be  held and worked horizontally, moving it
forwards and backwards without any pressure of the hand, but allowing merely its
own weight to keep it on the appointed place; and as it is moved forwards, even its
own weight should be lessened, by slightly supporting, instead of pressing down
the  saw.  After drawing the toothed edge  first backwards, and then  moving it
forwards lightly on the bone, till a  shallow track  is made, it may be moved freely,
so that at least two-thirds, or even  more  of the  saw shall act.  The strokes should
not  be quick, but long; and if so made, four or six of them  will cut through the
thigh-or shin-bone, more quickly and more cleanly than twice as many short, hurried
strokes, and without any risk of splintering the bone, or  slipping from  the part
chosen to saw through.—j. f. s.
   Liston (a) thinks that working the saw vertically is preferable to  horizontally;
" for thus, when the section is  nearly  completed, the uncut part of bone is deep, and
less likely to snap on the weight  of the limb  being allowed to operate, or when
undue pressure is made downwards."  He thinks, also, that "the regulating of the
position  of the limb during  sawing, should not be intrusted  to the assistant alone.
He  may, from anxiety to facilitate the action of the saw, snap the bone and splinter
it, when it has been  little more  than half divided; or from dread  of this, he may
lock the instrument, and so delay the completion of the operation.  The manage-
ment of  the lower part of the limb  should always be by the person using the saw."
(p.  764.)
   I do not think there is more danger in giving the lower part of the limb to an
assistant than the upper; for if the operator hold  the lower end, the last portion of
the  bone is just as likely to be snapped through by the muscles above, when they
begin  to lose the counterpoise  of the  limb below, if not specially guarded against.
This I have seen, again and again, in amputation through the thigh, that when the
bone has been  sawn through steadily, and without a splinter, the moment the saw
 has passed through, up jumps the  stump.
   One point, however, should never be forgotten, to wit, that immediately the soft
parts are completely divided, the assistant should grasp the limb below, as near as
possible to the place of sawing; and if  he have from circumstances,  grasped the
bone or bones below that which will  be sawn through, he should change his grasp,
and fix it on the end of the bone just about to be cut through.   This specially applies
 where amputation is performed for diseases of joints, as then  the  joint is too tender
 to permit being taken hold of, till  its nerves have been divided by the cuts of the
operation.—j. f. s.]
   2694. After the  bone has been sawTn through, the divided  vessels must
be tied,  according to the rules already  given (par. 291.)   The principal
artery is to be first tied,  and afterwards the smaller ones.   For this pur-
pose, it is not  necessary to  relieve the pressure on  the  arteries, so that
the mouths of the  vessels  should be seen by the spouting of the blood;
anatomical  knowledge must here guide  the operator.  All the spouting
vessels having been tied, warm  water must be  allowed to flow over the
(a) Elements of Surgery. 
644
AFTER-TREATMENT.
wound to ascertain whether there be any little vessel still bleeding.   The
more carefully the vessels are tied, the less need is there for the applica-
tion of cold water, which is generally only necessary when there is trick-
ling of blood from vessels which cannot  be distinguished, so  as to ensure
the patient against after-bleeding.                                    _
   The best material for ligatures is round,  not very thick, but sufficiently
strong silk threads ; either both ends of which may be cut off close to the
knot,  or only one is cut off at  the knot, and the  remaining one led the
nearest way  out to the  surface  of  the wound, where  it must be fixed to
the skin  with sticking  plaster {par. 293.)   What  has been already said
{par. 297) in reference to torsion, applies here.
   In the history of amputation, the mode of stanching the blood is of the greatest im-
portance, as its well-doing and less danger are in the closest relation With the manner
in which the stanching of the blood is  effected.  Before Ambrose Pare, in 1582,
re-employed the separate tying of vessels, already known, from Galen and Aetius,
surgeons endeavoured  to stanch the bleeding with boiling oil and pitch, into which
the stump was plunged, or with the actual cautery; or the amputation was per-
formed with a red-hot  knife.   Tying the arteries at first met with violent opposition,
and  but few  supporters (Guillemeau, De  La Motte, and others.)  From  the
absence of precaution against bleeding, together with the unfitting form of the liga-
ture instruments, the practice of tying the arteries was very difficult, and the bleeding
rendered amputation dangerous, on  which  account, in many cases, it was not under-
taken.  Only  on the invention  of the tourniquet, by Morel,  in  1674, and  its
improvement by Petit, in 1718, did amputation become more general.  For the
stanching of bleeding, however, the vitriol button, actual cautery,  the stick, and
tourniquet, were still used in preference.  The dread of cutting through the artery in
tying it when isolated, led to tying the artery and passing the ligature through it,
till this, as well as all the earlier modes of stanching the.blood, yielded completely
to tying the vessel alone.   It is incomprehensible that  in the present time there
should still be some, who, instead of the simple and safe practice of tying,  employ
the constant application  of cold water;  or in flap-amputations, the compression of
the principal arteries in the flap against the bony  stump and even recommend it (a).
   [The bleeding after an amputation is  not always from the arteries,  but sometimes
though the  arteries have been tied, and the tourniquet  taken off, and sometimes
when  the tourniquet has not been used, the larger veins pour out, and will not
be stopped, as they usually can be  by pressure for  a few  minutes with the  finger.
Under such circumstances, they must be tied without  hesitation, and generally no
evil results follow.  One of my late colleagues, Tyrrell, always tied the veins at
once, if they seemed  disposed to bleed.  1  have tied the femoral vein many times,
and in but a single case with ill consequence; the patient had inflammation and pus
in the iliac vein; but as this  occasionally happens, without a ligature having been
applied, it may be questionable, whether the ligature was the cause of the mischief
or not.—j. f.  s.]
   2695. When  the  vessels are  all properly tied, after the wound  is
cleansed from blood, and the  surrounding parts  are dried, the dressing
must be  proceeded with, which effects  the cure  of the wound, either  by
quick union, or by suppuration and granulation.
   Many surgeons leave  the wound  open from six to ten hours, and during this time
cover it with  sponge  or compresses, dipped in cold water, for the purpose of thus
guarding against after-bleeding.   Dupuytren (b) specially advised  this mode o
 treatment, and followed it in all cases.  The advantage of this proceeding is, that
 if an after-bleeding ensue, the vessel can be at once tied.  Small retracted vessels,
 generally, do not bleed, even if some time be occupied with the operation; they are
 retracted  among the spasmodically contracted parts, but some hours after when this
   (a)  Koch,  De prrestantissima Amputa-  Journal fur Chirurgie und Augenheilkunde
 tionis methodo.  Landsch., 1826.  On the  vol. xii. p. 18.
 contrary,  compare  von  Graefe;  in his     (b) Above cited, p. 411. 
TREATMENT AFTER AMPUTATION.              645
condition subsides, or there is a greater flow of blood to the wound, they begin to
bleed.  If the dressing have been applied, the bleeding is first noticed, when it be-
comes completely penetrated by the blood.  The wound is filled with clotted blood,
which renders the discovery of the vessels very difficult.  I have treated in this way
those cases only where peculiar circumstances afforded the probability of an after-
bleeding; as a general practice, however, I do not think it advantageous.
   [Chelius's opinion on this subject is most certainly correct, the exposure of the
surface of the stump should be the exception and not the rule; and if  practised,
should not be continued more than three or four  hours, within which time, with due
attention the patient's warmth and circulation will generally have recovered the im-
mediate shock of the operation, and the clots in the little vessels will either have
been forced out or become so completely fixed as to prevent bleeding.   The prac-
tice sometimes adopted of covering the whole face  of  the stump with a thick wad
of lint dipped in water, kneading it in, and leaving it on for twelve or fourteen, or
even twenty-four hours is bad; as  during this  time the adhesive matter is poured
out, and instead  of sticking the surface of the wound together, sticks the lint tightly
on, so that it can only be removed with difficulty and with great pain to the patient,
and indeed, imperfectly, as the fluffy part of the lint remains tangled in the surface
of  the stump, the whole of which must therefore be cleared off by suppuration be-
fore union can take place.  If  the surgeon will leave  the face of the stump open,
and will apply cold water to it, linen which  has little or no fluff  should be laid
lightly over it and not kneaded in, arid frequently replaced before it can stick firmly ;
but a light sponge is still better.   Some practitioners leave the stump exposed, not
merely to guard  against after-bleeding, but because they fancy the union will  be
better if the surface of the wound have first glazed with the adhesive matter poured
out.  I have  not found  much  advantage  gained by employing this mode of pro-
ceeding.—j.  f. s.]
   2696. To promote quick union, after the  circular cut, an expulsive
bandage is  put on, from the upper part of the stump nearly to the end of
the sawn off bone ; the edges of the  wound are brought together in such
close  apposition  as to form a vertical cleft (1),  and in  this position are
fixed  with strips of sticking plaster, passed from one side of the stump  to
the other, so that the wound is  completely covered.    Upon the plaster is
laid, in the  direction of  the wound a pledget, and over it a wad of lint,
which is fastened with a compress laid crossways over the stump, with
some  descending  turns of a roller, also made to  pass over the face of the
stump.  The tourniquet is  applied loosely, so as to compress the  artery
in case of  bleeding.  The patient  is put to bed, the stump so placed
upon  a  pillow, that the cut surface is  a  little  higher  than the nearest
joint,  and protected (by a cradle) so that it  be not pressed by the  bed-
clothes.   On account of the disposition  to  cold shivering, the patient
should be covered up warmly,  and take a cup of warm tea, or  broth.
  The application of the sticking plaster over the expulsive bandage, is preferable
to that of putting on the plaster first and  the bandage after, because the plaster keeps
more firm, does not  so easily shift,  and does not so readily excite erysipelatous in-
flammation of the skin (2).   I have never noticed, from completely covering up the
wound  with  plaster, any inconvenience from collection of  the secretions of the
wound ; whilst indeed the edges: of the  wound as they swell, protrude irregularly,
and  often are completely strangulated if a space  be  left uncovered between two
pieces  of sticking plaster (3).
  [(1) With regard  to the direction  in which  the edges of  the wound  should be
brought together, it is questionable whether the vertical one is tbe best, or whether
the  horizontal one be not  preferable; I have tried both again and again, and  I am
rather more inclined to bring the edges  together in  a horizontal line, especially  in
amputations on the lower limb, because without effort and 6imply by the position
on its hind surface, on which the stump rests, the soft parts are kept closer together,
whilst  if the edges be brought together vertically, the resting  part of the stump ne-
cessarily tends to keep the cut surfaces asunder.  It may be objected, that the hori-
  Vol. in.—55 
646                           TREATMENT
zontal fitting together does not encourage the escape  of the fluid from the stump
so much as when the edges are brought together vertically, and renders the bagging
of matter and sinuses more likely, but this  is not the case, and when it happens,
depends more commonly on the carelessness with  which the after-dressings are
made.  I have, however, seen many very good stumps made  in both ways.
  (2) Chelius's recommendation of, and reason for, applying a bandage first, and
the plaster after are very good, but it must not be supposed a long bandage should
be applied ; a covering to the stump a single turn thick, is all that is proper or ne-
cessary to bring the soft parts well down to the end of the sawn bone, but more than
this heats the stump.  I do not agree with him  in covering the whole face of the
stump with  plaster, the less of this  the  better, provided the object of keeping the
skin close upon the face of the stump be  effected ;  but I have not generally noticed
the protrusion of the swelling  edges between the gaps  of the plaster, unless the
plaster have been too tightly applied, which however is often done, and the lips of
the wound  dragged together as tightly as possible, a proceeding bad, painful and
useless, and generally consequent on too little skin having been saved so that the
edges will not, if the wound be properly dressed, come together at all.   It should
be remembered, that the plaster is not to pull the wounded surfaces  together, but
merely to support them when they are fitted together.  I think it therefore  better
not to fix one end of the strip of plaster on one  side, carry it across the face of the
stump, drag the edges of the wound together, aad fix the other end on the other side,
but whilst an assistant  gently brings the edges of the wound  together with the
finger and thumb of each hand  above and below, to place the middle of the plaster
strap across  it, and then run the ends up  along the sides of the stump ; this brings
the cut surfaces into better contact, and  gives all  the support necessary without
giving'the patient pain.   The first strap should be put on the middle  of the stump,
and one or two above and below it, a quarter of an inch apart, that whatever fluid
oozes out may readily escape, for otherwise, in nine cases  out of ten, most  cer-
tainly quick union of the cut surfaces will be interfered with, if not prevented, and
the wound will have to  unite by granulation, and not be cured within eight or ten
weeks, instead of three or four as  commonly, and sometimes in a fortnight as I have
not unfrequently seen.   As to the protrusion of the swollen edges of the wound,
when this happens it is  easily controlled either by merely snipping the tight strap a
little, near the wound,'or by cutting it across just at the edge of the circular bandage,
the plaster with which it is spread being  softened by the warmth of the stump  rea-
dily, in the  course of a few minutes allows the strap to move down and the swell-
ing disappears.
  As  to the  plaster  for dressing stumps, provided it be not stimulating, it is not of
much consequence  whichever is chosen.  That commonly used in  our Hospital
practice  is soap plaster with a little resin, to make it more sticky ; but I prefer the
soap plaster  alone.   Tyrrell thought equal parts  of soap plaster and compound
frankincense plaster made the best dressing.   Liston prefers a solution of isinglass
in spirits of  wine, spread on oiled silk;  and Torboch of Sunderland, recommends
caoutchouc web,  straps of which are said to be capable, from their elasticity, of
yielding to the swelling around  the wound.   The fact is however, that it  is matter
of little consequence what is used, if it do not irritate, and the surgeon may follow
his own fancy.
  (3) Covering up a stump with  pledgets and compress and roller, after the plaster
strips are applied, is better left alone, as they heat the stump and encourage suppura-
tion.  The stump should be kept as cool as possible, and when the patient is in
bed, it is a  very good practice  to lay a  thin, cold, wet linen rag lightly over the
stump, and  repeatedly  renew it.  The  cradle  (4)  also, should be merely covered
with  a  sheet, though the patient's  trunk and other limbs should be sufficiently
covered to keep him warm, without making him hot.
  (4) Cradles are generally made of half circles of stiff iron wire, the  ends of which
are fixed firmly in two  pieces of wood, about eighteen inches  or two feet long,  as a
base,  above  which the  wires rise about twelve or eighteen inches, and support the
bed-clothes away from the limb.  As the comfort to the patient from the use of this
apparatus is great,  and it  cannot always be obtained in country  practice, directly
when wanted, it is  well to know how to make a substitute or makeshift.   A com-
mon-sized, flat wash-tub hoop, sawn  across,  and  each half sawn down the middle, 
AFTER AMPUTATION.
647
furnishes the arches, two, three, or more, as may be needed, and these, having their
ends nailed to a lathe on each side, make a very good cradle.—j. f. s.]
  2697. The dressing after flap-amputation is  to be put on in the  same
way,  excepting that if but one flap be made, it must be laid over the
surface of the wound, and its edge fitted closely to the corresponding
edge  of the  skin  with  sticking plaster and  compresses, applied in the
direction of the flap, and kept in place by a bandage, of which  several
turns should  pass  over the front of the flap.   If the amputation be with
two flaps, both their surfaces  must be brought together, and their edges
made to fit completely, and so kept with the dressings already directed.
Union of an amputation wound  with sutures I  consider injurious.
  [I do not think it of much consequence whether sutures be used or not, in bringing
the  edges of the wound together; sometimes  I use them, sometimes not, as I feel
disposed at the time ; but I have never seen any inconvenience arise from their em-
ployment, and therefore the surgeon, I think, may use his own discretion, in regard
to them.—j. f. s.]
  2698. If the amputation wound be to be cured by suppuration and
granulation, then, after having put on  the  expulsive bandage, a pledget
spread  with mild ointment must be inserted between the edges, straps of
plaster  laid transversely across, to bring its edges together, and  after-
wards a compress and bandage, as already mentioned.
  [I can scarcely imagine a case  in which  this treatment of a stump can be called
for.   Occasionally, indeed, it happens that the surface of a stump will become
sloughy, and then must unite by granulation; but to  make a positive determination
to promote union by granulation from the first, can hardly be  warranted under any
circumstances.—j. f. s.~]
   2699. The further treatment  of the patient and of the wound must be
conducted according to the rules laid  down for wounds in general.
   The  accidents  which may  ensue after amputation are, after-bleeding,
violent inflammation, erythism,  torpor, gangrene, very copious secretion
and bagging of matter, nervous symptoms, protrusion of the bone, sup-
puration, and exfoliation of its edge, and ulceration of the soft parts.
   2700. The patient should observe the strictest bodily and mental  quiet.
On the first  day he  should take merely a little broth  and almond milk.
An  assistant conversant with the use of the  tourniquet should  be near
him; and  dressings and every  necessary for tying vessels should  be  in
the bed-chamber.
   If  nothing untoward occur, if the general reaction  keep up, and if in
the stump inflammation ensue within the bounds necessary for the  union
of the  wound, the dressing may be left  till fouled by  the discharge from
the wound, or its renewal on account of  ill smell be required.   If the
discharge be very slight, it often dries up quickly, and the dressings may
be left  off in the  third week, when, after  removing the first dressing, I
have  found the wound  completely healed.
  In  taking off the  dressings, all its clinging portions  should be well
softened with lukewarm water, and in doing this, as well as in re-apply-
ing the  dressing, dragging the ligature-threads should be carefully avoided.
Every day, or every other day, or still less frequently, according to the
quantity of discharge, should the dressing in this way be replaced.   If
any parts remain ununited, the clotted blood or the pus must be emptied
by gentle pressure.  On the seventh or eighth day, it may be attempted to 
648
TREATMENT OF
 remove the ligatures on the small vessels with a gentle pull, and those
 of the larger ones  towards the twelfth and sixteenth.   They, however,
 often remain for a longer time, being held fast by the granulations; the
 ligature must then be twisted between the fingers, and pulled at the same
 time (1).  I have never seen inconvenience from the ligatures being long
 retained.   The  same  plan  is  to  be continued till the  scarring of the
 wound be  completed; and for  some  weeks after,  the  stump must be
 covered up, and the scar protected from the dragging  of the muscles
 with a bandage.  An  artificial leg can only be fitted when the scar has
 become quite tough and the edge of the bone is rounded.
   The general  treatment must depend  on the different periods of the
 cure, and  according to  the condition of the  general  health.  Proper
 regulation of the diet, if no particular symptoms occur, renders the use of
 medicine in most cases superfluous.
   Benedict's (a)  mode of treatment in which the  stump is wetted with spirits of
 wine and bark, and valerian and volatile stimulants given internally at the same time,
 immediately after the operation, is generally objectionable.
   [(1)  I am not disposed, even when a ligature is retained three or four weeks, to
 do more than make a gentle pull upon it;  for I have known awkward consequences
 from greater energy.   If the ligature, therefore, cannot be got away easily, it is better
 to fasten its end to a thin piece of whalebone, fixed with sticking  plaster on the side
 and  bent over the face of the stump, so as  to form a spring; the gentle and  constant
 pull which  this makes, generally brings the ligature away in two or three days.—
 J. F. S.]
   27Q1. Should after-bleeding  occur, it must be  managed as already
 directed in the treatment  of wounds in general {par. 302.)  If it be not
 considerable, but from small vessels immediately  after the amputation,
 the  tourniquet must be screwed tight, and cold water poured over  the
 stump for some time.  But if the bleeding be greater, if it come from the
 branches of an artery, or from the trunk itself, then after the tourniquet
 has been properly tightened, the dressing must  be removed, the wound
 cleared of the clotted blood,  and the bleeding vessel tied.   If this  cannot
 be done, a sponge dipped in ice-cold water must be applied immediately
 upon the wound, and pressure also made upon  it.    Plugs strewed with
 styptic  powders, and bound on with a compressive bandage, may also
 be here useful (1).   If the after-bleeding come on with smart fever, with
 violent beating of the arteries, and great heat in the stump, it  may often
 be stayed by a free  bloodletting, and by continued  cold  applications to
 the stump.
   If the bleeding happen later,  and cannot be stanched by either of  the
 above-mentioned means,  which is usually the case, because the edges of
 the wound are for the most part  united, or the walls of the arteries, on ac-
 count of their inflammatory condition, baffle the operation of any ligature,
the trunk of the vessel must be cut down upon and tied at some distance
 from the seat  of amputation (2).   This practice  is simple  and safe,
 as the experience  of Dupuytren, Delpech,  Zang, and myself have
 proved.
   The so-called parenchymatous bleeding, where the blood trickles from
the whole surface of the wound  as from a sponge, depends either on irri-
 tation of the wound being kept  up by improper or  too tight dressing, or

         (a) Dresdner Zeitschrift fur Natur und Heilkunde, vol. iv. part iii. 
AFTER-BLEEDING.
649
on the loss of tone of the capillary vessels, or on copious suppuration, in
weakly cachectic persons.  In the first case, the dressing must be properly
adjusted, and every thing which can irritate the wound removed ; in the
second, those  means must be employed which will raise the tone of the
capillary system, as the mineral acids and quinine; cold applications and
other styptics must be made to the stump with moderate pressure; and even
the actual cautery (3) or tying the trunk of the artery above the bleeding
part, resorted to (a).
   When in ossification or cartilaginous thickening of the arteries, their tying with a
broad tape does not secure against after bleeding, nothing remains, if this happen,
but smart application of the actual cautery, or tying the principal  trunk above the
amputation (b).
   [(1)  I do not think the application of a tourniquet to arrest bleeding is advanta-
geous, as the blood will find its way into the veins and they will bleed.  But I think it
best, if the bleeding occur within a few hours after the operation, to open the stump
completely, and clear away every particle of clotted blood, and  especially, to get it
out of all the chinks between the muscles.   If this be done, and the stump exposed
to the air for an hour or two, it frequently ceases to bleeds  If any vessels be found
bleeding, they must be at once taken up.   I do not like plugs, either simply such,
or with the addition of styptics, as they always  irritate, and usually are inefficient.
   (2)  It is only in very rare cases that the principal artery should be  tied at a distance
from the stump, and in general I do not believe  it called for.  It does not often hap-
pen that the bleeding is at first so alarming as to warrant even disturbing the stump;
for I have several times seen bleeding occur two or three times during the course of
cure, and yet, merely by keeping the patient as low as his  condition will permit,
and the stump cool, no further mischief ensues.  But when the  bleeding recurs
again and again, and increases in  quantity, there  is always reason to suspect that
there is a cavity within the walls of the stump, into which the bleeding vessel opens,
and that the irritation of the clot therein keeps up the bleeding.  If this seem pro-
bable, the finger, must be gently insinuated between the edges of the wound, till the
whole cavity be  laid open, and then the entire clot must be cleared away, and if
possible, the vessel which hasbled must be found. If it do not then bleed, it had better
be left exposed to the air, and often this simple  proceeding puts an end to the busi-
ness.  But should it bleed again, I think, from my own  experience, and from the
practice of others which I have observed, that it  is better to follow a bleeding vessel
up the wound, and more especially, if it be near the edge, as then, a probe having
been passed into it, the skin may be cut through, and the vessel easily and properly
secured.  This seems preferable to tying  the main trunk, by which the supply of
blood necessary for the union of the wound is, in general, either completely cut off,
or withheld for some days, and°a sloughing condition is the result.  And sometimes
even the collateral circulation is so free that tying the principal artery will not stop
the  bleeding.
   (3)  The use of the actual cautery in after-bleeding especially, if it come on some
days subsequent to the operation is excellent practice.  Some examples of it I have
already mentioned {par. 302, note.)—j. f. s.]
   2702.  If violent inflammation of the stump occur, it  must be reduced
to proper  bounds, by less  tight application of the dressing, by continual
cold applications, and by keeping the patient cool.   If the inflammation
be so great, that it is accompanied with much fever, it will require, ac-
cording to the  patient's constitution, a strictly antiphlogistic treatment.
   If there be  an  erythetic condition, as frequently happens with  very
sensitive persons, in which the stump is very tender, painfully tense, and
burning, the heat much raised, the redness of the edges of the skin  and
wound very slight, the patient exceedingly restless^ the pulse contracted

  (a) Chelius, Ueber Nachblutung nacli Amputationen ; in Heidelb. klinisch. Annalen,
vol. iii. part iii. p. 337.
  (&) Chelius, Bericht ueber die Errichtung der chirurgischen Klinik. p. 16..
                                  55* 
650         TREATMENT OF PARTICULAR CONDITIONS
       and quick, and the countenance anxious, ice-cold water must be applied
       to the stump, till the heat be diminished, and internally aqua lauro-cerasi,
       opium with  nitre, almond  milk,  oily mixtures  and purgative clysters,
       must be given, and the patient should take light nourishing food.  If the
       inflammation be accompanied with erythism, leeches and emulsions with
       camphor and nitre rhust be employed.
        The cause of death after amputation, is not unfrequently inflammation of the ves-
       sels;  in some cases the veins, in others the arteries are inflamed, often even to the
\       heart, and sometimes filled with pus.  In such instances, the stump is excessively
       tender, accompanied with severe shiverings, and  very  depressing sweats. Local
       bloodletting and cold applications, with calomel internally, must be here used.
         2703. An. insufficient degree of inflammation,  or a torpid state, in which
       the stump is little or not at all painful, the warmth little, even less than
       natural, the  wound flabby and pallid, with a frequent secretion of serous
       or clammy ichor,  the patient very much  depressed, and the  pulse very
       small, weak, and  quick, requires both a general and local strengthening
       and  exciting mode oftreatment.  The stump must be  bathed with spi-
       rituous aromatic remedies, covered with aromatic poultices, mixed with
       camphor, the dressing moistened with spirit of camphor, or of turpentine,
       the edges of the  wound  washed  with them,  and some even injected
       into it.
         2704. Sloughing  requires various treatment according to its cause.
       {par. 71.)
         2705. In  copious  suppuration, strengthening remedies must  be used
       both  internally and externally.   If collections of pus" form, its free escape
       should to the  utmost  be provided for.   With this  view a part of the
       wound not being drawn together with sticking plaster, the pus should  be
       emptied  by  moderate pressure and injections, and a proper bandage ap-
       plied.  It is rarely necessary to make use of the  knife.
         2706. Protrusion  of the bone  is  either the result of an improperly per-
       formed operation, in which too  little soft  parts are preserved, and these
       with  difficulty drawn over the bone;  or copious suppuration and a torpid
       state  come on, in which the muscles and cellular  tissues visibly, waste
       and retract*   In the  former case, if the muscular surface itself do not pro-
      ject in a rounded form, nothing can be done but waiting for the exfolia-
       tion  of the bone, to promote which, the marrow must be destroyed, and
       a bougie dipped in spirits of wine, thrust into its cavity, or the projecting
       bone must  be sawn off.   But  if the muscular  mass do protrude, the
       superficial muscles must be pressed back, a portion of those attached to
       the bone removed, and the bone itself sawn  off at the necessary height.
       In the latter case, f have  almost invariably observed a fatal result from
       wasting  suppuration.  Proper general and local treatment of this torpid
       state, and when it is removed, and the soft parts  have not applied them-
       selves over  the bone, which, however, I have frequently noticed, then
       the above-mentioned destruction of the marrow in the projecting piece of
       bone, for the purpose of encouraging its exfoliation, or sawing off the
       bone, is  the only thing which can  be done.   Pushing forwards the mus-
       cles  and skin, by bandaging, will not in this case prevent the  protrusion
       of the bone;  on the contrary, every bandage which makes much pressure,
       and draws the parts  together, renders this state  worse, as it increases the
       consuming suppuration and the  wasting absorption. 
AFTER AMPUTATION.                     651
   [Protrusion of the bone is one of the most tiresome and vexatious consequences
of amputation, as, although it more frequently arises from the circumstances men-
tioned by Chelius,  yet it occasionally happens, when, although at the  time of the
operation an ample covering of soft parts had been preserved, after-bleeding comes
on some days afterwards, and the wound requiring to be opened completely once or
twice, or even more, the soft parts retract, cannot be restored  to their first situation,
and the bone protrudes.  Or sometimes, though there be plenty of soft parts, the
dressings may have been too tightly applied, and the soft parts being pressed by it
over the bone, slough, even although the  mischief be quickly discovered and  the
pressure removed.   Exfoliation, however,  is not always the necessary consequence,
for I have seen instances in  which  a bone  protruding half an inch has  not lost its
vitality, but itself granulates, and  is also  covered by the granulations  of the soft
parts, and the stump, by careful dressing,  heals as well as can  be desired, though
slowly, and becomes well shaped.  When exfoliation does take  place, it is often
confined to a  small portion of, or a mere ring of the end of the bone, and then scar-
ring soon follows.  But occasionally, though  rarely, the bone dies, to some dis-
tance, from the face  of the stump, and a long portion is thrown off.  I hardly, how-
ever, recollect an instance in which any material inconvenience  even, excepting re-
tarding the cure, much  less  serious symptoms, have  arisen  in consequence.   The
wound generally heals, except  a small ring of granulations around the bone, and
there is little trouble with it.
   For these reasons, I cannot agree with the violent proceeding of exciting exfolia-
tion by destroying the cancellous structure, nor even  with the less severe operation
of sawing off the end of the protruded bone, as  it is impossible  to know to what
distance the mischief has extended. The case simply requires to be treated as if no
bone protruded, by bringing the soft parts forward with  gentle  rolling; and when
the bone is certainly dead and protruded, then to make occasional and gentle attempts
to remove it by pulling it with  dressing or other forceps.—i. f. s.]
   2707.  In necrosis  of the  bone, either only a  thin piece  of the surface,
or a complete ring of it may be dead; in the former  case, the  necrosed
piece is usually removed  by absorption ; in  the latter, it exfoliates, up
to which  time the opening  leading to the bone, must be kept duly open,
mild injections made, and when the  separation is  completed,  it may be
pulled out.
   [Sometimes very  enormous pieces of protruding bone exfoliate, being thrown off
from a considerable distance  beyond the face of the stump.   There is in St. Thomas's
Museum a piece nine inches long, which came away from the stump of a  thigh-bone.
I recollect seeing this removed, by merely drawing it away, after several months,
with dressing-forceps.  The patient had not been further inconvenienced by it, than
by his cure being retarded.  Such  cases are best left to nature;  at least some  half
dozen cases I have seen, were left alone, gave  the patient no pain, did  not irritate
his constitution, and came away in due time.  The practice of causing  exfoliation,
by destroying the medulla, as recommended in the preceding paragraph, cannot be
for a moment entertained.—j. f. s.]
   2708.  Ulceration  of the  bone or of the soft parts is almost  invariably
the consequence of some dyscrasic disease, which must be met  by proper
treatment.   Continued superficial ulceration of the soft parts is frequently
the consequence of improper dressing, or of its too early removal.   A
fungous growth from the  medullary hole may, according to my experience,
in most cases be  got rid of by proper compression, and  by touching it
with  lunar caustic ; but when any dyscrasy is in causal relation  to it, cor-
responding  treatment must  be  employed.
   [According to my experience, a fungous, growth from the medullary cavity is of
no consequence; and generally, the granulations inosculate with  those  of the soft
parts, and there the matter ends, sooner or later, without further notice.—j. f. s.]
   2709.  As regards  the  preference of the several modes  of proceeding in
amputation of the limbs in their continuity, I must, according to my own 
652           COMPARISON OF THE  SEVERAL MODES.
 experience, prefer amputation by the circular cut, and that method indeed,
 in which the skin is divided and drawn  back, and at  its edge  the cut
 carried vertically through the  muscles  down to the bone, and then the
 muscles still remaining attached  to the bone cut through still higher, and
 thus  a conical  surface of  wound  formed.   The  superior  advantages
 ascribed  to the flap-operation, to  wit, a  better covering of the stump
 with  muscle, more speedy union, and therewith a shortening of the cure,
 over  the circular operation just recommended, are  groundless.  In refe-
 rence to  the  first  point, Brunninghausen (a) makes  a remark which I
 have also observed, that  the covering  of the stump with  muscle may
 indeed be effected at the  moment of union and for some time, but that
 after  a longer period the bone is merely covered with skin (1).   On the
 other hand, after amputating the thigh  with  merely saving  skin,  I have
 never seen  protrusion of the bone.   But it must be held: as  an objection
 to flap-operations, that tying the  vessels wrhich are obliquely cut through,
 and often wounded in  several  places, is more difficult, and the number
 of vessels to be tied is always greater than with the circular cut, that the
 wound is larger, and therefore, if union do not take place, wasting sup-
 puration is  to be earlier feared.  In other respeets, I do not  consider the
 dispute as to  the preference of the circular  or the flap-operation of so
 much consequence as  many do,  as  I  am  convinced that  the  successful
 result depends not merely on the mode of operation, but on the manner
 of its performance, and specially, on the proper conduct of the after-
 treatment.  The  flap-operation,  however, must always be  considered
 more suitable when the amputation is-performed at the upper third of the
 thigh ; when the limb cannot be brought  into a proper posture for per-
 forming the circular cut, and when the destruction of the soft parts is such,
 that by the  flap considerable saving may be effected.   I also admit, that
 in flap-operations, the knife  suffers less than in circular operations, a cir-
 cumstance  of  importance in Military Surgery, and that,  with artificial
joints, or fractures of bone requiring amputation, there  may be advantage
 in the flap-operation (b).
  (1)  This observation, as regards both flap and circular amputations, will be found
 confirmed by every one who examines a  stump a sufficient length of time after its
 complete healing.  Although Langenbeck (c) believes the contrary, and that it does
 not happen in his mode of operating, " in which the  stump becomes corpulent, and
 the bone being completely rounded by absorption, cannot press against the muscles;"
 I must, however, dispute that this thickening of the stump does occur  after every
 well performed amputation, but  depends  only on the skin and underlying cellular
 tissue, and it is a great mistake  to refer it to the muscular mass.  Langenbeck may
 probably bear this in mind in his further observations, especially if he have the op-
 portunity of dissecting a body which has died  long after amputation; and I am con-
 vinced he will find  it necessary to retract this statement.  That the cure of the wound
 by agglutination or by suppuration makes a difference, as Blasius supposes, and
 can only be observed after the cure by quick union of the muscular bolster, I cannot,
 from my own experience, assent to.

  (a) Above ciied, p. 58.                  above cited, in von Graefe und von Wal-
  (6) Chelius, Bemerkungen iiber die Am-  theu's Journal, vol. vii. p. 173.—Langstaff,
 putationen ; in Heidelb. klin. Annal., vol. i. p.  Practical Observations  on the healthy and
 190.—Beck, Ueber der Vorzuge der Lappen-  morbid changes of Stumps; in Med.-Chir.
 bildung bei der Amputationendiecontinuitat  Trans., vol. xvi. p. 128. 1830.
 der Gliedmassen und die  ihr zukommenden    (c) Nosologie und Therapie der chirurgi-
 Operations, etc..  Freiburg,  1819,-^-Klein,  schen Krankheiten, vol. iv. p. 313. 
OF AMPUTATION OF  THE LIMBS.               653
   Textor (a) has only under certain conditions given preference to the old mode of
 treatment with the circular, or does he usually prefer the latter 1
    [Liston is so great an advocate for flap-operations, to the  entire exclusion of the
 circular, that in his Elements of Surgery, he does not even describe the latter opera-
 tion, giving as reasons for its omission,  that " its inferiority to the method by flaps,
 is so obvious,  and so generally acknowledged, that  detail of the different steps  of
 the operation is altogether unnecessary.  It  is more tedious in  performance, more
 painful to the patient, does not afford so good a covering for the end of the bone, and
 consequently,  not so convenient and useful a support for an  artificial limb, and the
 cure of the wound is protracted.  The stump is  almost  always conical,  the end  of
 the bone, is ultimately at least, covered only by integument,  and  from  even very
 slight pressure, this  is apt to ulcerate; exfoliation of the bone  follows to a  greater
 or less extent,  or  unhealthy ulcer of the soft parts continues along with caries of the
 bones, and partial death of its surface ; and at length it becomes necessary either  to
 perform a second  amputation, or to curtail the length of the bone.   It may some-
 times succeed  tolerably well  when there is but one bone: when there are two, it is
 altogether inadmissible.   In very muscular limbs, when amputation is demanded on
 account of destruction of the bones and joints, with  laceration of the soft parts, as
 when the  patient  is not required  to have pressure made on the stump, it suits well
 to make the flaps  of integument only, and to  cut the  muscles short.  The advocates
 for the circular amputation wish it to be believed, (and this is their main argument,)
 that the exposed surface of the flaps is much  greater than that  in  their favourite
 method, * * * and  have measured, it is said, the area of the one and the other, and
 given their verdict in favour of the roundabout incision.   The  accompanying draw-
 ings (pp. 770,71) from nature, and the corresponding diagrams, speak pretty plainly
 in favour of the other (the flap) method.   In the first there is a cone formed by the
 cut skin and muscles, with  a corresponping  hollow and  ragged cavity; and the
 second set shows  two smooth nearly triangular surfaces." (pp.  769, 70.)
   As regards these serious objections to  circular operations, I must observe, that in
 the large hospital with which I am connected,  for many years,  I  scarcely ever wit-
 nessed the performance of any other than circular amputations, except on the fore-
 arm, and that the  ugly consequences which Liston has detailed, were of great rarity,
 and not, I believe, attributable to the mode of operation.  Of  late years, however,
 more flap-operations have been performed among us  than previously and probably,
 their relative number is now about the same.   I have performed about  an equal
 number of each, and the result has been  so nearly the same, that in most cases, I
 hardly think one is to be preferred to the other.   The flap-operations are more smart
 and showy in their performance, but in their result maybe as  untoward and unsatis-
 factory as circular operations  have been stated to be.   The true  eause of the well or
 ill doing of the case is to be  found in the proper or improper dressing of the stomp,
 not  merely immediately after the  operation, but up to the complete  union of the
 wound.  A stump may be plentifully and superfluously covered with soft parts at
 the first dressing,  yet if not properly managed, or if under peculiar circumstances,
 the patient have been very restless, and continually moving the limb, the soft parts
 get displaced, unite awry, and the bone protrudes  more or less, or  presses  so against
 the soft parts as to cause them to slough.  I have seen this occur in flap as well
 as in circular amputations, and I am convinced  that in most cases the fault is in the
 dressing, and not  in the operation, whichever it may be.
   I believe, with  Fergusson (b), that " if rapidity is to^be taken as the test of supe-
 riority, the flap-operation must be allowed the preference; but in the hands of a good
 surgeon, the difference of time required for  the efficient performance of either, seems
 of so little consequence, that  such a calculation should not be  taken into account.
 *  * *  I cannot but think, that the same hand  which rapidly and safely completes
 the flap incision, would with  almost equal facility, if equally well trained, accom-
 plish the circular." (pp.  151,  52.)  And  I also agree with him, that "the  compara-
 tive extent of cut  surfaces in the respective operations seems of  trifling import;  a
 few inches more or less, provided always that a good stump  is left,  will never de-
 termine the issue of an operation." (p.  152.)
   Fergusson also  remarks, in reference to amputation through the calf of the leg
and at the  shoulder-joint, that " in either of these cases, and  whether the operation
(a) Neue Chiron, vol. i. p. 483.
(b) Above cited. 
654   COMPARISON OF THE  VARIOUS MODES OF AMPUTATION.

has been by flap or by circular wound, the stumps are at last so much alike in certain
parts of the  body, that it-is  occasionally difficult, after the lapse of years, to say
whether an amputation has been by one mode or the other; at all events when such
distinction can be drawn from the shape of the cicatrices, it is evident that  the end
of the bone is covered by  much the same thickness of soft parts in one instance as
in the other.   If there has been a full  fleshy stump shortly after the operation, all
muscular fibre has at last  disappeared, and  the skin with a substance resembling
condensed cellular texture, alone covers the bone." (pp. 153, 54.)  The correctness
of these observations must be fully admitted, as must also that " this substance, un-
doubtedly, gives great protection to  the  end of the bone, and its presence is absolutely
necessary," (p. 154,) not, however, as "a useful support for an artificial limb," as
Liston states, for in no case, if an artificial limb be properly adjusted, does it bear
on the end of the stump;  but if it be made to do so, it may be pretty certainly ex-
pected that the part exposed to pressure will ulcerate, and this perhaps be followed
by exfoliation of bone.
  So far as my own experience proves, flap-operations in the continuity of the bone
may be performed as successfully as circular operations on every limb  but the leg,
in which the calf muscles  are so bulky, that it is often difficult to get the skin well
over them, if they be left, and I do not think the cure is so quick as with the  cir-
cular.  But if a  skin flap be made and the muscles cut through directly, I do not
think  more time is gained than by the circular operation.  There is, however, a more
serious objection to flap-amputation through the calf, in the  greater frequency of
after-bleeding; this has occurred to me two or three times, and the number of vessels
I have had to take up and the sloughy condition of the whole one, and its  tedious
union by granulation have almost induced me to determine never to operate on the
leg but with the circular.
  On any other part, 1 believe it is of little consequence which of the two operations
is performed.  Some surgeons have been accustomed to practise one and some the
other  mode, and  thus having acquired  experience,  perferred their  own method.  I
have employed both, and shall probably continue  to do so, believing, with  the ex-
ception I have made, that either will answer equally well, provided due attention
be paid to the dressing throughout the whole course of the cure, without which all
the objections that have been made to either will most certainly be verified.—j. f. s.]
  2710.  Opinions are  divided as to the preference of uniting  the  ampu-
tation wound by quick union, and its cure by suppuration and granulation;
the former  method has, however,  the  most supporters, and is, generally,
the most proper.  As for the  rest, many practitioners  have  exaggerated
the evils  accompanying the cure by suppuration and granulation.   When
in this  treatment the rules already laid down be  observed, the wound
not stuffed with lint, and its union not prevented  at bottom, but merely
at the edges of the skin, according to my experience, the cure proceeds
as quickly  as with quick union, for the wound  after amputation of large
limbs never takes place by complete agglutination, in  the strict sense of
the word.   The cure  of the wound by suppuration and  granulation is
specially proper for those cases where the patient has  long been  subject
to ulcers and considerable suppuration, where the  quick  suppression of
the discharge has ill consequences, and translations to the cavities of the
body may take place, where issues and  other  drains are not always  able to
prevent these evil results (a).   Klein, Textor, and others, have  denied
these statements.
  This is also Dupuvtren's (6) opinion.  He considers that dressing of the ampu-
tation wound, by which it is at every  point closely united, as injurious, as  a com-
plete  glutination does not follow, and by the collection of the discharge in the bottom
of the wound, injurious consequences  ensue.  He collects all the ligatures into a
bundle, which he carries out at one corner of the wound, and if this bundle be not

  (a) Rust, Ueber die Amputation grosseren Gliedmassen; in his Magazin, vol. vi. p. 337.
  (b)  Above cited, p. 417. 
RESULTS OF AMPUTATION.
655
sufficiently thick, he increases its size in rare cases, by adding charpie to it.  The
results of this practice are more favourable than  those in which the edges of the
wound are completely brought together.  Only in amputations required for injuries,
and which are at once performed, does he close  the wound; in all cases where long
continued disease with irritation and suppuration have rendered amputation necessary,
the above treatment should be had recourse to, as with complete bringing together,
inflammation of internal parts, especially of the belly, may occur.
   [Among English Surgeons there is  no  difference of opinion, as to the mode in
which union of  an amputation wound is to be attempted.  In all cases it is  en-
deavoured and hoped to produce  quick union, whether  by sticking plaster or by
sutures and  linen dipped in cold water.  The object is to  promote adhesive not sup-
purative inflammation, as the patient's constitution suffers less from the former than
the latter, and the cure is infinitely quicker.  The fear of metastasis in consequence of
the sudden checking of a drain upon the constitution, by the removal of a limb having
a large  ulcer upon it, or in a case  of  compound  fracture  or  other injury where the
discharge is profuse, is amongst English  surgeons  little thought of, as their  ex-
perience proves  it to be, except in very rare cases, without foundation.  And  the
usual rallying of the patient's  powers after the  amputation of such limb, which at
once puts a  stop to the drain on the constitution, and  relieves  the irritation of  the
nervous system affords no inducement to follow Dupuytren's practice of establishing
another after getting rid of one suppurating wound.  Experience as to success is  the
only way by which the  correctness of practice can be proved, and  the results of
English practice in regard to amputation will prove its superiority, if fully carried
out, and the necessary and only necessary, dressings  for  keeping the edges of  the
wound  together, be employed, without swathing in rollers and cross bandages, and
even  in wollen  nightcaps, which in  my earlier days  I  have seen, employed,  the
only effect of which  is  that they encourage the  suppurative and discourage the  ad-
hesive process.—j. f. s.]
                    OF  RESULTS  OF  AMPUTATION.

  This is a subject of the highest consideration to the surgeon as regards his deci-
sion on the performance of this operation, and his expectation of the success result-
ing  therefrom.  Benjamin Phillips (a) has given a highly interesting paper on
this  very serious topic, and the result of his inquiry isj that  the mortality after am-
putation in France, Germany, America, and England together, is 23T7ff per cent.
  Dr.  Lawrie (b) has also  occupied himself with the same important matter, and
draws his conclusions from  a series of 276 cases of amputations of all kinds, per-
formed in the Glasgow Infirmary;  from  which it appears there were  176 reco-
veries, and 100 deaths, or a proportion  of deaths to recoveries as 1 to 1*76.
  Potter  (c) about the same  time gave to the  Medico-Chirurgical Society an ac-
count  of the  amputations performed in University  College Hospital, from  June
1835 to January. 1841, amounting to  66, with their results, among which there were
only 10 deaths, and three  of these were among 10 cases of primary amputation for
accident.
  I  now give a brief account of 54 amputations which I performed between the
years 1835 and 1840  inclusive, at  St. Thomas's  Hospital; some particulars, of
which  I  shall give more  at  length, after  the  description of the several amputa-
tions :—
  («) Observations arising out of the Results don   Medical  Gazette, vol. xxvii.  p.  394.
of Amputations in  different Countries; in  1841.
London Medical Gazette, vol. xxii. p.  457.   (c) Results of Amputations at University
1838.                                  College Hospital,  London, statistically ar-
  (fc) On the Results of Amputation; in Lon- ranged; in  Medico-Chirurgical  Transac-
                                       tions, vol. xxiv. p. 155.  1841. 
656
AMPUTATION THROUGH THE THIGH.
—		Lived.	Died.	Total.
Through the Thigh . . . For Accidents, Primary .... ------------, Secondary . . . Scrofulous Diseases of Knee . .	28 14 6 5 1	1 13 4 6 5 5 1 1 4 1	5 1 4 *3	5 2 17 4
Through ihe Leg . . . For Accidents, Primary ....				*9 5 . ____« 1,1
Through Upper-Arm . . For Accidents, Primary .... ------------ Secondary . . .				5 1
Through Fore-Arm . . For Accident, Primary .... Other Diseases .......				1 4 ■- 5
Through Shoulder-Joint . .				1 1
	54	41	13	.. 54
  The result of these cases  is pretty much  the same in general at St. Thomas's
Hospital, and putting these together with the cases at University College Hospital,
it must be evident, that the mortality is a long way below the 50 to'75 per cent.
which has been stated by some surgical writers, as the ordinary average  of fatal
amputations.  It will be observed also that the largest mortality is among the cases
operated on for accidents,  and on the lower  extremities.  In 7 amputations through
the thigh, I lost 6 ; and of 9 through the leg, 3 died.  Whilst of 6 primary and 1
secondary amputations in the upper extremity, not a single case was lost.  This
excess of mortality in operating after accidents, is to be ascribed, when the patients
die early, to the conjoined shock of the accident and operation.   Besides which the
persons admitted into hospitals for such  injuries  are  commonly free livers with
broken down constitutions, the like of whom are not unfrequently destroyed by the
results of trivial accidents, which run either into erysipelas, or diffuse cellular in-
flammation and gangrene.—j. f. s.]
   [On the Results of Amputation, see the papers of
  Norris, in the American Journ. of  the Med.  Sciences, vols. 22  and
26.   1838-40.
  Hayward, in the same Journal, vol. 26.  1840.
  Eve, in the Southern Medical and Surgical Journal,  vol. 2.  1846.
  Betton, in the Philadelphia Medical Examiner.  Feb., 1846.—g. w. n.]
Third Section.—OF  AMPUTATION IN CONTINUITY OF THE
                      SEVERAL LIMBS.
           I.—OF AMPUTATION THROUGH  THE THIGH.
  (Amputatio Femoris, Lat.; Amputation oder Ablosung der Obersehenkels, Germ.;
                       Amputation de la Cuisse, Fr.)

  2711. In  amputating  through the thigh, the circular, or flap cut may
be practised, the patient being so placed on a table covered with a mat-
tress, that the limbs  extend freely beyond  its edge, and the  trunk be in 
AMPUTATION THROUGH THE THIGH.            657
a posture between sitting and lying.  The sound limb should be sup-
ported on a  stool  and held by one  assistant.   Another holds  the dis-
eased limb at the knee-joint in such  a way that the leg be  bent  at  an
obtuse angle towards the  thigh,  which itself is a  little bent on the
groin  (1).  A third assistant compresses  with his fingers or with a com-
pressor, the  femoral artery on the horizontal  branch  of the pubes (2).
A fourth standing  on the outside  of the  thigh, encircles it with  both
hands, and draws  the skin  well up so that there shall-be no folds (3);
and a fifth gives the instruments to the operator (4).
  Compression of the artery by an assistant is preferable to the application of  the
tourniquet, which can generally be only employed  when the amputation is per-
formed at the lower third of the thigh ;  and the place at which it must then be  put
on is the upper third of the thigh.
  [(1)  Except when  the injury or disease is in the leg, this direction  cannot be  fol-
lowed  out: therefore, as, at least with us, the greater number of amputations through
the thigh are  performed for disease in  the knee-joint, and that part  is commonly
fixed, or its slightest movement so agonizing when there is ulceration of its  carti-
lages,  that any change of its usual posture is not warrantable, the surgeon must be
content with his assistant merely keeping the limb steady in any position it can be
conveniently held.  Occasionally, indeed, the  leg can only be held  on  a pillow,
and not till the soft parts have been cut through can the knee  be grasped to steady
the limb, whilst the bone is sawn.
  (2)  In pressing on the artery at the groin, a very common mistake is to press the
vessel  down into the thigh, by which it is thrust upon the muscles, and can only be
compressed by great exertion on the part of the assistant, and with much unneces-
sary pain to the patient. The pressure should always be a  little inclined upwards
towards the belly, and then the artery can be thrust against the bone and  with little
effort.   It is of great importance, that the assistant who is intrusted with this serious
charge, should be well up to his business ; he should be well  satisfied of the posi-
tion of the vessel, and  his capability of commanding it with ease and  certainty,
and not have to be fumbling about for it during the course of the operation.  Having
determined this, it is  not right  that the  patient should be subjected to the pressure
longer than absolutely needed ;  therefore having adjusted his  hands,  which is best
done by placing one thumb on  the vessel and the other above  it, and grasping  the
sides of the thigh with both hands, he waits till the operation  actually commences,
and directly the knife touches the skin firmly presses upon the vessel.
  (3) This assistant  is superfluous, as  the operator  can himself better retract the
skin to the extent he desires, by grasping the thigh with the whole of his left hand.
  (4)  These  preliminary directions may by some be considered  superfluous;  but
they are very far from so, as upon the thorough knowledge of the duty of each as-
sistant, and his strict attention  to that and none other, depends the easy course of
the operation.   Of this I apprehend no  one will  doubt, who has had  experience in
the instruction of students.—j. f. s.]
   2712.  In performing the  circular operation,  the  operator standing  on
the  outside of the  thigh proceeds  in the  following  manner.   Carrying
his right hand, in which he  holds  a straight  bistoury, under the thigh
over  to  its  outer  side, he  places its edge vertically about a  finger's
breadth above the knee-cap, but always according to the thickness of the
thigh, about  three or four  inches below the part where the bone is to be
sawn through, and carrying it in a circular line around the whole thigh,
at once divides  the skin and underlying cellular tissue  down to the fascia
lata.   The   assistant now  again  draws back the  skin  throughout  its
whole circumference, and the  operator makes at the  edge  thus drawn
back some slight cuts, by which the cellular tissue connecting  the skin
is divided, and the latter can be drawn back two fingers' breadth.
  If the skin be not divided at one continuous circular cut, the cut upon  the under
     Vol. hi.—56 
658        AMPUTATION BY THE  CIRCULAR OPERATION.
part of the thigh must be first made, and then from the inner end of this the second is
carried over the front of the thigh into the outer end of the first.  The mere drawing
back the skin just mentioned, is better than separating and making flaps of it.  If
the larger amputating knife be used for this purpose, the cut will be less regular.
   [Notwithstanding Chelius prefers the circular cut and simple retraction, I think
the skin fits better on the face of the stump, if, after that is done, it be divided about
an inch vertically on either side, so as to make a sort of flap.  The largeness of the
knife is not of much consequence; but the best for the performance of the operation
is a heavy-backed  knife, which cuts more certainly and correctly.  I do not see any
necessity for  changing the knife, as  Chelius  recommends; one knife ought to be
sufficient for the performance of the whole operation.—j. f. s.]
   2713.  The operator now, sinking on  his right  knee, carries the large
straight  amputating knife, which he grasps with his whole right hand,
the upper part of the handle  resting between the thumb and  forefinger,
and the  rest of it  enclosed by the  other fingers,  beneath the  thigh, over
to its outside,  places its edge vertically at  the edge of the retracted skin,
and puts the thumb and forefinger  of the left hand upon the fore part of
the back of the knife (1).   He then cuts through.first the muscles on the
outer side down to the  bone, whilst he bears  the knife towards himself
and downwards, carrying  it round in a circle with a firm stroke, and cuts
through  the muscles down to the bone.  At the moment when the knife
reaches  the back of the  thigh the  operator rises and finishes the  cut,
standing.   The  assistant  who had drawn back  the skin,  now grasps,
with both hands in the muscular cut, in  such way that the thumb above
and the  finger below cross, and  draw back the superficial muscles, after
which those still remaining attached to the bone are divided higher by
a circular cut.   A third cut is now made  in  like  manner, by which the
periosteum is also divided.   By  means of a cleft cloth, the uncleft part of
which is placed  on the hind part of the  thigh, and its ends   carried on
both sides of the bone to the front,  the assistant holds back the muscles,
and the  bone is sawn through where the  periosteum has been divided (2).
   Cutting through the muscles on the outside of the thigh, whilst the knife is drawn
towards the operator and downwards has the advantage that the whole edge is made
to act,  and that it is not necessary to carry the knife round upon the outside of the
thigh, to  throio it,  that is so to change the true position of the hand on the handle of
the knife, that the  thumb  is on the back, and the other fingers on the opposite side
of the  handle.
   [(1) I do not see any particular advantage in  placing the fingers of the left hand
upon the end of the knife blade; at all events in  this country, we are accustomed to
use the knife with the right hand only.
   I may  lake the opportunity  here of hinting to the young operator, that the knife is
not to be, as I have occasionally seen it, forcibly jammed through the muscles down
to the bone,  and the circular cut completed with the smallest  possible quantity of
the hind  part of its blade.  Knives are not chisels, as this practice would  seem to
imply, but they may be compared to very delicate saws ; and  as every one knows
a saw will only act well, when it moves  in a long stroke, just so is it with the knife,
of which the cutting part, whether a  small portion only, or successive  portions of it
be used,  must be constantly in motion,  continually drawn along the part it has to
cut, which it will  then cut readily, and not violently forced through, as  some opera-
tor's fancy it very clever to do.
   (2)  I prefer spreading  my left hand over the face of the stump and  thrusting the
soft parts back,  to an assistant's aid  with  a cleft cloth, whilst  sawing through the
bone.—j. f. s.]

   2714. After tying the vessels and clearing the wound from  blood, and
drying the surrounding parts, a roller must be applied from  the upper-
most part of the stump, in descending turns, nearly as low as the end of 
      AMPUTATION WITH TWO FLAPS, THROUGH THE THIGH.   659

the bone, for the purpose of drawing the skin  and muscles gently to-
gether.  The wound is now brought together in  a vertical direction with
strips of sticking plaster of sufficient length, placed across it; upon these
a pledget spread with some mild ointment is applied ; a wad of lint and
over it a cross bandage, two ends of which come up on the sides, and
the others before and behind  the thigh, and the ends  confined with a
circular bandage, a few turns of which are to be passed over the face of
the stump.
   [The roller first and the straps of sticking plaster after, with one strap passing
over the whole length of the wound, and a circular strap to confine the ends of the
straps, are all that are requisite.  No wad of lint, cross bandage, or  second roller
are required.—j. f. s.]
   2715. Amputation through the thigh with two flaps is thus performed.
The patient having been placed as for  the circular operation,  the precau-
tions  taken against bleeding, and the  assistants  stationed as before, the
operator standing on the outside of the limb, with the fingers and thumb
of his left hand grasps the flesh on the outside of the thigh and draws it
outwards.   With his right hand he now thrusts a  long narrow double-
edged knife through the front of the thigh vertically down to the bone,
and with  its point close to the outside of the bone, still thrusts towards
the back of the limb  till it penetrate  behind exactly opposite where  it
had entered in front.   The knife is now carried  further downwards, and
its edge being turned  a little  outwards, cuts through the muscles and  ,
skin obliquely.   The  point of  the knife is then  placed vertically on the
upper (front) angle of the  wound, carried down on the inside  of the bone
to the lower (hind)  angle  of the wound, and as it  descends  along the
bone  with the edge  turned from it, a second flap, like the outer one in
size and length, is formed.  The length of the flap should be,  according
to the thickness of the limb, that of three or four fingers' breadth.   Both
flaps are now drawn back with a cleft  cloth by an assistant, and the  ope-
rator, with  a circular  incision at the bottom of the wound,  divides the
muscular parts still remaining attached, and cuts through the periosteum   v
where the hone is  to  be sawn.   The  dressing is to be performed in the
same  manner as after  the circular operation.
  According to Langenbeck's method, the operator should place himself in ampu-
tating through the right thigh, on the outside, and when through the left on the in-
side of the limb, and first make on the side next him a semicircular  cut from the
fore to the hind surface of the thigh, through the skin and muscles obliquely down
to the  bone ;  he then carries the knife beneath  the limb to  the other side, places it
at the  upper angle of the wound, and draws it, in the same way as in the first cut,
to the lower angle of the wound, at which part he must take special care to cut
through all the muscles.   Both flaps are now to be turned back, and with a circular
cut the operator divides all the parts still connected with the bone, at  the bottom of
the wound.
  I have stated in reference to this mode of operating (a), that carrying two semicir-
cular cuts through a large quantity of muscles as in the thigh, and their exact con-
nexion at the angles, would be difficult, and the cuts likely to be unequal; and I
find this opinion rather confirmed than disproved by Langenbeck's own observa-
tion (b), that "one who speaks from experience, and draws the knife through, instead
offirmly pressing it on, the parts will not allow this;" and that he had "amputated
after comminuted fractures through thighs which were as fleshy as such limbs could

      (a) Heidelberger klinische Annalen, vol. i. part ii.
      (b) Nosologic und Therapie der chirurgischen Krankheiten, vol. iv. p. 312. 
 660 AMPUTATION THROUGH THE THIGH, WITH SINGLE FLAP.

 possibly be, and yet the knife, drawn lightly along, flew through down to the bone,
 and  that too at the inner part of the thigh."
   [Liston (a) makes his flaps before and behind instead of on the sides as directed
 by ChElius, and I think his the better mode, as the flaps are well kept together by
 the position of the stump.   According to Liston's directions, " the surgeon places
 himself on the tibial side of the right limb, on the fibular side of the left; lays hold of
 the soft parts on the anterior aspect of the bone, lifts them from it, enters the point
 of his knife behind the vena saphena, in operating on the right side, passes it hori-
 zontally through to the bone, carries it closely over its fore part, and brings out the
 point on the outward side of the limb as low;as possible; then by a gentle and quick
 motion of the blade, a round anterior flap is completed.  The  instrument is again
 entered on the inner side, a little below  the top of the first incision, passed behind
 the bone, brought out at the wound on the outside, and directed so as to make a pos-
 terior flap, a very little longer  than  the former.  The anterior flap is merely lifted
 up after it is formed, but now that both have been made, they are  drawn well and
 forcibly back, whilst the surgeon  sweeps the  knife round the bone, so as to divide
 smoothly the muscles by which it is immediately invested.   The bone grasped by
 the left hand, is sawn close  to the soft parts, the saw being directed perpendicularly."
 (p. 384-86.)  The same method is also preferred by Syme and Fergusson, the latter
 of whom justly urges (b) the necessity, before entering the knife in front, of well
 elevating the skin and  other textures, without doing which the front flap will not
 have sufficient  breadth, more specially if the  operation be performed towards  the
 lower part of the thigh.  The reason, however, why the hind flap should be longer
 than'the front one is  not, as Fergusson considers, because the posterior muscles have
 greater  tendency to retraction  than the anterior,  but because by  the position in
 which the limb  is placed after the amputation,  the hind muscles being extended are
 drawn back from the face of the stump, whilst those in front are relaxed and have
 therefore no disposition to pull away from the stump.—j. f. s.]
   2716.  In the  amputation through the thigh with a single flap,  which is
 by many preferred to the double flap, because thereby the wound is more
 completely covered, and the projection of the bone more  certainly pre-
 vented, the flap is made from  the  outer, (Benedict, Textor, Jaeger,)
 from the  inner side,  (Zang, Textor,) or from behind, (Hey,)  or before
 (Benjamin Bell, Le Utras, Foulliay.)   A double-edged  knife is thrust
 in one of these directions down to the bone,  passed close to it, and thrust
 out  on  the opposite side, and then  being carried down along the bone, a
 flap  of four or five fingers' breadth is formed.   Whilst the assistant holds
 back this  flap, and  draws  up the skin on the other  side, the  operator
 makes  a  semicircular cut an  inch  below the part where  the knife had
 been thrust in and out,  through  the skin, draws it up, and then at the
 base of the flap divides  the muscles with a  semicircular cut down to the
 bone, and through the muscles still remaining attached.
   I  have only employed this method in those cases where there  has been
 unequal destruction of the soft parts on the one or other side, so as to pre-
 serve a  larger portion of the  limb, especially in  the upper part of the
 thigh.
  [Amputation with a flap from behind has been performed by Dr. Little of Sligo
 County Hospital.  Fergusson  observes, that "after making such a  flap,  he should
 out away a considerable portion of  the great sciatic nerve, so that it might not by
any chance be brought to lie against the divided surface  of the femur." (p. 408.)]
  [Syme (c) has made the following observations in regard to amputation through
the shaft of the thigh-bone :—" The danger immediately attending its performance,"
says  he, "and the inconvenience of its imperfect result, in rendering the stump un-
comfortable, have suggested various contrivances and modifications of procedure,
  (a) Practical Surgery.                          (6) Above cited, pp. 406, 407.
  (c) Surgical Cases and Observations; in  London and Edinburgh Monthly  Journal of
Medical Science, vol. v.  1845. 
RESULTS OF AMPUTATION THROUGH THE THIGH.      661
with the effect, certainly, of restraining the hemorrhage, diminishing the patient's
suffering, and promoting union of the wound.  But the stern evidence of hospital
statistics still shows, that the  average  frequency of death is- not less than from 50
to 70 per cent., while it cannot be denied that many of the survivors suffer from un-
easiness connected with protrusion of the bone.  Having from an early period of my
practice devoted much attention  to the  subject of amputation—having  seen the cir-
cular incision give place to the flap-operation*—and having witnessed the results of
these methods, variously modified, in the hands of many surgeons possessing every
degree of operative skill, I am at  length led to the conclusion, that there is some-
thing radically wrong in the  principle of the operation.   This error I believe  to
be, dividing the thigh-bone through its shaft instead of the condyles or trochanters.
* *  *  The most frequent occasion for amputation of the thigh is afforded by dis-
eases of the knee-joint.   Next to this may be ranked compound fractures of the leg
and thigh, and  then tumours-of the leg  and thigh.   *  *  *  Dense bone dies  more
readily than that of a spongy or cancellated structure; and the action of a saw, to say
nothing of ruffling the periosteum, must always be apt to cause exfoliation, which,
by impeding union of the soft parts, delays  union, and opposes its perfect comple-
tion, by increasing the scope afforded to contraction of the muscles.   It would, how-
ever, be a narrow view to suppose that the direct effect of local injury is alone con-
cerned in causing death of the bone after amputation, and there can be no doubt that
inflammation of the medullary membrane may co-operate, if it does not act exclu-
sively, in its production.  * *  *  But if the medullary membrane be liable to inflam-
mation, suppuration of its texture, and inflammation of the veins cannotfail to be the fre-
quent consequence.  *  *  *  But when the bone is divided through the condyles,
nothing more  than the epiphysis being concerned, the medullary membrane is not
at all disturbed, whilst the cancellated structure is not liable to exfoliate, either from
proneness to die from  injury, or through inflammation of any other texture." (pp.
337-39.)  Two cases of scrofulous disease of the knee-joint, in general very favour-
able cases for amputation, are given as successful examples of the result of this prac-
tice, and upon these the recommendation of amputating through the epiphyses of the
thigh-bone is founded.
   In reading the above paragraph, I was surprised at the dangers and inconveniences
resulting from amputation, at the middle or near the middle  of the shafts of bones
which is most commonly selected for that operation, as detailed by Syme ; and still
more at the awful  mortality of from 50 to 70 per cent., which  " the stern evidence of
hospital statistics still shows."   And as my recollection of the usual results of am-
putation at St. Thomas's Hospital had not led me to consider amputation so formi-
dable an operation, either immediately, or in its consequences, except in the case of
primary or secondary amputations for accidents, which are always very serious, and
most commonly fatal, I referred  to my  notes of all the amputations I had performed
in St. Thomas's Hospital during six years.   From these is subjoined an account of
twenty-eight amputations through the  thigh; five of them were primary, and two
secondary;  the whole  were fatal except one of the latter; the remainder consisted
of seventeen cases of scrofulous disease of the knee-joint, of which four died; two of
necrosis; one of osteosarcoma,- and one of fungoid disease, all lived.  The total of the
fatal cases were ten, or 35*7  per cent.,- of the primary, all died ; of the secondary,
1 in 2,  or 50 per cent.; of the scrofulous,  4  in 17, or 23*5 per cent.   In none of  the
successful cases did any of  the untoward occurrences happen which are mentioned
by Syme, though all were amputated through the middle of the bone, excepting that
in three cases a very small ring of bone exfoliated, and in which only did protrusion
occur, and that only for a time.   The results of my colleages* practice in regard to
this operation, I am quite sure, correspond  with my own, though I cannot report
them, but the  cases I  have given afford a fair  estimate of this operation in our
Hospital.
   An account of eighteen amputations through the thigh by Liston has also been
given (a), of which for accidents, two were primary, one lived and one died; and
two secondary, one lived and one died; eight were for disease of the knee-joint, one
fatal;  two for painful  stump, one for ulcer, one for malignant ulcer, one for erysi-
pelas, one for tumour in the ham, all the last six successful.  The average of the
fatal cases here is 1 in 6, or 16-6 per cent.; in the primary and secondary cases^ 1 ha
2, or 50^>er cent.; and in the scrofulous cases, 1 in 8, or 12 J per cent.
                        (a) Potter, above cited, p. 172-176.
                                     56* 
662      REPORT OF AMPUTATIONS THROUGH THE THIGH.
   From these facts it may be inferred, that the cause of the awful fatality recorded
must be sought for elsewhere than in the damage which the dense bone in the mid-
dle of  the shaft suffers from the  saw; and some better grounds must be found for
giving up amputation in the middle of the thigh-bone, and resorting to amputation
close to its lower or  upper end;  in the  first  forming a stump, which, to  the great
majority of persons subjected to  this operation, either cannot be  used, or only«with
great inconvenience and liability  to ulceration; and in the  second, forming  such a
stump as will not permit the use of an artificial leg.   How the medullary membrane
should be less damaged by sawiug through the ends of bones, where  it is certainly
in larger quantity than  in the middle, where it is in smaller quantity, I confess I
cannot understand.   Hence, I should be little disposed  to follow  Syme's  recom-
mendation, of sawing a little beyond the articular surface.
Report of Twenty-eight Amputations through the Thigh,from the Year 1835 to 1840 inclusive.
     1835
Ann Quigley, aged
 25;admitted June
 18.
Charles Ayling,
 aged 47 (flour
 uorter), admitted
 Oct. 6.
Osteosarcoma of the lower
  part of the right th,gh-
  bone, of  three years'
  duration.


Simple fracture  of right
  leg with comminution
  and much bruising.con-
  sequent on being jam-
  med between a step and
  a dray-wheel. On eighth
  day tlie leg became gan-
  grenous ; hectic set  in
  and increased.
     1836
Edward Clark,
 aged 14, admitted
 Aug. 2.
William Allen,
 aged 8, admitted
 Aug. 23.
Disease or Accident.
Opera-
 tion.
Ulceration of the cartil- AuS- 19'
  ages of the right knee
  joint with-suppuration,
  and abscess in  bursa
  of m.  rectus.  Disease
  commenced,lthree years
  since, but has  not pre
  vented him walking till
  the last eight months
Sinus leading, into left Sept. 3.
  knee-joint; no disease
  of cartilages. A twelve
  month since sprained
  the knee; this followed
  by abscess, which burst
  a week before his ad
  mission.
July 3.
Oct. 21.
John Ricksett,
 aged 23 (sailor)
 admitted Aug.. 24
Ulceration of  the cartil
  ages of the left knee
  with suppuration and
  sinus, leading down to
  a large abscess in m
  gastrocnemius,   which
  opened  externally by
  other two sinuses. Dis-
  ease  commenced two
  years since, after expo-
  sure to wet and cold
  at sea.  In  this  case
  the knee  was  nearly
  straight.
Sept. 3.
Remarks.
  Dis-
charged.
With circular cut; five arteries were Sept. 10.
 tied, and the wound dressed at once
 with, straps of plaster;, went on well
 throughout.


With circular cut; in dividing the mus-
 eles a large abscess was cut into be-
  tween the m. vastus intervus and bi-
  ceps; free venous bleeding;three arte-
  ries were tied, but he sunk rapidly.
 Oct. 21
  Seven
  hours
and a half
 after the
operation.
With two vertical flaps; three arteries
 tied, and a fourth an hour after
 wards.  Seven hours after, the flaps
 werebrought together with straps of
 plaster.  On third day  had a smart
 attack of irritative fever and great
 heaviness, which  subsided  about
 four days after.  The wound healed
 'kindly at bottom, but one flap slip-
 ped over the other a little and caused
 a good deal of trouble.
With circular cut; three arteries were
 tied.  The  stump dressed at once
 with,  straps of plaster, but  did not
 adhere, became sloughy, a large por
 tion of skin separated, the bone pro-
 truded, and the wound healed  by
 granulation;  but  a  ring of bone,
 about a quarter of an inch deep, ex-
 foliated,  and  the  stump was very
 conical ; but after a-few months, as
 he gained flesh, it ceased entirely to
 be so.
With two  horizontal flaps; the knife
 passed through a large abscess in the
 bursa of the m, rectus,,in making the
 front flap;  this portion of the ab
 scess  was dissected out.  Five arte
  ries were tied.  The  femoral vein
  bled  profusely,  but ceased on  re
 moving th» tourniquet band. The
  flaps  were brought  together with
  four sutures and straps of, plaster;
  three of the sutures were removed at
 fifty hours, and the fourth next day.
  On the fourth day was attacked with
  troublesome  cough,  followed  by
  bleeding from the stump for some
  hours, which was stayed by the ap
  plication of  a cold wet cloth.  On
  the evening of the fourteenth day he
  had a smart attack of bilious vomit
  ing.
Nov. 7.
Dec. 27.
Nov. 29 
REPORT OF AMPUTATIONS  THROUGH THE THIGH.
663
      1837
Samuel Paddon,
 aged  29  (sailor),
 admitted  March
 17, 1836.



      1838
James Brooks,
 aged  25,  (paper
 maker), admitted
 Feb. 20.
Joseph Lee, agec
 20 (carter), admit
 ted May 26.
John Millard, aged
 42 (sailor), admit-
 ted May 29.
Scrofulous  .'disease  of
  knee-joint.
Ulceration  of  cartilages
  of left knee-joint.  Dis-
  ease  commenced  five
  years  since, and  two
  years  after received a
  blow on that joint.
Compound^ comminute
  fracture of right thigh
  bone, with severe lace-
  ration  of muscles by
  transit   of   wagon-
  wheels.
May 12.
Anchylosis of left knee-
  joint, with severe pain
  on  slightest  touch  of
  the knee.
Feb. 3.
With two horizontalflaps.
May 26.
  Four
  hours
  after
accident.
With circular cut, and the skin divided
  upwards on each side.   The skin re-
  tracted, and on the sixteenth day the
  bone protruded  through  its upper
  part. Between three and four months
  after a thin  ring of bone separated,
  but the wound had not healed when
  he left the house.
With vertical flaps, and through the
  little trochanter; the femoral artery
 ■ tied before  the  completion  of the
  first flap. Flagged very much during
  the operation, and lost much venous
  blood; and though brandy was freely
  given,  he became very low and rest
  less, and with much jactitation, and
  he sunk rapidly.
June 2.
Mar. 11.
Nov.
                              With vertical flaps; five arteries were
                               tied; lost much blood at the opera
                               tion,  and became very faint; the
                               medullary artery bled very fiercely,
                               but was stopped by pressure.  As he
rallied bleeding began again, and did not cease.till sixteen other ves
sels, all of small size and much retracted, had been taken up; the me
dullary artery  again burst forth, and was again stopped by pressure
Another vessel was tied two or three hours after, and the  bleeding
then ceased. The Haps could not be  adjusted as at first; next day he
complained of pain in his belly; had tightness at chest, and sighed fre-
quently; continued very restless.  On  the fourth day suppuration com-
menced; and he complained of pain on the outer and under part of the
stump; a bread poultice was applied. On the fifth day the stump be
came  more  painful, and when pressed much pus was  discharged from
the upper gap of ihe wound, which was dressed to day, and he became
a little the easier; in the evening the pain in his bellyceased.  On the
sixth day, the pain in- the stump, which  had  diminished, became very
severe, and the outer flap was much inflamed, some way up the thigh ;
he was very restless, and had much constitutional excitement.  On the
following day he was rather better; hut the erysipelatous blush  had ex
tended upon the buttock.  Has hitherto taken laudanum to allay irrita-
tion and give  rest, which, however, has not been very effective, and
beef tea; the latter of which was to-day changed for a mutton chop
and a pint of porter. On the eighth day was  worse, his tongue coated;
pulse  very quick and irritable; looks anxious; erysipelatous blush ex-
tending to the  iliac crest; discharge  from wound diminished in quan-
tity,  and thinner.  On the following morning had  some hiccough
looked wild, though perfectly sensible; and had some mucous  rattle in
his windpipe, which towards evening increased, and the  hiccough con
stant. He continued getting lower,  and the breathing worse-  Brandy
was given to keep him  up, and the  bronchial affection  attacked with
blister, and afterwards mercurial  friction, but without avail; his
bowels got out of sorts, but he  went lingering on till the evening of
the twentieth day.  The  right pleura  was found' covered  with  coagula
ble lymph, and contained four ounces of serum, with  flakes, both lungs
gorged with sero-pumlent fluid: the bronchial membrane deep  red.
The mucous membrane of the stomach thickened and  mammillated
with brownish-red patches; and that of the intestines, small' and large,
here and  there ulcerated in patches,  the stump sloughy. 
664
REPORT OF AMPUTATION? THROUGH  THE  THIGH.
      1838
    continued.
Charles Russell,
 aged 28 (farm-ser-
 vant),   admitted
 Dec. 27.
Severe laceration of the
  skin of the  right  leg
  and of the m.-gastrocne-
  mius;  consequent on
  injury  by cart-wheel
  Was much depressed at
  his admission.
      1839
William  Wilmott,
 aged 26 (carman),
 admitted Nov. 6-
 1838.
James Arnold,aged
 22, admitted Aug
 27,1838.
Disease or Accident.
Dec. 27.
 Eight
 hours
  after
accident.
Severe contusion  of the
  right  leg,  consequent
  on being jammed be-
  tween a cart-wheel and
  the curb-stone; follow
  ed by extensive slough
  ing of the skin  of the
  back of the leg.and sup-
  puration  beneath the
  whole remaining  skin
  of the leg  and upper
  part of the  thigh; and
  great depression.

Soft anchylosis,  ulcera-
  tion of cartilages and
  abscess in  left knee-
  joint.  Not much af-
  fected constitutionally
  by the disease, and very
  urgent for  the  opera
  tion.
Eliza Phillips, aged
 22, admitted April
 23.
Opera-
tion,
Jan. 23.
April 18
Soft anchylosis  of left
  knee-joint,  with  con
  stant severe  pain, spe-
  cially  at night.  The
  disease began  at two
  years of age. The knee
  bent  at a very  acute
  angle, and very tender.
May 10.
Remarks.
With circular cut; four arteries tied;
 lost much venous  blood during the
 operation,  and was much exhaust-
 ed ; wound brought together with a
 single strap, and the  dressing com-
 pleted twelve hours after.  On the
 fourth day irritative fever came on,
 and he became much excited.  On
 the sixth day little union, and free
 suppuration of the wound, the bone
 a little protruding.  On the eleventh
 day  a little graze on  the other leg
 was observed to be separating, and
 on the eighteenth  about a pint of
 pus was discharged from beneath it;
 subsequently suppuration extended
 beneath the  skin of the whole leg.
 He improved a little, but afterwards
 sunk again, complaining the day be
 fore he died, of severeaamin in the
 chest.  On examinatioriUje femoral
 vein was found filled with pus up
 .to a valve four inches above its cut
 end.  The  bronchi were  acutely in-
 flamed.
With circular cut; lost but little blood
 during  the operation; the femoral
 artery  was  tied   before  sawing
 through the bone, and  other three
 after.  The wound  was brought to
 gether vertically with straps of plas
 ter.  He bore  the  operation very
 well, but was sick on being put to
 bed.  From this time he gradually
 improved, and in thirty-three days
 the wound had healed,  and he  got
 up.
With two horizontalflaps;the soft parts
  much  consolidated,  and the flaps
  turned  back with difficulty.  Had
  little arterial, but  much  venous,
  bleeding.  Five arteries and the  fe-
  moral vein tied; the  latter had bled
  most pertinaciously.  The flaps were
  at  once brought  together with ad
  hesive straps.  Next  day, much ooz
  ing having  taken place, the flaps
  were opened,  a  small vessel found
  and twisted.  In the afternoon  he
  began to vomit; another vessel was
  lied, and the stump dressed. Third
  day, vomiting continued,   and  at
  night be wandered much; but on the
  morning of the fourth day he  was
  senseless, continued so for six hours
  and died. The examination threw
  no additional  light upon the cause
  of death, which seemed to  rest  on
  the constitutional shock from the
  operation.


With circular cut; six arteries  and the
  femoral vein were tied.  The edges
  of the wound were brought together
  transversely,  and   fastened with
  eight  pins  and twisted suture;  a
  wet rag applied.  The pins removed
  at seventy hours, and union opposite
  them; dressed with adhesive plaster.
  In course of  a  month  the  wound
  healed, except a little sinus, where
  the ligatures had been brought out.
  Dis-
charged.
May '
June 12.
Died.
 Jan. 19.
 Twenty.
three days
  after
operation.
 April 21.
 Seventy-
five hours
  after
operation. 
REPORT OF AMPUTATIONS THROUGH THE THIGH.
665
     1839
    continued.
Edward Moore,
 aged 27 (tailor,)
 admitted June 4.
Elizabeth  Harley,
 aged 15, admitted
 May 28.
Disease or Accident.
Opera-
 tion.
Abscesses around.but not
  communicating  with
  the  right  knee-joint;
  synovial    membrane
  thickened,  soft,  and
  jelly-like, spotted with
  red; disease began with
  a fall sixteen months
  since.
Necrosis in head of right
  shin-bone, and partial
  destruction of the joint
  cartilages;   at  other
  parts    the   synovial
  membrane of the three
  bones adherent at the
  corresponding surfaces.
June 19.
June 30.
Remarks.
Charles Walder,
aged 21 (labourer,)
admitted June 5.
Ulceration of cartilages.
  with  suppuration  in
  left knee-joint, and ex-
  ternal   Abscesses  not
  communicating ; after
  a fall two years since.
Mary Hutchins,
 aged 46, admitted
 Aug. 1.
James  Lee, agec
 28 (ostler,) admit
 ted May 7.
Fungoid tumour on upper
  part of calf of left leg,
  abdut the size of an
  orange.
Ulceration  of cartilages
  of right knee, with sin
  uses; had had amputa-
  tion performed through
  the  leg  seven  years
  since; two years ago
  fell  and  bruised  his
  stump;  the knee has
  swollen  since, and ab-
  scesses formed about it
  during his stay here
  These have been open-
  ed, and  continued dis
  charging.
July 10.
  Dis-     Died.
charged.
Aug. 27.
Aug. 21.
Oct. 2.
With two oblique flaps; eleven ligatures
  applied.   Suffered great  agony at
  operation and for an hour after, on
  which account forty drops of lau-
  danum given; this quieted him, and
  the  wound was left open for nine
  hours; two small vessels then tied,
  and the edges brought together with
  eight pins and twisted suture; these
  removed at  sixty-eight hours,  and
  the edges found generally united; in
  their place adhesive  straps applied.
  In about a month the wound healed,
  and the scar began to draw in

With two flaps, oblique, upwards ajidin- Sep1- 1"
  wards; six arteries  tied;  the stump
  left open nine hours till glazed, then
  all  remaining clots removed, and
  another vessel tied; the edges of the
  wound brought together, and fas-
  tened with five pins and the twisted
  suture; these were removed ^ninety-
  six hours, and adhesive  straps ap-
  plied. Some weeks after, when the
  wound had  healed, the scar con-
  traded and  drew in, so that there
  was a cleft appearance of the face
  of the stump:

 With two oblique flaps; in making the
  front one a large abscess was pene-
  trated, whence  much  pus escaped;
  lost  much  blood,' and ten  vessels
  were tied, and afterwards the sac of
  the abscess was dissected out; flaps
  left open, and another vessel taken
  up; nine hours after the clot remov-
  ed, another vessel tied, and the flaps
  brought together with seven  pins
  and twisted  sutures; these were re-
  moved at sixty-nine hours, but not
  much union. On the next day his
  bowels were disturbed,and therefore
  beef tea changed for arrow root and
  a little meat; and in the evening had
  pain at the  pit  of the stomach and
  nausea.  On the eighth day had a
  shivering fit.  Sores formed on the
  buttocks, hips,  sides of the chest,
  and shoulders about a month after,
  most of which healed; but early in
  October psoas abscess appeared in
  right groin, under which he sunk.
 With two horizontal flaps; thirteen arte-
  ries were tied; the femoral was tied
  two inches above  the edge of the
  flap, but the lower end  bled  after-
  wards, and  required  tying,  when
  the flaps were brought together, ten
  hours after, with six  pins and the
  twisted suture;  these were removed
  at  seventy-two hours,  and adhesive
  straps  then  put on.  She  went on
  without a bad symptom.
 With  circular cut, and cut on each
  side of the skin;  the muscles did
  not retract  in the  least; nine arte-
  ries were tied, and the vein also, as
  it bled very freely; bleeding recurred
  during  the  afternoon,  and  three
  more vessels were taken up. Did
  very well, and the wound healed in
  twenty-six  days.  Six weeks after
  had a severe attack of  acute rheu-
  matism  in  the  right  wrist, and
  afterwards his  heart was  attacked;
  he recovered after a month.
Oct. 18.
Nov. 23
Mar. 17,
  1840. 
666
REPORT OF  AMPUTATIONS  THROUGH THE THIGH.
Disease or Accident.   Operation
Remarks
 Dis-
charged.
     1839
    continued.
Sarah  Dowles,
 aged 50, admitted
 Oct. 1.
     1840
Edward Berry
 aged 13, admitted
 Dec. 31,1839.
William Parker,
aged 27 (labourer,)
admitted Jan. 22.
1840.
Samuel Armstrong
 aged 16, admitted
 March  24.
Hugh Evans, aged
 20 (sailor,) admit
 ted May 2.
Necrosis  of  right thigh-
  bone just  above  the
  articular  surface   of
  condyles, and  commu-
  nicating with sinuses
  opening above the knee
  cap and on the inner
  condyle.  Has had dis-
  ease in the knee-joint
  for  forty  years ;  but
  three years ago received
  a blow on the  lower
  part of the thigh from
  a boot.
Soft anchylosis  of right
  knee-joint and necrosis
  in head of shin-bone
  communicating with a
  sinus.
Compound  fracture  of
  leg, with simple  frac-
  ture of left thigh, and
  severe laceration of the
  skin over, but not com-
  municating   with it;
  consequent on having
  been run over  by
  steam-carriage  whilst
  fallen on the rail yes-
  terday, at 6 p. m.
Ulceration  of cartilages.
  with suppuration and
  adhesive deposit on sy-
  novial   membrane  of
  right knee-joint.  Much
  out of health.
Oct. 12.
Jan. 18.
 Jan. 22,
Twenty
two hours
  after
accident
Compound fracture of left
  left leg,  with  severe
  laceration of muscles
  and simple fracture  of
  same  thigh into  the
  joint,  consequent  on
  timber falling upon the
  limb.  Had lost much
  blood.
  May 2
  Three
  hours
and a-half
  after
 accident
Henry  Parker,
 aged 43 (brewer's
 servant,)  admit-
 ted June 1.
Compound fracture of the
  left thigh, with lacera-
  tion from the inner
  condyle to nearly the
  pubes,  but not much
  bruising:  laceration of
  right hand and disloca
  ted metacarpal bone;
  consequent on  transit
  of a loaded dray-wheel
  Much depressed on his
  admission.
June 1.
  Four
 hours.
  after
accident.
With two oblique flaps; twenty-one ves
  sels were taken up, and  the  flaps
  brought  together  at  once.   Re-
  covered,  without  any  untoward
  symptom.
Dec. 24.
With two oblique flaps; nine  arteries
 and the femoral vein  were  tied;
 nine hours  after the  face of the
 flaps was cleansed, other six vessels
 tied, and the flaps brought together
 with adhesive plaster.

With two vertical flaps;  the femoral
 artery was tied immediately after
 making the inner flap; afterwards
 the femoral vein, the deep femoral,
 and two small arteries. He did not
 lose two tablespoonfuls of blood;
 but  the operation  depressed  him
 considerably; and he sunk rapidly
With two horizontal flaps; three arte
  ries tied, but the medullary artery
  oozed  freely, except when  stopped
  by pressure; the flaps brought toge
  ther four hours after with adhesive
  plaster.  On the fifteenth day irrita
  tive fever came  on,  with much
  headach, and could not be checked.
With two horizontal flaps; four arteries
  were tied.  The wound was sloughy,
  but had cleared on the eleventh day
  up to which time he had been  tole
  rably  well. On the thirteenth day
  was attacked suddenly with pleu
  ritic   symptoms, and  the  sputum
  slightly  tinged  with blood;  some
  little cessation of these symptoms
  occurred, but he sunk.   The left
  pleura  contained  straw-coloured
  serum, with flakes of coagulable
  lymph, and both costal and pulmo-
  nary surfaces covered with lymph;
  the lower lobe of left lung infiltrated
  with pus; its apex consolidated.

With twoflaps; immediately on making
  the first he was violently sick, and
  I tied the femoral artery before
  making the  second.   Some  other
  arteries tied; an hour after opera
  tion was  violently sick, and  once
  after.   Four hours after the  flaps
  brought together with three sutures
  and straps of plaster; vomited again
  during the night.   Twenty  hours
  after the first operation, amputation
  through the wrist-joint, with a flap
  from the back of the hand, and five
  ligatures applied.  Sutures in thigh
  removed after one hundred and eigh-
  teen hours; the  wound sloughy. On
  seventh day attacked with irritative
  fever,  and on the day following was
  much  purged,  and this  continued
  till he sunk.  On examination there
  were found a little lobular pneumo-
  nia, principally in left  lung; some
  ulceration of mucous membrane of
  intestines.
Mar. 17. 
REPORT OF AMPUTATIONS THROUGH THE THIGH.
667
    1840
   continued.
Robert Richards,
 aged 15, admitted
 June 16.
Soft  anchylosis of right
  knee.  Disease began
  nine years since, after
  a fall.
Benjamin Scott,
 aged 9, admitted
 June 9.
James Vinson,
 aged 35(farm-ser
 vant,)  admitted
 Aug. 18.
Disease or Accident.
Operation.
John Pearman,
 aged 19, admitted
 Nov. 10.
Soft  anchylosis of  left
  knee.  Disease began
  five years since, with
  out known cause.
Ulceration  of cartilages
  of right knee-joint, ad
  hesive  deposit on  the
  synovial membrane;the
  joint full of pus; and
  the bursa of the m. rec
  tus full of pus.  Origi
  nated in a blow with
  shovel nine years since
Soft anchylosis of the left
  knee; abscess above the
  head of the shin-bone;
  the  remaining  joint-
  cartilages ulcerated.
Remarks.
 Dis-
charged.
Died.
July 25.  With horizontal flaps; six arteries tied;
          the wound brought together with a
          single strap, and the dressing com-
          pleted eight hours after.  On the
          fifth day the bone began to protrude,
          and could not be replaced, but the
          wound  healed, excepting immedi-
          ately  around  it, in  course of six
          weeks; and at the end of two mouths
          a little ring of bone  separated; the
          wound  had not completely healed
          when he left.

Sept. 19. With circular cut; four  arteries and
          the femoral vein were tied; the
          edges of the wound brought together
          with a  single  strap, and the  dress
          ing completed seven  hours  after;
          went on without a bad symptom.

Nov. 14. i With circular cut; the muscles did not
          retract; and in dividing them, the
          abscess  beneath the tendon of the
          m. rectus was  cut through, but the
          part on the stump was left; nine
          arteries were tied;  he was much
          exhausted  by the operation, and
          passed  his motions involuntarily
          the  wound was  brought  together
          at onte with  adhesive straps; the
          stump was, perfectly healed in three
          weeks.
Dec. 5.
With  circular cut; six  arteries and
 the  femoral vein were  tied;  the
 edges of the wound were at once
 brought  together  with  adhesive
 scraps, hut three hours after  bleed
 ing  recurred, and four more small
 arteries were tied; the wound was
 dressed  as  before;  went on  very
 well for  a  fortnight, and then the
 stutnp became sloughy, but it clear
 ed in a few da vs.
Oct. 20.
Dec. 15.
Feb. 2,
 1841.
Feb. 2,
 1841.
   [Since the last sheet has been worked off, I have met with another paper of Syme's
on amputation of the thigh (a) which I had accidentally overlooked, in which, after
having advocated since 1823  the superiority of flap-amputations over those by the
circular cut, he now states :—" When  the flaps are placed together it seems as if
nothing could prevent their perfect union so as to effect a speedy cure, and afford a
comfortable covering to the bone.   In some cases these favourable anticipations are
fully realized ; but though a  good  many days, and even  one or two weeks, may
elapse without making manifest the disappointment  to be experienced, it much more
frequently happens that the soft parts, however  ample they may have appeared in
the first instance, gradually contract and diminish until care is required to keep their
edges  in  apposition over the  bone, which sometimes, notwithstanding every pre-
caution, at length becomes  denuded, and presenting itself to  view, whether dead or
living, proclaims the unavoidable  misery of a sugarloaf stump.   This distressing re-
sult depends upon the vital contractility of the muscular tissue, which continuing in
operation so long as the cut surface is not prevented from yielding  by the formation
of new adhesions, not only lessens the mass of flesh provided for covering the bone
but gradually retracts  it together with the superjacent integuments."  He thinks  that
this effect is, among other  circumstances, cautpd by amputating through the lower
third of  the thigh, and has,  therefore, for  many  years recommended amputating
through the middle of the thigh in preference, " to  prevent the great risk or almost
certainty  of protrusion to which the  bone is exposed when divided at or near its lower
third."   He then compares the result of amputation  with the circular cut through the
lower third  of the  thigh, "which being the thinnest part of  the limb, most readily
admits of forming a stump composed only of skin," and then directs that "the in-
                 (o) Monthly Journal of Medical Science.  Nov., 1846. 
668
AMPUTATION THROUGH  THE LEG,
 cision of the skin should be made as near the knee as possible, not in a circular di-
 rection but so as to form two semilunar edges, which  may meet together in a line
 from side to side without projecting at ihe corners. The fascia  should be divided
 along with the integuments, which are thus more easily retracted—not by dissecting
 and turning them back, but by steadily drawing them upwards through means of the
 assistant's hands firmly clasping the limb.  This should be done  to the extent of at
 least two  inches or more if the thigh is unusually thick.  The muscles are then to
 be divided, &c." (p. 223-25.)
   These remarks from so able a surgeon as Syme, cannot be passed by without
 notice, as  they might lead the inexperienced to fear operating with flaps in the lower
 part of the thigh, whilst  in reality there is  nothing to be dreaded.  I have always
 been accustomed to amputate as low as possible through the thigh, not that the pa-
 tient might rest on the end of his stump, which is not to be permitted, but simply to
 give the socket of the artificial leg a better grasp, and I certainly never had a perma-
 nently protruding bone nor a conical stump.  Indeed, so far as I  have had opportu-
 nity of seeing amputations through the thigh, either  by the circular  cut  or by
 flaps, in London practice, conical  stumps are  rarities, and I am certain  that  within
 the last thirty years, I have not seen half a dozen, and I am convinced that when
 they do occur, except in the comparatively few cases of sloughing  of the stump,
 even in which they are rare, they are produced, not by the mode of  operating, but
 by want of  proper attention to the after-dressing.  Indeed I have seen again  and
 again, in olden time, after amputations in which both skin and muscles had been so
 badly cut, that with all the operator's efforts it was impossible  to make the edges of
 the  wound meet by  a finger's breadth,  and  the  more he  endeavoured, at first, to
 close the wound and cover up the bone, the more pertinaciously it  stuck out, and
 would not be covered ; yet  notwithstanding, I have been again and again surprised
 at finding towards the end of the treatment, as good a stump made as if the operation
 had  been ever so well performed ; the whole secret of which was that  the after-treat-
 ment was most sedulously attended to.   As to " steadily drawing the integuments
 upwards, not by dissecting and turning them  backwards, but through the means of
 the assistant's hands," I have only to observe that in scrofulous disease of the knee,
 in most cases, this cannot be done, as the cellular tissue is completely glued up and
 fixed'with the adhesive deposit in it, and will not move ; neither in case of accidents
 with large fat thighs, will the cellular tissue yield to any thing like this extent; and
 it can alone be effected in thin persons of loose fibre, and then only when the disease
 is  of the leg, and not of the knee.
   With regard to amputating through the epiphyses, which not long  since he had
 warmly inculcated, Syme now  says, in  this same  paper:—"As the  soft parts re-
 quired to form the stump  in this situation (amputation at the knee) aTe apt  to be so
 deranged in their texture as to delay, though not prevent recovery, and thus in some
 measure, counterbalance the advantage of exposing cancellated, instead  of dense bone,
 together with the contents of its medullary cavity, I do not persist  in advocating
amputation at the knee, now when satisfied that the operation by circular incision,
 if performed with due care, on proper principles, maybe employed  at the lower third
of the thigh safely and advantageously (p. 225.)  Is not  this in fact giving up this
much-praised operation?—j. f. s.]
             II.—OF AMPUTATION THROUGH THE LEG.

  (Amputatio Cruris, Lat.; Amputation des Unterschenkels, Germ.; Amputation de la
                                 Jambe, Fr.)
   2717.  If the disease  which renders amputation through the leg neces-
sary, permit, it may be perforrfed above, below, or through the calf; in
poor persons, however, the best place is three fingers' breadth below the
tubercle of the skin-bone, as with the shortness  of the  stump, it  easily
bends back, and the knee becomes the  point of  support on the artificial
limb.   The amputation may  be performed with the circular cut, or with
one«or two flaps. 
   AMPUTATION THROUGH THE LEG, WITH CIRCULAR CUT.    669

   2718.  The position of the patient is the same as in amputating through
 the thigh. The tourniquet must be so applied immediately above the knee-
 cap,  that its head  may directly compress the popliteal artery (1), and it
 is intrusted to an assistant.   Two other assistants support the leg hori-
 zontally, and moderately bent at the knee, the one grasping above the
 foot  and  the other  below the knee, and the latter at  the same time draws
 up the skin moderately tight.   The  operator should  always stand for this
 operation on the inner side of the leg.
   [(1) The application of the tourniquet as here directed, is highly objectionable,
 for it must make voilent pressure upon  the popliteal nerve, and cause much un-
 necessary  pain.  It should be put on immediately above the middle third of the
 thigh, and its pad should rest on the femoral artery, where  it lies close against the
 inside of the thigh-bone.—j. f. s.]
   2719.  In the amputation with the  circular cut, the operator makes the
 skin  cut, two or three fingers' breadth,  according to the size of the limb)
 below the part where he will have to saw through the bone, in the same
 manner with the straight knife, as in amputating  through the thigh (1).
 He then  with his left thumb and forefinger takes hold of the edge of the
 skin, draws it a little up, and with  sufficient strokes, separates together
 the whole fat and cellular tissue, all  round from the fascia up to the place
 where the limb is to  be removed ; the detached skin is then turned inside
 out, and  so kept by an assistant. The  operator now grasps a  straight
 long amputating knife  with his right  hand, and sinking down  on  one
 knee, carries it beneath the limb over  to the  inner side, places its edge
 close to the edge of  the  retracted skin, and  putting the left thumb and
 forefinger on the fore part of the back of the knife, with proper pressure
 bears the knife towards himself and downwards, draws it circularly round
 the limb, rises up,  and cuts the  muscles through to  the bone.  He th§n
 takes a narrow double-edged knife (or catlin)  so that the thumb rests on
 that part  of its handle corresponding  to the edge, and the fore and middle
 fingers on that to its back, passes it under the limb,  and places its edge,
 near the junction of the blade with the handle, upon the front of the shin-
 bone, carries it over the spine, and then with the point of the knife always
 following the bone, thrusts it  from without  into the interspace between
 the bones, down to  the handle.   He now drops the edge of the knife upon
 the splint-bone, draw's it, without leaving that bone, up out of the inferos-
 seal space around the hind surface of the splint-bone, and then thrusts  it
 on the inside through the same space up to the handle, bears it  against
 the shin-bone, and  again withdraws it upon that bone.   In this way all
 the parts  between  the two bones and the periosteum are cut through.
 Care  must be taken in doing this, that  the point of the knife be not again
 pushed through the already  divided muscles.  The muscles are now held
 back  with a three-headed cleft  cloth, of which the uncleft part is placed
 on the inside of the  limb, and held by an assistant, the middle head passed
 between the two bones, and then laid  on the  front  of the leg, and  the
 inner and outer head  so drawn together over the surface of the  wound on
 the inner  and outer side, and crossed with the upper part  of  the  middle
head, that all the muscles may be covered.   Trie  assistant now holding
the cloth properly drawn together, the operator places his left  thumb on
the edge of the shin-bone near  the place where it is to be cut through,
forms first a groove with the saw in the shin-bone, sufficient to  determine
  Vol. hi.—57 
670  AMPUTATION THROUGH THE LEG, WITH CIRCULAR CUT.

its track, and then drops the  saw in such way that the splint-bone may
be cut  through  before the shin-bone.
  Amputation through  the leg in  its* lower third was preferred by the surgeons of
old; and even up to the present there are some who defend its performance at this
place, as on account of the smaller size of the soft parts and  of the bones, the ope-
ration is less important and dangerous, the wound  heals  more quickly, and a well-
constructed artificial  foot can be more easily worn.   But this latter  point has been
directly denied by many  surgeons; and on account of the price and of the frequent
necessary repairs of such artificial feet, this place  of amputation is fit only for the
rich, and on account of the smaller wound for old persons.  The  ordinary mode of
amputation with the circular cut is here objectionable, as it is always difficult to dis-
sect back-properly the pretty thick and adherent skin, and to turn it up for the pur-
pose of cutting through  the circular part of the limb.  The skin also easily morti-
fies, or  a  badly-covered  stump is formed.  The formation of a hind flap made, as
now to  be described, is  therefore  preferable.
  Salemi (a) first makes the semicircular cut over the  front of the leg and  after-
wards the flap  cut, by piercing the calf with the knife, which answers no  purpose
at all.
  Or the circular cut should be made according to Lenoir's (b) method in  the  fol-
lowing  way :—"The surgeon standing on the  inside of the limb, makes with  a nar-
row catlin a circular cut through the  skin to the fascia, about an inch and a half be-
low where the bone is to be sawn through.  With the point of .the knife he makes
a second cut perpendicular to the  former, an inch and a half long, along the inside
of the  shin-bone near its spine.  Then holding the corners of the wound, one after
the other, he divides the cellular tissue and its connexion with the fascia and perios-
teum and forms with them two flaps, which he turns back  at their  base.  These
flaps must be made as thick as possible and not extend below the  front third of the
leg, as  the cellular bridges which connect the  skin with the underlying parts, must
be divided only behind and on the sides.   In  this way  a sort of ruffle is preserved,
cleft in front, and of which the front part alone is turned back on the  two  sides of
the shin-bone, giving to  this part of the leg an oval shape, which the knife follows
in making the first cut through the muscles.   For  this purpose the operator places
the edo-e of the instrument on the outer edge of the shin-bone, and carries it to the
inner edge exactly following  the oblique  direct  of the cutaneous ruffle, cutting
through the whole thickness of the superficial  layer of muscles at the back of the leg.
 The  assistant now lifts up this muscular layer with the skin covering it, and when
 they have reached the point where the bones are to be sawn through, the operator
 makes  a second cut, giving it a direction exactly transverse to the axis of the limb,
 which  at once passes through to the deep layer of muscles, and after this he pierces,
 as usual, the interosseal  space and  cuts  through  the periosteum.  The retractor is
 then applied, and both bones sawn through at once and in the same plane.  After
 the vessels are tied, the flesh  brought over the bone, and held together by a circular
 bandage moderately tight around  the whole limb, the two lips of the vertical wound
 in front  of the  shin-bone are brought together with a suture, and the wound con-
 verted  into the  circular amputation wound, which is united in the direction  of  the
 antero-posterior  diameter of  the  leg.  The patient is then put to bed with his limb
 laid a little on the outside."                                                 .
   According to Baudens, the  amputation may be made even through the ankle-joint,
 in which case one flap is made from the skin of the instep,  and the other from that
 covering the back of the heel, and the sides of the ankles, and both ankles and  the
 hind part of the shin-bone must be sawn through (c).
    When the leg is cut  off higher than three fingers'-breadth below the tubercle of
 the shin-bone, the operation must be performed precisely in  the way directed above.
    Disjointing the head  of the splint-bone is dangerous on account  of the opening of
 its capsular ligament (d) ; but according to Jaeger and others, this is not to be feared.
 The operation must not be performed above the tubercle of the shin-bone,  as other-
 wise the insertion of the patellar ligament is  cut through, the mucous bag behind it,
 and even the joint on its sides opened, by which drawing up of the knee-cap  and in-
    to)  Pes  Inconveniens de 1'Amputation de  tomie de Phomme, comprenant la medecine
  la Jambe au lieu d'election.  Paris, 1825.    Operatoire, vol.  vi. pi. 83.—Froriep, above
    (b)  Archives  generates  de  Medecine.  cited.
  1840; vol. viii. p. 263.                        (d) Zang, Operationen, book iv. p. 1 <0.
    (c)  Boubgery, Traite  complet de PAna- 
DRESSING THE STUMP.                    671
flammation of the mucous bag and of the joint ensue.   Larrey^*) has amputated
the leg immediately through the articular head of the shin-bone.
   [(1) Amputation through the leg should be performed not more than four fingers'
breadth below the apex of the knee-cap, in working persons, on whom the Opera-
tion is most commonly performed, as the kneeling posture in the bed of the wooden
leg is the best and most useful for them;  and if the stump be of greater length, its
only use is to be in the way and  be liable to injury.  In persons  of easy circum-
stances, who can afford to be idle, and are not required to be always a-fopt, a long
stump, by amputation a little above the ankle, if possible, which is  not always, may
be permissible; and they will enjoy the movements of the knee-joint; but for useful
purposes, gentle or simple,  will find the short stump  the  best; for it must be re-
membered, that in no properly-fitting artificial leg is the weight of the body thrown
upon the end of the stump,  as some surgeons pretend it ought to be, forgetting if it
be, than a sore stump is generally the consequence.—j. f. s.]

   2720. Tying the vessels is performed in the usual manner, but is often
difficult when the amputation is performed high up, because  the  vessels
are here collected together in a bundle.   If  the  nutritious  artery  of the
shin-bone  bleed violently, a little ball  of wax  must be thrust into its
mouth. (1)
   When the  vessels are  tied, the ligatures  arranged,  and the  circum-
ference of the wound dried, the edges of the skin must be brought to-
gether vertically (2), and kept in this position by strips of sticking.plaster,
not too  tightly applied.  A wad of lint and  a compress  are applied, and
lightly fastened with a roller.   The position  of the stump must be either
outstretched or  bent at the knee, according as it is intended to preserve
the  movements of  the knee in the application of an  artificial legT or to
let the maimed person go upon the knee.   The after treatment must be
directed according to the general rules.

  Although in the above mentioned mode of amputating through the leg, the skin
merely is preserved to cover the stump, I have always found it  sufficient, and have
never noticed any  protrusion of the bone.  I have  never seen the skin become gan-
grenous and burst through by the  pressure of the sharp end of the shin-bone, and I
therefore consider  the recommendation.of sawing it off obliquely, useless and super-
fluous (3).
  [(1) One of the most troublesome circumstances, in regard to tying the vessels
in amputating high  up through  the leg, is when the anterior tibial artery has been
divided just after it has passed through  the  interosseous ligament, and retracts so
that it cannot be pulled out  and tied, but sometimes bleeds fiercely, especially after
the posterior tibial artery has been taken up.  It must then be managed, either by
carefully cutting through the interosseous  ligament till it can be got at and tied,
which is the best  mode of proceeding; or by passing  a needle  and thread a little
above the divided  edge of the ligament on one side of the spot whence the bleeding
issues, from before to behind, and then bringing the  thread back again from behind
forwards, on the other side of the bleeding point, and tying all contained within the
loop,  which sometimes answers the  purpose.  Dipping with  the tenaculum, and
tying all it hooks up,  is not advisable, for even if it catch the artery, the ligament
is also caught with it, and the ligature cannot be made so tight as  to ensure safety
from after-bleeding.
  I have occasionally seen bleeding from the nutritious artery of the shin-bone very
tiresome but have never seen it require more than pressure for a little time till a clot
is formed.  If I could not so succeed, I should rather prefer applying the actual cautery
than using a pellet of wax as here recommended.
  (2) I do not  think bringing the edges of the wound together vertically answers
so well as horizontally; for in the former case, the skin is not merely unsupported
as the stump rests on the pillow,  but the pressure tends to  make the wound gape]
I therefore prefer bringing it together horizontally, by which means the hind par^
(a) Memoires de Chirurgie Militaire, vol. iii. pp. 56, 359. 
672  AMPUTATION THROUGH THE LEG, WITH  SINGLE FLAP.

of the stump is supported by the pillow, and  the fore part readily drops to meet it
without any stress, and even relieves the tightness of the dressings.
  (3) I cannot say that I have always had Ohelius's good fortune in regard to the
skin covering the sharp end of the shin-bone, as it has happened two or three times
in my own practice, and I have occasionally noticed it in the practice of others, that
the skin has been pressed on and sloughed.  This generally arises from the edges
of the wound having been drawn too tightly together, in consequence of the skin saved
not being of sufficient length to cover the stump properly, in whatever direction the
wound has been brought together; and even when sufficient and the wound has been
properly dressed  for the  first few  times, yet occasionally the patient's restlessness
and sometimes negligent after-dressing will lead  to this tiresome result.   I there-
fore think it is better to saw off obliquely merely the projecting point of the bone,
which prevents any pressure on the skin, except from great carelessness of the me-
dical  attendant in the dressing.—j. f. s.]
  2721. Amputation through the leg with a single flap, is  performed in
the following way.  The precautions against bleeding  and the position
of the assistants is the same as  with  the circular cut.  The operator stand-
ing on the inside of the leg-, places at the  part where  the  bone is to be
sawn through, the left thumb on the inner edge of the shin-bone, and the
fore  and middle finger upon the splint-bone, at the same time pressing the
soft parts back to the calf.  He now takes in his right  hand a  narrow
double-edged knife, places its point at the part marked  by the thumb, on
the inner edge of the shin-bone and thrusts it deeply  through  the skin
and  muscles, a little obliquely from within  outwards and backwards till
it rest upon the splint-bone.   He then carries the point of the knife close
behind this bone, and whilst sinking the handle a little, thrusts it through
the outside of the leg, directly opposite  the point of its entrance.   The
knife is now carried far down along the  hinder surface of both bones,
and  then its  edge being turned obliquely downwards divides the muscles
and  the skin.  The length of the flap must correspond to the bulk of the
leg,  it should-always be one-third of its circumference.  The skin is now
to be divided on the froat  of the leg,, half an inch below both corners of
the wound by a transverse cut, and separated at the base of the flap, where
it is  turned upwards, and  held baGk by an assistant, who  at the  same
time properly retracts the  flaps.  For the purpose of dividing whatever
still  remains attached to the bones, the catlin is carried  round at the base
of the flap,  exactly  as in the circular  cut.   The doubly cleft cloth is now
put  on, and  the sawing of the bones  performed as after the circular cut.
When the vessels have been properly secured and the wound cleansed,
the flap is laid  up over the surface of  the  wound, and brought close to
the edge of  the skin;  in which position it is kept by straps of sticking
plaster passing from behind to before, $nd. from side to side.   Some turns
of a roller are  made about the stump, the flap covered with lint, a cross
bandage applied over the stump, and its ends fastened with a continua-
tion of the circular bandage,  some turns of which are  carried from be-
hind forwards over  the  stump.
  In those who have thick calves the knife is not to be thrust close behind the bones,
or the flap would be too thick and could not be placed properly upwards.  Graefe
(a) has invented a peculiar knife for this purpose, of hollowing out the inner surface
of the flap.
   [I have already mentioned (par. 2709 note) the reasons on which I object to flap-
(a) Above cited, pi. vii. fig. 4, 5. 
        AMPUTATION THROUGH THE LEG WITH TWO FLAPS.    673

amputations in the leg, and why I think the circular operation should be preferred.—
j. f. s.]
  2722. Amputation through the leg with twoflaps was first proposed by
Le  Dran {a),  under the notion that two wounded surfaces applied to each
other would take on a quicker union:  it has been several times perform-
ed  by Roux (6); Klein (c)  also proposed and Weinhold first practised
it in Germany.
  2723. Amputation through the leg with two flaps  is not without diffi-
culty, in consequence of the unequal disposition of the soft parts on the
two sides of the calf, and of the unequal size  and not parallel position of
the two bones.  No peculiar advantage is obtained  from this operation,
and it is decidedly less preferable  than the circular or than the ordinary
flap-cut.
  It is performed in the following way.   The skin is drawn  as much  as
possible inwards, the double-edged narrow knife thrust in close on the in-
ner edge of the shin-bone vertically in such direction that the point should.
come out on the back of the  leg* rather outwards, and as close as possible
to the splint-bone.   The knife is then carried  down along the bones and
forms a flap about three fingers' breadth in length.   Both  corners of the
wound are then drawn  as  far out  as  possible, the knife placed  in the
upper corner,  and being thrust in  at the outer edge of the shin-bone,  so
that it runs over the  outside of  the splint-bone  into  the  lower corner of
the wound, forms a  second, corresponding  in  length to  the  first  flap.
The flaps being now  held back by an assistant, the operator cuts through
as  in the former manner with the eatlin, whatever remains attached to the
bones; applies the double cleft cloth  and saws through the bones.  The
dressing is to  be performed as in the flap-amputation through the thigh.
  If the skin be so firmly attached on the front of the shin-bone that it cannot be re-
moved as directed, a vertical cut must be made into it upon  the shin-bone, and the
edges of this cut drawn inwards and outwards*
  The outer flap may also be first formed by a semi-oval cut, which  beginning on
the  spine of the shin-bone terminates in the middle of the calf, by obliquely pene-
trating through the skin and muscles, and separates  the above-mentioned flap  to its
base, whilst all  the soft  parts are carefully detached from the bones.  The inner flap
is formed by placing the knife  in the  upper corner of the wound  and thrusting it
through the lower, and by drawing the knife down from within outwards.
  [Liston performs his  amputations of the leg with two flaps, " at one of two points
according to the circumstances of the patient, the bones being sawn either about mid-
way betwixt the knee and ankle, or close to their upper ends. (p. 379.)  The ends
of the bone  when sawn high, are not exposed to pressure, and then there is less oc-
casion for a muscular cushion.   A sort of anterior flap should be made below the
knee,  but it is short and thin;  the principal covering  is obtained from behind, and
the incisions must be so contrived that the edges and surfaces shall correspond.   A
proper fleshy cushion cannot be  got lower than the middle of the leg. * * * When
the right limb is the subject of operation, the point of the knife having been entered
on  the outside behind the fibula, is drawn upwards along the posterior border of that
bone,  with a gentle sawing motion for about a couple of inches, the direction of the
incision is then  changed, the knife being drawn across  the fore part of the  limb,  in
a slightly curved direction, the convexity pointing  towards the foot; this incision
terminates on the  inner side of the limb, and; from  this- point the  knife is pushed
behind the  bones and made to emerge near the top  of the first incision, the flap is
then completed.  All this is done smoothly and continuously without once raising
the knife from the limb.  The  interosseous muscular and ligamentous substances
are  cut; the anterior flap is drawn back, and its cellular connexions slightly divided s
      (a) Traite des Operations de Chirurgie, p. 568.  Paris, 1742.
      (6) Relation d'un Voyage a. Londres, p. 342.    (c) Above cited, p. 5f).
                                   57* 
674            AMPUTATION JliST ABOVE THE  ANKLE.
 both are held out of the way by the hands of the assistant, and the separation com-
 pleted with the saw.   By proceeding thus, all risk is avoided of entangling the knife
 with the bones, or betwixt them.  In dealing with the left limb, the  proceeding is
 very similar;  the internal incision is not made quite so long;  but it should still be
 practised, for  a longitudinal opening of about an inch or more in extent is more
 easily found in the transfixion, than the mere point at- which the anterior incision is
 commenced. * *  *  Amputation close to the  joint is performed^ precisely in  the
 same manner: the incisions being made so that the fibula is exposed,  and sawn im-
 mediately below, its  head, the tibia close to the tuberosity. *  * * The flap-opera-
 tion may occasionally require  to be  modified.  When muscular plethoric subjects
 meet with sudden  and severe  accidents, which demand immediate amputation, the
 large quantity of muscle which is necessarily left in the flap is liable to suppurate,
 to retard very much the patient's recovery, and sometimes to produce dangerous con-r
 sequences.  In such cases I have performed the following operation.  Supposing
 the left leg  to be injured, with a common amputating knife an interior  semilunar in-
 cision  is made through the skin, commencing from the inner side of the  tibia, about
 four fingers' breadth below its  superior extremity, and  passing over its anterior
 aspect.  A similar semilunar  incision is made at the posterior part of  the leg, its
 extremities joining the bones of the  previous incision.  The integument is then re-
 flected upwards to a  sufficient extent to cover the bones,  and the operation finished
 after the manner of the circular amputation.  In fact, this operation differs from the
 circular only in the form of the incision through the integuments." (p. 379-82.)
   FuRGUssoNrs mode of operating differs from Liston's in the front flap being shorter.
 He thus describes it:—"The heel of the instrument (an amputating knife seven
 inches long) should be laid, on the side of the leg furthest from the surgeon, and  the
 blade should then be drawn across the front, cutting the semilunar  flap of skin until
 its point come opposite to where the  edge was first laid on;  without raising the in-
 strument, transfixion should next be  made behind the bones, and the rest of the pro-
 ceedings conducted as in  other,instances, (p. 398.)  In  whatever part of the limb
the incisions are made, I. invariably  preserve a semilunar flap  in front,  varying in
length, in different cases from  half an inch to an inch.  I prefer this to the straight
incision across the  front, recommended by Mr. Hey, believing that  the  opposite sur-
faces will thus fit more acurately to eaeh other."- (p. 400.)]
   [The ordinary place of amputating thorough, the. leg is, as already mentioned, a
little below the knee, but formerly the

                AMPUTATION JUST ABOVE THE ANKLE
was commonly practised, though not laid aside, and very rarely performed ; it how-
ever requires some notice.
  The Dutch surgeon, Solingen, advocated the preservation of as much  of the leg
as possible, and- that the amputation should be performed  immediately  above the
ankle ; so that an artificial foot with^ narrow steel plates might be screwed on to the
sides of the leg, by which he is able to walk as. well as  on that  which he brought
into the world  with him.  And DioNis;(a) "is of the same opinion, advising the
cutting off a leg as low as, possible, provided we  find ourselves able to preserve
the motion of the knee." (p. 407.)  White  of. Manchester (b) also took  up  this
practice in 1761, in consequence of having seen in the previous year " a woman who,
twenty years before, had her leg taken off a little above the ankle, by advice of her
brother, who was a carpenter, and had promised to make  her a wooden  leg of his
own contrivance.  The surgeon at first refused to  amputate it  in this place;  but
being told if he would not, they would apply  to another, he consented to do it  con-
trary to his .own opinion.  The operation was performed by the single incision, and
the stump was twelve months in healing." (p. 169.)  He mentions  nine cases in
which he performed* this operation, and was fully satisfied of its superiority over the
ordinary mode.  In his earlier cases he employed a double flap,  butafterwards fol-
lowed O'Halloran's (c)mode  with a single flap, dressing it and- the face of the
        (a) Cours d'Operations de Chirurgie.   Translation. Edit, of 1710.
  (6) An Account of a new method of Am     (c)  A complete Treatise on Gangrene and
putatine the lea-  a little  above  the Ankle-  Sphacelus, with a new  method of Amputa-
joint. &c.; in Medical Observations and In-    tjoo
quiriee, vol/iy, 
         REPORT OF AMPUTATIONS THROUGH THE LEG.         675

stump  as separate wounds, and not applying the flap till the twelfth or fourteenth
day.
  Bromfield (a) also, from having noticed (about the year 1740) how well a woman
walked who had lost both her feet and about three inches of the lower ends  of the
bones of the leg by frost-bites, in his lectures, recommended "the operation, when
made below the knee, to be as nigh the ankle as the nature of the case would admit
of."  He  was, however, induced to  withdraw  this recommendation from " some
eminent surgeons, assuring him  it would be impossible to heel the stump if the am-
putation was made very low; for the tendons or  their thecse would  slough, and most
Hkely a second amputation might become necessary." (p. 189.)  These absurdities,
however, were disproved by some cases in which the operation was performed by a
pupil of his, named Wright, first in 1754, which encouraged Bromfield " to put
his theory in practice," and "since he received Mr. Wright's papers, he performed
the operation many times, and it  always succeeded." (p. 192.)   How  soon Brom-
field operated in this  way does not  appear, but his book was published  in 1773,
and  he there states he had operated  " many times."  Alanson also followed this
method, but applied the flap at once.   Hey (b),  however, disapprovedjof this prac-
tice in  consequence of "some oases  occurring,  in  which, from a scrofulous  habit,
the wound  would not heal completely, or remained healed, so that the patient could
neither bear the pressure of a socket, nor conveniently use a common wooden leg,
(as the length of the  leg projecting backwards  exposed the stump to  frequent  in-
juries,) I determined to try whether amputation  in a more muscular part of the leg
would  not secure a complete healing, and give the patient an opportunity of resting
his knee on the common wooden leg, or using a socket, as he might find most con-
venient."  (p. 540.)  He therefore amputated through the middle of the leg with a
single flap from the gastrocnemial muscles, making as Iconsider, a very inconvenient
stump.
  Solingen's operation had thus, in fact, gone completely out ofi use till, about two
or three years since, Lawrence performed it suceessfully  on a young gentleman
who had had his foot crushed.  Having become acquainted with this, and  having a
young woman under my care with scrofulous disease of the  foot-which she did not
object to part with, though  she was indisposed to lose her leg, I determined to prac-
tise it,  and  accordingly on March, 9, 1844,1 amputated three  inches above the ankle-
joint with a single flap from the back  of the leg with as much muscle as I could get
upon the knife, but the principal part of the flap  consisted of the Achilles' tendon.
Four arteries were tied, and the flap fixed with three sutures  and a wetoloth applied
for twenty  hours, when my assistant removed  the  sutures  and  applied straps of
plaster.- The  wound  healed very slowly, and  had  not  scarred  till after twelve
months, when it made a very good stump, and she walks very well on an artificial
foot.  The course of this case, is tediousness, and the expense  of the apparatus satisfy
me, though  it might be advantageously  employed with persons  in easy circum-
stances, that it is not a fit operation for those who have to labour for their living.
  In the accompanying report of fourteen amputations below the knee, it will be
seen that nine were primary, for  accidents, mostly very severe, of which two died,
and seven survived ; the other five operations for disease, in two  of which  a very
small portion of the spine of the shin-bone exfoliated, all terminated favourably, so
that the deaths on the  whole number was only 14-3 p&r cent.
  Liston's (c) reported cases of amputation through the leg are twenty ;  of' these
two were primary, and two secondary, for accidents,.all four recovered; one iniwhom
primary amputation, and a few  days after, secondary, of the other leg, fatal; nine
for scrofulous disease of the ankle, two for disease  of the foot, one for necrosis, one
for osteosarcoma,  one for ulcerated stump,  all which fourteen  recovered; and one  for
ulcer of the leg, who died.  Hence tke deaths on the whole number were lOper cent.
  These accounts do not confirm Lawrie's (d)  statement that " of the more com-
mon amputations, that below the knee is least favourable."   Neither do they sustain
his rule of  practice, " in all cases except those of necessity  (not a very comprehen-
sible expression, j. f.  s.) to abandon the operation below the knee." (p. 398.)]

  (a) Chirurgical Observations and Cases,    (c)  Potter; in Med. Chir. Trans., above
vol. i.                                  cited-
  (b) Practical Observations on Surgery.    (d London Medical Gazette, above cited.
Second  Edition. 1810. 
 676         REPORT  OF AMPUTATIONS THROUGH THE LEG.


Report of Fourteen Amputations through the Leg, from the year 1835  to 1840, inclusive.
Accident or Disease.
Operated
Remarks.
  Dis-
charged.
Died.
     1836
John Johnson,
 aged 36  (sailor,)
 admitted May 4.
Severe laceration of the
  muscles of the foot, and
  the innerplahtar artery
  torn,consequent on leg
  falling on the fluke of
  an anchor.
 May 4.
six hours
  after
accident.
     1837
John  James,  aged
 52, admitted April
 11.
Ueorge Powell,
 aged 22 (towing-
 rope man,) admit-
 ted  June |.
Fungous ulcer on heel, of
  eight mouths.
Severe laceration of lower
  part of left  leg,  and
  crushing  of the lower
  end of both its bones,
  by transit of  trait* of
  steam, earn ages.
April 23.
June 4.
an hour
 aftes.
By circular cut; six arteries  tied; in-
  teguments scanty, and could not be
  well brought together. Eight hours
  after, free bleeding, and three more
  arteries taken up.  Except having
  restless  nights, he  went  on  very
  well till the fourteenth night, when
  the stump was exceedingly painful;
  and  on  the   following  morning
  about  half an ounce  of arterial
  blood   was  discharged  from  the
  wound, but stopped by little  pres
  sure.  Next afternoon the  bleeding
  recurred  in a jet to four or six
  ounces; the bleeding part was there-
  fore cleared df clot, but no vessel
  could be found;  no more  bleeding
  occurred till early on the twenty
  second morning, ahd . then  to  such
  extent as  to render him faint; and
  this recurred twice in the  course of
  seven  hours,   but only in  small
  quantity.   The  wound  was laid
  open and  left till night,  when  as
  there was no  more bleeding it was
  dressed.  On  the twenty-third day
  he bled again; the granulations sur
  rounding  the  ligature, by the side
  of which the blood flowed, were
  separated, and a little cavity,  as
  large as a nut, found lined with  a
  polished membrane; and at its high-
  est part an aperture, as large  as  a
  pin-hole, through which the blood
  flowed.  This little sac could not be
  separated  from   the  surrounding
  parts, a probe was therefore passed
  into  the hole up the artery, and
  being felt externally, the skin was
  cut  through,  and the artery  tied
  an inch above the face of the stump
  No  more  bleeding  after  this, and
  he went on very well.
With single flap  of m.  gastrocnemii;
  three arteries tied;  much difficulty
  in  securing the  anterior  tibial.
  which retracted nearly through the
  interosseous ligament.  The flap
  brought together with three sutures
  and straps of  plaster; the sutures
  removed after forty-eight hours.
With circular cut; the muscles did not
  retract at all; three arteries tied
  did not lose  much blood, but was
  much  prostrated by the  operation;
  edges  of  wound  brought together
  transversely, and three sutures put
  in; the latter removed at sixty-nine
  hours.  On the ninth day the middle
  of the wound sloughy; and the skin
  having been pressed on the spine of
  the shin-bone,  had  a small gangre
  nous spot on it; suffered much from
  pain in the stump.  On the fifteenth
  day this  had  cleared  off,  but  the
  stump was still sloughy, and the ab-
  sorbents up the thigh had inflamed.
  In the evening of this day had se
  vere pain at the pit of the stomach,
  which subsided after cupping.  A
  small bit  of  bone exfoliated from
  the spine of the shin-bone.
June 30
June 20
July 11 
REPORT OF AMPUTATIONS THROUGH  THE  LEG.            677
     1838
James  Trussler,
 aged 27 (excava
 tor,) admitted Ja-
 nuary 12.
Thomas Berridge,
 aged  44  (ware
 houseman,)   ad
 mitted April 10.
Accident or Disease.   °Perated
Compound fracture  of
  tarsal bones of left foot,
  with  large  laceration
  and  wound of ankle-
  joint,  by  transit  of
  steam-carriage on rail-
  road.
Strumous abscesses in the
  ligaments of the tarsus
  and metatarsus,of seven
  months' duration.
     1839
Barnard Lane,
 aged 54 (porter,)
 admitted Jan. 31
George Stilt, aged
 33 (labourer,) ad
 mitted March 2.
Compound fracture of the
  right leg, with protru-
  sion of the shin-bone;
  consequent on bag of
  wool falling upon him.
  On the second evening
  there was slight arterial
  bleeding,which recurred
  on the slightest move-
  ment, and continued.
  The   wound   became
  gangrenous on the third
  day ; and seemed likely
  to spread,as he was fast
  hurrying into  a typhoid
  state.
Compound fracture of left
  leg. with severe lacera-
  tion, and the shin-bone
  protruding.  Great de
  pression on  his admis-
  sion.
 Jan.12
  Three
  hours
and a half
  after
 accident.
June 2..
 Feb. 2,
Midnight.
 Fifty-
 seven
 hours
  after
accident.
March 3-
Twenty-
six hours
  after
accident.
Remarks.
With single flap ofm. gastrocnemii; six
  arteries tied; too much muscle and
  too little skin,  therefore part of the
  former left protruding, and the rest
  supported  with  two  sutures and
  plaster; sutures removed at forty
  two hours, and a small  vessel which
  had continued  oozing, was  tied
  On the seventh day the wound was
  sloughy, and there was slight  arte
  rial bleeding; on the eleventh a sud
  den gush of arterial  blood to the
  amount of  half-a-pint,  occurred,
  which  depressed him  very much
  the flap was therefore opened, and
  a cavity found behind the interos
  seous  ligament,  which  had  been
  formed by a muscular branch in the
  flap bleeding into this part when
  the  flap had been  brought to its
  place; it was tied, and the bleeding
  ceased.  On  the forty-seventh day  a
  small  piece of  the end of the spine
  exfoliated.

With circular cut;  he suffered exces-
  sively during the operation, and in
  sawing through the bone-more  than
  I had ever witnessed.  The muscles
  did not retract; did not lose above
  two or three ounces  of blood; three
  arteries tied, and  edges of  wound
  brought together obliquely  with
  strips  of plaster;  an  hour after
  very free dripping of blood,  and on
  opening stump five more were taken
  up;  the stump left  open, and six
  hours after three more, after which
  the wound  was  brought together
  with strips of plaster.

With the circular  cut; very free bleed-
  ing at  the operation; three arteries
  and  the posterior  tibial vein  tied;
  the wound brought  together  hori
  zon tally with straps of plaster.  He
  improved  at  first after the opera
  tion;  but on the evening  of the
  fourth day after the operation, be
  came suddenly  and violently deliri
  ous.  On thejf/tA he began to vomit
  frequently,  and  the  stump  was
  sloughy; next day  he was  better
  On the eighth day was attackedwith
  trismus, and could scarcely swal-
  low even his spittle; the muscles be-
  tween  the lower  jaw and hyoid
  bone were violently contracted, and
  the latter forcibly pulled up between
  the  branches of the  former.  On
  the ninth had  some severe spasms
  about the throat like those of a hy
  drophobir. patient when  about  to
  drink.  On the  tenth day became ge-
  nerally tetanic, in which state he
  continued till death.

With circular  cut;  lost very  little
  blood; two arteries only tied; wound
  brought together horizontally,  with
  a single strap of plaster; the dress
  ing completed four hours after  with
  plaster.  Fart  of the  stripped-up
  Bkin had been used for  the covering,
  but this sloughed, as did afterwards
  the whole of the skin saved;-the
  wound healed  kindly by granula-
  tion.
  Dis
charged.
May 29
Sept. 18
May 29
Died.
Feb. 12.
Ten days
  after
operation. 
678              REPORT  OF AMPUTATIONS THROUGH THE LEG,
Accident or Disease.
Operated
   on.
Remarks.
 Dis-
charged
Died.
     1839
    continued.
John Cartwright
 aged 52 (labourer)
 admitted May 28.
Sarah  Hattam,
 aged 57, admitted
 Sept. 10.
Ulceration  of cartilages
  of the tarsal and meta
  tarsal joints of the left
  foot;   consequent  on
  sprain  fifteen  months
  since.
Dry gangrene  of toes of
  right foot.
June 15.
Nov. 26.
Jesse Gooderich,
 aged 15£, admit-
 ted Sept. 20.
     1840
James  Neal,  aged
 12, admitted Jan
 18.
Severe laceration of the
  skin and muscles of the
  left  foot  and  ankle;
  consequent  on  wheel
  of rail-carriage passing
  over it.

Severe laceration of the
  skin and muscles of the
  upper part of the calf of
  the  leg and fracture of
  the fibula; consequent
  on  being caught in  a
  tobacco-cutting engine.
 Sept. 20.
  Seven
hoursafter
 accident
 Jan. 18.
  Three
  hours
and a-half
   after
 accident
William ShearingjUlceration of the leg and
aged  33 (actor,)
admitted Feb. 4.
parti al pes equinus after
compound  fracture of
the right leg four years
since.
With circular  cut; five arteries tied,
  and two more two hours afterwards.
  Ten hours after  the  operation the
  wound was  brought  together hori
  zontaily, and fixed with four pins
  and twisted  suture; these were re
  moved after fifty-eight hours and a
  half;  surface  of  stump  became
  sloughy.

With circular  cut; four arteries tied
  at  the  operation,  and  four more
  seven hours  after, and  in  another
  hour a ninth, and then the stump
  dressed with plaster. Free oozing
  of  bloody serum  for several  days
  On the tenth day the greater part of
  the skin covering the face  of the
  stump was sloughy; ten days after
  the line of demarcation became dis-
  tinct,  and  healthy  pus  secreted.
  The wound afterwards  granulated
  kindly as her health improved, but
  had not healed when she left.

With circular cut;  six arteries tied ;
  wound  brought  together horizon
  tally with straps of plaster; no irri
  tative fever.
With flap from inside of leg; removed
  the broken fibula at its joint; seven
  arteries and the posterior tibial vein
  tied, and soon after another artery
  was tied; a single strap was put on,
  and the wound dressed  properly
  eight hours  after.  On fifteenth day
  some bleeding, from one of the liga-
  tures having been dragged accident-
  ally; on the  next  day bled  again,
  from a little superficial vein, and at
  each of the two following dressings.
  One of the ligatures remaining fast,
  a whalebone spring was put on it
  on the  thirty-ninth  day;  it  came
  away  three days  after.  On  the
 fifty-first day some swelling  upon
  the m.  vastus  internus, which  he
  says  has been coming on  a few
  days, it fluctuated; was left alone,
  and filled the whole  of the front
  sheath of the fascia  lata.  On the
  hundredth and second day this was
  punctured, and a pint and a-half of
  pus discharged. The abscess filled
  again, pointed at the  great trochan
  ter twelve days  after, and two pints
  of pus  discharged by puncture.  A
  fortnight after, when the discharge
  of pus had nearly ceased,  the upper
  part of the thigh was attacked with
  erysipelas,  which spread over the
  loins and back, on the left side of
  the belly, and did not subside for a
  week; after this he slowly recovered.

With flap of the m. gastrocnemii; four
  arteries tied, and bleeding still con
  linuing three hours after, five more
  were tied, and the face of the stump
  left open.   Eight hours  from the
  operation three more arteries were
  lied, and the wound  brought toge
  ther with straps of plaster.  Went
  on well, but slowly; excepting that
  one ligature would not come away
  and, therefore, on the forty seventh
  day,  a  whalebone spring was put
  on; but two days after the ligature
  broke off short and remained.
Aug. 27
Feb. 4.
Nov. 13
June 16. 
AMPUTATIONS THROUGH THE UPPER-ARM.
679
     1840
   continued.
Philip Jas. Punch,
 aged 14, admitted
 May 23.
Accident or Disease.
Michael Daly, aged
38, admitted May
26.
Compound fracture of the
  right tarsal-bones  and
  inner ankle, with great
  laceration  of the  soft
  parts, and the posterior
  tibial artery and^nerve
  torn through at ankle;
  consequent  on  being
  caught   between  the
  spring and wheel of a
  locomotive carriage,

Compound fracture of left
  leg; the shin-bone com-
  minuted; skincutclean,
  but  the  muscles much
  lacerated;  consequent
  on locomotive carriage
  wheel passing over.
Operated
   on.
Remarks.
May 23.  With circular cut, and side cuts; two
 Four    arteries tied; and the wound brought
 hours    together at once with straps of plas
 after    ter horizontally,
accident.
 May 26.  With circular cut and side cuts; six
  Four    arteries tied; venous bleeding great;
  hours    wound brought together  at once
and a-half  with straps of plaster.  An hour
  after    after, bleeding came on, and  two
 accident.   more arteries were tied; but it con
          tinued, and seven hours after seven
          other arteries were tied. Fivehours
          after, the bleeding continued to the
          amount of twelve ounces, and three
          more arteries were tied. The stump
          was then left open, and not. dressed
          with plaster till twenty-six\ hours
          after the operation. On the fourth
          day th? edge of the ski n was sloughy,
          and the whole of the face of the
          stump became so afterwards; on the
          following day irritative fever set in.
 Dis-
charged.
Died.
July 18,
 June 7.
 Twelve
  days
  after
operation.
        III.—OF AMPUTATION THROUGH THE  UPPER-ARM.

   (Amputatio Brachii, Lat. ; Amputation des Oberarmes, Germ.; Amputation du
                                   Bras, Fr.)

   2724. Amputation through the upper-arm may be performed with  the
circular cut or with flaps, and both are performed in the same way as in
the thigh.   The patient is placed on a chair, and the upper-arm separated
from the trunk, so as to form a right  angle.   If the amputation  be per-
formed in  the lower third, or in the middle of the arm, the brachial artery
must be compressed by an assistant in its upper third.   If the amputation
be performed in the upper third, the subclavian artery must be compressed
above the clavicle against the first rib.
   [In amputating through the upper arm it is always advisable to  make the stump
as long as possible; as thereby an artificial arm is better fixed, and is rendered more
useful.
   In the accompanying  report five of the amputations through the  upper arm were
primary, and one secondary for accidents; all recovered, but in two of them a narrow
ring of bone exfoliated.
   Liston's amputations through this limb are seven, of which one was primary for
accident and lived ;  four for scrofulous disease of elbow, of whom two died; one for
disease of elbow consequent on burn, and one for senile gangrene»both of whom re-
covered.  Thus, the deaths on the whole number were 28.5 per cent.] 
680
REPORT OF AMPUTATIONS THROUGH  THE  UPPER ARM.
Report of Six Amputations through the Upper Arm, from the Year 1835 to 1840, inclusive.
Accident or Disease.
      1835
Edward  Walpole, Gangrene of fore- and up
aged 31, (wagon-
er,) admitted Feb.
9.
      1836
James Cook, aged
 8£, admitted July
 25.
per-arm, consequent  on
a blow from a box ten
days since on the former.
Was fast sinking at the
time  of  operation,
consequence of irritative
fever and diarrhaa,
MurtaghDowning
 aged 20(machine-
 boy,)    admitted
 Sept. 3.
     1838
Daniel Edwards,
 aged 50 (excava
 tor,) admitted Fe
 bruary 22.
William Beevers,
 aged 27 (stoker,)
 admitted Feb. 23
John Hall, aged 14,
 admitted Feb. 17,
Severe laceration of skin
  and muscles around  the
  elbow, consequent on re
  ceiving the discharge,of
  a carronade close by him.
  Said not  to  have  lost
  much blood. The radius
  was fractured,  but  the
  brachial  artery and  el
  bow-joint  were  unin-
  jured.
Compound  fracture of  the
  left   olecranon,    with
  wound into joint, and
  extensive laceration of
  the skin   and  muscles;
  consequent  on  having
  been caught by the drum-
  strap of a printing-ma-
  chine.
Severe laceration  of skin
  of the back of the hand,
  and of adducting mus
  cles of the thumb, con
  sequent   on  earth-slip
  falling on him.  A  fort-
  night after, great suppu
  ration, irritative fever,
  and erysipelas came on,
  which extended  above
  the elbow; sloughing of
  cellular  tissue of  fore-
  arm.   Troubled  much
  with cough, and  bowels
  very lax;  and he became
  much exhausted.  Bleed
  ing to the amount of two
  ounces from an  artery
  near the wrist.
Extensive laceration of the
  skin of the right forearm,
  with some laceration of
  muscles,  and the  skin
  separated some distance
  above the elbow, conse-
  quent ou  being jammed
  between    steam-engine
  shaft and deck timbers

Compound fracture of the
  right upper and fore-arm,
  with severe laceration of
  soft parts, consequent on
  cart wheel having passed
  over the arm whilst fal
  len on a rail road.
Operated
 Dis-
charged.
  Feb. 17. With circular cut through insertion ofm. coroco- April 19.
 Eighteen   brachialis;  the parts  All  so glued together
days  after  that the skin could not be retracted, but was
 accident,   dissected up.  A portion of sloughy skin was
            included  in the  cut, which also divided a
            sinus close  to the bone.  Four arteries were
            tied: wound brought together with straps of
            plaster.   Felt better next day,  but on third
            day had hiccough, with cold sweats; these,
            however, soon subsided.   On fourth day the
            bone protruded; on the following day was
            attacked  with erysipelas of the ears and
            face; on  the eighth day  was delirious, but
            better on the tenth, and  then  steadily im-
            proved.  On the  thirty-eighth  day a ring of
            bone was easily removed, and soon after the
            bone was covered with granulations, which
            skinned slowly,  and  the wound  had not
            healed when he left.
 July 25.  With circular cut, just above insertion of m. Sept. 17.
   Two      deltoides; four arteries  tied;  the brachial
  hours     exceedingly small; the wound was dressed
   after      With straps of plaster four hours after; went
 accident.   on  very well, and in a  month the wound
            healed, except opposite  an edge  of bone
            which seemed likely to  exfoliate, but it
            did not, and the bone  was completely cover
            ed before he left.
 Sept. 3.
  Two
  hours
  after
accident.
 April 17,
Fifty-four
days after
 accident.
Feb. 23.
 Nine
 hours
 after
accident.
 Feb.  17.
  Nine
  hours
  after
accident.
With circular cut; through insertion of m. del- Nov 1.
  toides, but some  of the detached skin was
  used to cover the slump,  as there was not
  enough without.  Three arteries were tied,
  and the wound brought together with  three
  sutures and straps of plaster;  sutures re-
  moved  at  seventy-two hours.   About the
  tenth day there was a little sloughing at the
  edge of the detached skin

With circular cut,  and two side cuts; five  arte- June5.
  ries tied;  very little bloo  lost;, three hours
  after the wound was brought together with
  straps of plaster; went onwel) for a fortnight
  then flagged, but soon rallied.
Withaflap of the separated skin, and a circu-
  lar cut through the muscles, about middle
  of arm;  the muscles did not retract at all;
  four arteries tied; wound  brought  together
  with two sutures;  and  six  hours after,
  dressing, completed with strips of plaster;
  sutures removed it forty-five hours; the skin
  sloughed, and the stump healed by granula
  tion.

With circular cut; in making which, the mus-
  cles had been separated  beneath  from  the
  skin, burst out, and  became tightly girt by
  it;  three arteries  were tied; a single strap
  put on, and the  dressing completed with
  straps of plaster twelve hours after.  On
  Ihe fourth day part of the skin covering the
  stump was sloughy, and  afterwards sepa-
  rated; the bone protruded, and about two
  months after the  operation  a narrow ring
  of bone was removed.
April 10.
April 28. 
[   681   ]
          IV.—OF AMPUTATION THROUGH THE FORErARM.

(Amputatio Antebrachii, Lat.; Amputation des Vorderarmes, Germ.; Amputation de
                            VAvant-Bras, Fr.)
   2725.  The fore-arm may be amputated with the circular cut, with two
or with one flap.  The patient either sits on a chair or lies near the edge
of his bed.   The brachial artery is compressed by  an assistant, or with a
tourniquet,  in the middle of the upper-arm ;  the  fore-arm  held by one
assistant at its lower,  by another at its  upper part horizontally, and in a
position between pronation and supination ; the latter assistant at the same
time drawing back the skin moderately tight.  The operator places him-
self on  the outer side  for the right, and  on the inner side for the left arm.
   2726.  The practice with the  circular cut  is  precisely the same as that
for amputation through the leg.   Both  bones  must be sawn through at
once.
   Amputation with a  single flap is performed with  the  flap on the inner
(front) surface of the  arm.  At the part where  the bone is to be sawn
through, the narrow double-edged knife is to  be  placed vertically upon
the radius,  and  whilst with the  fingers of the left hand the skin and mus-
cles are drawn inwards (forwards,) the knife is passed vertically on the
inside (front) of the bones, so that its point may project on the ulnar side,
directly opposite the point of entrance;  it is then carried down along both
bones,  and  with its edge inclined  outwards  (forwards) cuts out.  The
length of the flap  must depend on  the thickness  of the  fore-arm (par.
2721.)   Upon the back of the  fore-arm and a finger's  breadth from the
two angles  of the wound, the skin is to be cut through with a transverse
cut, dissected back to the angles, and the operation completed as in the
flap-amputation of the leg.
   If two  flaps be made, the first is to be formed as just mentioned, the
knife is then placed in the upper angle  of the cut, carried on the outer
(hind) surface of the bones into the lower angle and then forms a second
flap corresponding to  the first in length.   Both are then held back, so that
whatever remains attached to the bones, and the interosseous membrane,
may be divided as in  amputation of the leg.  The doubly cleft cloth is
then applied and the  bones sawn through.
  In amputating through the fore-arm there should be, as through the leg, sufficient
skin to cover the ends of the bones completely.
  After  the circular cut, three or four ligatures are usually sufficient for tying the
vessels,  and of these, the  interosseal artery requires the pressure on the brachial artery
to be relieved, so that its mouth may be seen.
  In single flap-amputation tying the vessels  is more tiresome, and with  two flaps
even eleven arteries may be tied (a).
  [Not unfrequently in flap-amputations through the fore-arm, the muscles retract
less than the  skin after division, and consequently the tendons are often left project-
ing and cannot be properly got in, on closing the wound.  When this happens, as
it does most usually in the lower third of the fore-arm they should be shortened about
an inch with  the knife.  It must also be recollected, that the ends of the radial and
ulnar arteries are to be looked for at the edge of the front flap, and sometimes the
muscles  will  have retracted from them so much that they actually stand out, and for
the moment may be mistaken for little tendons.

                        (a) Klein, above cited, p. 46.
  Vol. hi.—58 
682    REPORT OF AMPUTATIONS  THROUGH  THE FORE-ARM.
  Amputation through the fore-arm should always be made as near the wrist a9 pos-
sible, so that the socket of any kind of artificial hand may have better hold.
  The amputations I have performed through the fore-arm were only five ; of these
one was primary for accident, and  four for scrofulous and other diseases.   I have not
here included another amputation  through the fore-arm  for accident, as the patient,
Henry Parker, has been already mentioned (p. 666) among the fatal cases of ampu-
tation through the thigh.  This second operation was performed twenty-six hours
after the accident.
  Liston's cases were six, of which four were for scrofulous disease ; one for ence-
phaloid disease of the hand; one for painful stump, all of which recovered.]
Report of Five Amputations through the Fore-Arm from the year 1835 to 1840 inclusive.
     1831
Samuel Winter,
 aged 68 (labourer)
 admitted June 20.
     1838
Thomas Voung,
 aged  42 (water-
 man.)  admitted
 March 24.
     1839
Henry Brewer, _
 aged 36, admitted
 Sept. 10.
     1840
Benjamin Neal,
 aged  15|,  admit-
 ted Jan. 17.
William Dodds,
 aged  35, (tailor,)
 admitted May 19.
Accident or Disease.
Scrofulous disease of right
  wrist-joint, of eighteen
  months.
Contraction of the anus
  cles  pf  the hand and
  fingers  after  diffuse
  cellular  inflammation,
  nine months since.
Scrofulous ulcers on right
  hand, with stiff fingers.
  Disease first showed it-
  Self twenty-ene months
  since.
Compound fracture of the
  first three metacarpal
  bones, and severe lace-
  ration of the skin and
  muscles.

Medullar  sarcoma  of
  right raMfut; first com
menced
since.
four  months
Operated
July 21.
March 31
Oct. 10.
 Jan. 18.
 Twenty-
four hours
  after
 accident

 July 18.
Remarks.
With two flaps just above m. pronator
 qaadratus; three arteries were tied
 and the flaps brought together with
 three sutures and strips of plaster.
 In the evening felt severe smarting
 in the stump; became sickish, and
 constantly  retching;  about four
 hours after vomited profusely, and
 the smarting subsided. Sutures re
 moved at forty-four hours.

With twoflaps; two arteries tied, flaps
 brought together with four sutures
 and straps  of plaster; sutures  re-
 moved at forty-six hours. Attacked
 with vomiting on third day, but not
 continued.  On fourth day stump
 attacked  with  erysipelas, which
 subsided after two days. On twenty-
 sixth day a.  whalebone spring ap-
 plied to the remaining  ligature
 which would not come off, and after
 wearing for  ten days it was pulled
 out.

With twoflaps; five arteries were tied,
 and the wound  brought  together
 with straps of plaster; but free ooz
 ing continuing.it was opened again,
 and two more arteries were tied;
 the dressing left for a few hours.

With twoflaps; four arteries tied; the
 flaps brought together with straps
 of plaster five hours after.
With twoflaps; five arteries were tied;
 the venons  bleeding very free, as
 the veins were  very bulky. Flaps
 brought together with plaster three
 hours after.
  Dis-
charged.
Sept. 2.
MayS-
March S-
    V—AMPUTATION THROUGH THE METATARSAL AND META-
                                CARPAL BONES.

(Amputatio Metatarsi et Metacarpi, Lat.; Amputation der Mittelfuss-und Mittelhand-
       knochen, Germ.; Amputation des Os du Metatarse et du Metacarpe, Fr.)

   2727.  Amputation through the metatarsal bones is differently perform-
ed, according as the metatarsal bone of the great or little  toe, or of those
between  them are  to  be removed; and according as  the soft parts are
more or less destroyed. 
         AMPUTATION THROUGH THE METATARSAL BONES.     683

   The tourniquet should be applied  above the knee and intrusted to one
assistant;  another holds the foot, and a third draws the toes asunder.
The patient is to be placed as jn amputation through  the leg.
   2728. Amputation through the metatarsal bone  of the great toe is per-
formed in different ways,  according as the  condition of the soft parts
admits the formation of an inner, upper, or under flap.
   2729. If the flap be formed from  the sole, the  operator, when the left
foot is operated on, grasps the great  toe, and draws it inwards, whilst an
assistant draws the next toe outwards; but if the right foot be operated
on, the operator grasps the second toe and draws it  outwards whilst an
assistant draws the great toe inwards.   The knife is now carried between
the toes vertically, along the outside of the  great metatarsal bone, to the
part where it  is to be sawn through.   The  knife is next placed on the
inner side of the bone,  at like height with the angle of the first cut, near
the lower edge of the bone, and makes, as it is drawTn out along the under
surface of the metacarpal bone, to its junction with the toe, a cut which
separates the  soft parts.  The two cuts are now  united by a transverse
one running over the dorsal surface of trie metatarsal bone about two lines
below the angles of the  two wounds; and a second transverse cut on the
sole connects  the  front  angles of both side cuts.  The  two  flaps thus
bounded are separated from the bone as far as the upper angle of the side
cut, turned back and held  by an assistant, who at the same time draws
back the skin  on the dorsal surface of the foot as far as possible, whilst
the operator pulling the toe well inwards, away from  the  others, carries
a narrow knife upon the back of the foot into the angle of the outer cut
between the two bones, guides its edge towards the great metatarsal bone,
cuts through the tendon, which he fixes with the  thumb of his left hand,
and carries the knife at  the edge of  the  retracted skin, over the dorsal
surface of the  foot inwards, to cut through every thing remaining attached
to the bone.   The knife is then passed  from the  sole, between the two
bones, and carried along the edge of the retracted flap upon  the under
surface of the  bone inwards.  All the soft parts having been thus divided,
are held back by a cleft cloth, and  a thin splint  being passed between
the two metatarsal bones  and  held  by an assistant,  the  bone is  sawn
through with a bow saw at the edge  of the retracted skin.
   The bleeding is stanched either by Jying the vessels or by cold water,
and after the wound has been properly cleansed,  the flap is laid  up  over
the bone in such wray that  its front edge is brought in close to the edge
of the skin on the  dorsal surface of the foot, and here fixed by several
straps of sticking plaster applied from the sole.  The edges of the wound
on the second metatarsal bone  are  also brought  together with sticking
plaster.
  Cutting through the tendon is often very troublesome;  it is best done by thrusting
the point of the  knife between  it and the bone, with the edge toward the tendon, up
to the broad part of the blade.
   2730. When the condition of the soft parts requires the flap to be made
on the inner side  of the metatarsal bone of the great  toe,  the skin  there
must be drawn inwards with the  thumb and fore-finger of the left hand, a
straight knife thrust in vertically on the outer edge of the  bone, about a
finger's breadth from its tarsal junction, its point carried on the inside of
the bone to the sole, and pushed  through.   The  knife is then carried 
684     AMPUTATION THROUGH THE  METATARSAL BONES.


close along the bone, on its inner edge, to its junction with the great toe,
and there cuts out obliquely.   A cut lengthwise between  the great and
next metatarsal bone is now made in the same manner as in the former
case, and continued to like height with the flap-cut; the flap is then held
back, the knife placed in the upper angle of the longitudinal cut between
the two bones, and carried over the  back of the  metatarsal bone to  the
angle of the flap-cut.  The knife is  next passed in below, between  the
bones, and carried round semicircularly, in  the sole, to the lower angle
of the flap-wound, and thus the division  of all the soft parts still remain-
ing attached to the bone completed.   The  cleft cloth having been now
applied, the bone is sawn through  in the same way as directed in the
former case, and after the  bleeding has  been  stanched, the flap  is laid
down over the bone on the corresponding wound-surface of the second
metatarsal bone, confined with plaster, and dressed as already mentioned.

  Where the condition of the bone permits, it is best sawn through obliquely from
within outwards, so that the cut surface may correspond with the inner edge of the
foot, by which the projection of the stump of the bone is prevented.  In doing this,
the longitudinal  cut between the two metatarsal bones should end half an inch be-
low the beginning of  the flap cut, and the upper and  lower cuts through the skin,
tendons, and periosteum, connecting the two longitudinal cuts, carried obliquely from
the one to the other, and the bone sawn through in a corresponding direction (a).

   2731. When it is requisite to make the flap on the dorsal surface of the
metatarsal bone of the great  toe, a cut is made lengthwise between the
first and second metatarsal bones up to the part where the bone is to  be
sawn through ; next a longitudinal cut along the inner edge of the great
metatarsal bone, and both connected by  a transverse cut behind the head
of the bone.  The  flap thus bounded,  is  separated from the side cuts,
drawn back by an assistant, and, as in the formation  of the flap on the
sole, every thing covering the bone is  divided by two semicircular cuts,
at the edge of  the retracted flap.  The sawing through the bone and the
dressing are to be as already directed.

  Amputation of the metatarsal bone of the little toe is precisely similar to that of
the great toe.
  [These amputations of the great toe are exceedingly neat and well-looking opera-
tions, and if the  metatarsal bone be sawn obliquely as Chelius directs, but little de-
formity ensues.   Unfortunately, however, it often  happens, especially in working
people, that the flexor muscles of the other toes are incapable of sustaining the longi-
tudinal arch of the foot, the great support of which is lost by the removal of the ball
of the great toe,  and the absence of firm attachment for the great flexor tendon of that
toe, in consequence of which the whole inner edge of the foot comes to the  ground,
and the weight of the body upon the flap.  The irritation to which its scar is neces-
sarily subject, often also causes it  to ulcerate, and a very troublesome and inconve-
nient sore, which completely lames the patient, is produced.   I have seen this occur
two or three times; for although  the patient  had left the surgeon's  hands with a
very good-looking and well-shaped  foot, yet a few months after he has returned in
the condition I have just described.   The surgeon should, therefore, always endea-
vour to save the  great toe, if possible; and if its amputation be absolutely necessary,
I think amputation through the whole  metatarsus, or even above the ankle better, for
a working man certainly, than amputation through the great metatarsal bone.
  Amputation through the little metatarsal bone is not liable to these objections, at
least not to the same extent, because the weight of the body is thrown more on the
inner than on the outer side of the foot.—j. f. s.]
   2732. Amputation through  the intermediate metatarsal  bones is thus
(a) Zang, book iv. p. 184. 
         AMPUTATION THROUGH THE FINGERS AND TOES.     685

performed.   A longitudinal cut is made on each side of the diseased me-
tatarsal bone, by carrying the  knife close along it, to the place where it
is to be sawn through, in such way, however, that, on the sole, the cuts
run into each other, in a V like shape, and one of them, for instance, on
the left foot that on the outer, and  on the  right that on the  inner side,.
should be three or four lines shorter than its fellow.   The skin upon the
dorsal surface  of the foot is  next cut through obliquely,  from the angle of
one to that  of the other longitudinal wound, about two lines before the
place of sawing.  The skin is now to be  drawn back, and  all the soft
parts separated by passing the knife between the  bones on the sole and
on the dorsal surface of the  foot, in the oblique direction of the  skin cut.
The cleft cloth is now applied, the wooden splint passed in, up to the
top of the side cut, and the  bone divided obliquely with a  fine saw from
side to side.  When the  bleeding has been stanched,  the neighbouring
bones are brought together, and  the skin brought over the  end of the
bone, by straps of plaster applied from the  top  of the  foot downwards.
The edges  of the wound are to be  kept together with several circular
straps round the foot, and a simple covering (o).
  2733. Amputation through  the metacarpal bones is performed in exactly
the same way  as that through ihe metatarsal bones, already mentioned.
  Of the above modes of proceeding it must be decided which shall be followed, for
the removal of some or all the metacarpal bones, except that of the thumb.
  For amputating through the metacarpal bone of the thumb, a flap must be made on
the volar surface, the soft parts on the back of the hand, divided correspondently with
the base of the flap ; then those in  the space between the bones divided, and the me-
tacarpal bones sawn off.
  [In amputating through the metacarpal bones, and  specially if only the head of
the hone be cut off, as commonly practised, when the whole finger is to be removed,
as the other.fingers fall readily  together, and  do not produce the deformity which
amputating at the knuckle does, it  is better to cut through the bone with nippers than
with a saw.   Liston observes :—" In using the forceps, the flat side is applied to-
wards the trunk, so that the  surface which is left may be perfectly smooth.  One.
great advantage gained by employing the forceps is, that the palm can be left entire,
the  hand is much less deformed, the palmar arch  is in general not interfered with,
and the haemorrhage is accordingly more trifling." (p. 365.)   I do not think the
palmar arch is more safe with the nippers  than with the saw,  as the soft parts re-
quire equal separation in both.—j. f. s.]
     VI.—AMPUTATION THROUGH THE  FINGERS AND TOES.

  (Amputatio Digitorum Manus et Pedis, Lat.;  Amputation der Finger und Zehen,
               Germ. ; Amputation des Doigts et  des Orteils, Fr.)
   2734. Amputation through the phalanges of the fingers is only indicated
when some particular advantage is to be gained by keeping the stump, as in
amputating the fore part of the second phalanx;  in all other cases, dis-
jointing the phalanx is to be  preferred.  In the toes, amputation must be
restricted to that of the first joint of the great toe ; because, by preserving
the ball of that toe, advantage is gained over disjointing it.
  Amputation of the phalanges, by means of sharp nippers, performed in the earliest
times; or with the chisel, recommended by Heliodorus, Paulus jEgineta, and Al-
bucasis, and subsequently by many other writers, both within and without the joint,

                         (a) Zang, above cited, p. 187.
                                  58* 
686
OF EXARTICULATION.
is  entirely discarded ; and  in general, the disjointing of the phalanx is preferred.
Le Dran, Guthrie, Samuel Cooper, Langenbeck, Averill, Rust, Malgaigne,
and Jaeger agree in preserving the phalanx, and as to the advantage of amputa-
tion, though they differ from each  other in regard to  its application .to a  single
finger.  Ru§t holds only with the amputation through the second phalanx of the
fore- and ring-fingers, and forbids it on all the phalanges of the two middle-fingers.
Langenbeck practises it on the first and second phalanx of the fore- and ring-finger,
and on the first of the thumb and little finger.  Averill, on the other hand, employs
it only for the thumb and fore-finger.  Jaeger thinks it maybe performed  at the
second phalanx of the fourth finger, with much advantage to the patient, especially
the further forward it is done; and knows from experience that with the phalanges of
the three outer fingers Which can be  drawn  into  the palm, better resistance can be
produced.
  Langenbeck, Zang, Rust, and Jaeger, are all in favour of amputation through
the first phalanx of the great toe.
   2735. In amputation through  the phalanges, the  skin having been pro-
perly drawn back, a circular cut is made with a scalpel, the skuTagain
drawn back, the tendons  and periosteum divided, sawn through, and the
bone then sawn  through.   If the skin  on the back,of the finger be too
much destroyed, or the  phalanx too thick and broad, as that of the great
toe, a  flap  may be made on  the palmar surface, by thrusting  the  knife
through  there, and dividing the soft parte,on the back with a semicircular
cut, which is better than  a dorsal flap,  or than a flap before and behind,
or on the side.   (Langenbeck, Zang.)
   In cutting the finger off with a chisel j {Dactylosmileusis, Lat.,) the fin-
ger must be laid on its  dorsal surface on a little wooden block, and held
by an  assistant,  who  at the same time draws the  skin back: a  sharp
chisel, as  wide  again as the finger, is to  be placed vertically on  the
palmar surface, and  held with the left  hand, and the finger is struck ofl
with a smart blow* from a wooden mallet.    In this way, which is gene-
rally objected to  as  rough and barbarous,  and  only  recommended by
Graefe  and Jaeger,  there  is  not any splintering;  the operation is
quick and little painful, and the  cure  is not more tedious  than in the
operation with the circular cut (a).
   Mayor (b) has recommended the removal of the phalanx by a peculiar instrument,
the tachytome, with which, at the same time, sufficient flaps of the soft parts are
formed.
Fourth Section.—OF EXARTICULATION, OR AMPUTATION THROUGH
                             THE JOINTS.
(Exariiculatio Membrorum, Lat.; Ablosung der Gleider, Germ.; Disarticulation, Fr.)
  Brasdor, Essai sur les Amputations  dans  les Articles;  in Memoires  de l'Aca-
demie de Chirurgie, vol. v. p. 747.
  Walther,  Ueber  die Ampntationen in den Gelenken; in Abhandlungen aus
dem Gebiete  der praktischen Medicin, besonders der Chirurgie und Augenheil-
kunde, p. 91.  Landshut.
  Munzenthaler, Versuch iiber die Amputationen in den Gelenken.   Leipzig,
1822.
  Lisfranc, Memoire sur les regies generales des Disarticulations ; in Revue Me-
dicale, 1827, vol. i. p. 373.
  Scoutetten, La Methode Ovalaire, qu Nouvelle methode pour amputer dans les
Articulations.  Paris, 1827.  4to.
  Zanders, Die Ablosung der Glieder in Gelenk.  Dusseldorff, 1831.
  (a) Schkeiber, Dissert, de Dactylosmileusi.  Lips., 1815.—Jaeger, above cited, p. 250.
  (b) Revue Suisse.  1843. 
OF EXARTICULATION.
687
  [Mann,  Observations on Amputation at the Joints, in N. York Me-
dical Repository, vol. 8, N. S.  1822.
  Hubbard, On Amputation at the Joints, in the same Journal, vol. 7.—
g. w. N.]
  2736.  Amputations through joints are in some cases the only means
of preserving life, as in amputations at the shoulder- and hip-joints.   In
other cases amputation  in  the  continuity of  the  bone cannot  be per-
formed, on account  of its shortness, as in some phalanges of the fingers
and  toes.  And, finally, there may be a choice between exarticulation
and amputation in the continuity of the limb, in which case the exarticu-
lation must be preferred, if the patient will be benefited by preserving' a
greater length of stump, as in exarticulations of the instep, in the knee-
and wrist-joints.   The danger of exarticulation, formerly held so great,
is contradicted by the experience of modern times; and is by some, as
Larrey, thought to  be  even less than in  amputations in the continuity
of limbs.
  2737.  The proceeding in exarticulation is very different.  In general
one  or two flaps are formed, the size and direction of which  depends
partly on the nature  of  the joint, and partly on the injury which renders
amputation  necessary.   Scoutetten has proposed a particular method
(Methode  ovalaire) for  all joints, the  peculiarity  of which consists in
an oval wound being formed, the extremity of which is near the joint,
by two cuts  being carried into  one triangle.   If the soft parts on the
upper region of  the joint be destroyed, they may be included by this
method ; the edges of the wound do not retract unequally, as they often
do in the formation  of flaps, and the wound unites  by a linear scar.  In
many joints, however, exarticulation,  according to this method, is  more
difficult than that with flaps.
  Langenbeck and others had long previously operated in this same way in the re-
moval of several joints.
  2738. The processes  of the bones most surely point out the place of
the joint, which may even be  discovered through the swollen parts.
The knife  should never be violently thrust into  a joint, and  in  those
joints, especially where their surfaces are locked into  each other, not
before their particular connexions have been cut through.  In  carrying
the knife through the joint, its edge should always be  directed towards
the bone that is to be removed.
   2739. It  is frequently found  in  those  cases where  exarticulation  is
necessary, that the soft  parts surrounding the joint are  converted into a
white, firm, lard-like  substance.  If this substance have not become
soft, like pap, the flaps may be formed from it.  By proper dressing this
swelling may, however, be quickly lessened;  and I have  seen, in such
cases, quick union take  place just as well as in a perfectly healthy state
of the soft parts (a).
  (a) Margot (Lisfranc), Sur les Amputa- ration; in  Revue Medicale. 1827; vol. i.
tions pratiques dans des Tissns lardacees, p. 41.
revenus a Fetat normal  a la suite de FOpe- 
[   688   J
      I.—OF EXARTICULATION OF THE THIGH AT THE HIP.

(Exarticulatio Femoris, Lat.; Ablosung des Schenkels aus dem Hiiftgelenke, Germ.;
                       Disarticulation de la Cuisse, Fr.)
  Morand, Sur l'Amputation de la Cuisse dans  son Articulation  avec l'Os de la
Hanche; in his Opuscules de Chirurgie, p. 176.   Paris, 1768.
  Vohler; in same, p. 189.
  Puthod; in same, p. 199.
  Lalouette, An Femur in cavitate cotyloidea.  aliquando arnputandum ?   Paris,
1748;  and in Halleri, Disputat. Chirurg., vol. v. p. 265.
  Barbet; in Prix de l'Academie de Chirurgie, vol. iv. p. 1.   Couronne en 1759.
  Meckel und Unger, An Femur e cavitatecotyloideS. arnputandum? Halae, 1793.
  Moublet;  in Journal de Medecine, vol  xi. p. 240.
  Tallichet, De resecto Femore exarticulo.  Halae, 1806.
  Larrey; in Memoires de Chirurgie Militaire, vol. ii. p. 180; vol. iii. p. 349;
vol. iv. pp. 27, 50.
  Thomson, John, M. D.,  Report of Observations made in  the  British  Military
Hospitals in Belgium after the  Battle of Waterloo, with some remarks on Amputa-
tion.   Edinburgh, 1816.  8vo.
  Guthrie, G. J., On Gunshot Wounds  of the Extremities requiring the  different
Operations of Amputation, with their After-treatment.  London, 1815.  8vo.  The
same translated into German, with remarks by Spangenberg.  Berlin, 1821.
  Hedenus, A. G., Commentatio Chirurgica, de Femore in cavitate cotyloided am-
putando.  Lips., 1823.  4to.; with plates.
  Metz, H., Ueber die Losung des Oberschenkels aus dem Huftgelenke.  Inaug.
Abhandl. .Wurzburg, 1841.
  2740. Exarticulation  of the  Thigh at the Hip-Joint, is, of all  amputa-
tions, the  most  dangerous;  and the danger of the operation itself is con-
siderably increased by the disease rendering it necessary.   Of the cases
hitherto published, in  which this operation has been performed, the pro-
portion  of successful and  unsuccessful results is  about  as  1 to 2| (a).
Many die so long after, and  in  such way, that death  cannot be directly
ascribed to the  operation.
  Jaeger (b), who has performed this operation successfully, has  collected all the
cases known to him, of which  the following, which were successful, must be men-
tioned, to wit, those of Baudens (c), Mayo (d), Sedillot (e), and Textor (/).
  Krimer (g), who lost a patient from sudden spasm, ten days after operating, ac-
cording to Larrey's method, considers this operation inadmissible on account of its
danger.  The results up to the  present time do not confirm this objection.   There is
also little advantage in Krimer's proposal of, instead of the exarticulation, tying the
common iliac artery so as to cause death of the diseased  extremity! 1
  If the Surgeon hesitate to perform the operation through the joint, he could have
no objection to perform it high up  through the great trochanter, by which opening
the joint would be avoided.—j. f. s.]
  (a)  Perault; in Sabatier, Medecine Ope-  Journal.  1831; p. 262.—M*cfallane, J.,
ratoire.—Larrey, Memoires, vol.  iv. p.27.—  Clinical Reports of (he Surgical Practice of
Brownrigg  and  Guthrie;   in  Samuel   the  Glasgow Royal Infirmary,  p.  182.
Cooper's Dictionary of Surgery, p. 84. Edi-   Glasgow, 1S32.   In a child of  two years.
tion of 1838.—Dei.pech; in Revue Medicale.   old, on account of a compound fracture.—
1824;  vol. iii. p. 333.1828.—Wendelstadt;   Co.*, W. S., Memoir  on Amputation of the
in  Hufelanu's Journal, vol.  vi. p. 110.   Thigh at the Hip-Joint.  London, 1845; fol.
1811.—Mott, V.;  in London Medical  and     (6) Hamburger Zeitschrift, vol. iii. parti.
Physical Journal,  vol. iii. p. 228.  1827.—     (c) In same.
Wagner, Ueber die Exarticulation des Ob-     (d) Lancet.  1836-7 ; vol. i. p. 110.
schenkels aus dim Huftgelenke;  in Rust's     (e) Archive* generales  de Medecine, vol.
 Magazin, vol. xv. p. 261.—Orton, J , A Case   ix. p. 225.  1840.
 of Ampuiation of the Hip-Joint successfully     (/) Metz, above cited.
 performed; in Med.-Chir. Trans., vol. xiii.     (g) vo\ Graefe und von Walther's Jour
 p.  605.—Bryce, C;  in Glasgow Medical   nal,  vol. xii. p. 121. 
EXARTICULATION OF THE THIGH, AT.THE HIP.       689
- 2741.  So great extension of mortification as effects the thigh through-
out its whole thickness, and such crushing of  the thigh-bone, and of the
soft parts as render flap-amputation below the great trochanter impossi-
ble, can alone be considered as indications for amputation at the hip-joint.
Caries  in the hip-joint can never indicate this operation  because the
socket is always  affected.
  [The first amputation through the hip-joint appears to  have been performed by
La Croix d'Orleans in 1748, on a boy of fourteen, both of whose lower limbs had
become  gangrenous from eating diseased rye; the first operation was through  the
right thigh, and four days after the  left thigh was amputated at the nip-joint; he
Seemed to be going on very Well, but died on the eleventh day after the second ope-
ration (a).
  Perrault, of St. Maare, in Touraine, first  operated with success in 1773 on a
man who had gangrene of the thigh nearly up to the pelvis, in consequence  of his
thigh having been crushed between the pole of a carriage and the wall (b).
  The first reported case in England, but which was unsuccessful, is that  operated
on by Kerr (c) of Northampton, in]  December 1774, (as appears from a letter from
Harden of Northampton, to the late Sir William  Blizard, for which I  have to
thank my friend Curling.)  The patient was a girl between eleven and twelve years
of age, with an abscess in the right hip-joint and hectic fever; after the operation
Kerr " found not  only the acetabulum  carious, but  also the adjacent parts  of the
ossa innominata to  a very considerable extent."  She went on  very well  till "the
tenth or  eleventh day, but then her respiration  became more difficult, expectoration
ceased, her mouth and tongue were covered with apthae, and she died on the eigh-
teenth day from the operation." (p.  341.)  This operation was performed with  a
single flap.
  John Thomson (d) states, he has "been informed  it (amputation at the hip-joint)
was  performed in  London by the late Mr. H. Thomson,  Surgeon to the  London
Hospital," and imagines " it must have been his operation to which Mr. Pott al-
ludes." (p. 264.)  The passage  referred to in Pott  (e) is  the following :—" I can-
not say that I have  ever done  it  but  I have seen it done, and am now very sure  I
shall never do it unless it be on a dead body," (p. 394, in note reviewing the  opinions
of Bilguer and Tissot on amputation  at the  hip-joint.)   Not being able to find
any published account of this case, I have inquired of Curling whether there be any
record of it at the London Hospital, and he informs me that there is not any.   Proba-
bly it did not succeed, as no notice is left of it;  and whether Thomson or Perrault
operated first, or whether Thomson operated before Kerr I cannot ascertain.—J. f. s.]
  2742.  The  modes of proceeding  in exarticulations  at  the hip-joint
have been, since the time of Vohler, who  broached the idea of this
operation, variously laid  down; many of these, however,  rest  only on
experiments on the dead body, and depend generally on the condition of
the soft parts, and the nature of the injury.  The several modes  of ope-
ration may be  disposed under the following heads—a.  the circular cut;
b. the flap cut, with one or two flaps ; c. the oval cut.
                          a.  The Circular Cut.

  2743.  Here  belong  the modes  of Abernethy, Veitch, Kerr, and
Graefe.
  2744.  According to Abernethy (/), the surgeon standing on the  outer
side of  the limb, the femoral artery being  compressed by the  fingers upon
  (a) Barbet, above  cited, p. 9.               (d) Report of Observations made  in the
  (6) Sabatier, Medecine Operatoire, vol. iv. British Military Hospitals in Belgium, after
Pi 542.                                the Battle of Waterloo, with some  Remarks
 ' (c) An account of the Operation of Ampu- on Amputation.  Edinburgh, 1816.  8vo.
tating the Thigh at the Upper Articulation,    (e) Chirurgical Works, vol. iii. Edition of
lately  performed; in Medical  and  Philo- 1783.
sophical Commentaries, by a Society in Edin-    (/) Lectures, on authority of S. Cooper.
burgh, vol. vi. 1779. 
690              EXARTICULATION OF THE THIGH,
the pubic bone, makes, an inch below the joint, two successive circular
cuts, by which he divides the muscles from the great and little trochanter,
cuts into the capsule, dislocates the head and divides the round ligament.
   2745. Veitch (a) proposed making the amputation of the thigh below
the joint in the common way with  the circular cut, and sawing through
the bone  two inches below the cut.   After the arteries have  been tied
the patient is to be placed on  his side and  a vertical cut  made from the
great trochanter  to the wound, the muscles to be separated on the out-
side of the thigh, the joint opened and the bone disjointed.
   Cole's (b) method, who amputated through the trochanter major and removed the
neck and head, corresponds with this.   Jaeger proceeded in the same way in his
successful case, in which, whilst  amputating through  the upper third of the thigh
with an external flap,  he noticed the caries extending^higher between the lamelke,
again sawed off the bone two or three inches higher, and  even then finding the dis-
ease extending up to the trochanter, he merely extended the upper angle of the flap
on the fore and outer side two inches upwards, cut into the capsule without any great
difficulty, then through the round ligament and easily removed the bone.  The stump
had everywhere flesh to spare which was however no evil, and after the cure it was
six inches long, felt hard as if the bone  was still remaining in it, and could in some
degree be drawn inwards.
   2746.  Kerr (c) having first bent  the thigh at a right  angle with the
trunk, made a cut through the skin, from behind the top of the trochanter
obliquely backwards and  downwards to the inside of the  thigh, and from
thence  obliquely upwards  to within two inches from the femoral artery;
then a second beginning at the  same place as the former, but carried in
an opposite direction over the upper extremity of the trochanter, and from
thence  obliquely forwards and downwards  to within the same distance of
the vessel as in the former cut.  He then cut through the muscles in the
direction of the skin cuts,  and separated  the bone from the joint; grasped
firmly the flap  still undivided, and  containing the  artery, betwixt the
fingers  and thumb of his left hand, his fingers on the skin side of it, and
his thumb on the muscular side, cut it through about four  inches below
the inguinal ligament,  and tied the artery.
   [Kerr states further that the compression was  so complete " as to prevent the
loss of a single drop of blood, and the  haemorrhage from the other arteries was full
as inconsiderable as in any other amputation of the thigh. * * * The ligature fell
off at the fourth or fifth dressing." (p. 341.)  In Harden's letter it is further stated,
that " two other small arteries only were taken up, and  the blood  lost during the
operation was very trifling.  The large artery was tied immediately above a branch
going off which I think is called the profunda.  Perhaps the operation could not be
done with so  much ease where the ligaments of the joint had  not been previously
destroyed, as was the case here."]
   2747.  According to Graefe's  (e) experiments  on the dead body, the
femoral artery should be compressed with a  roller, and Pipellet's or
Moore's compressor;  the skin is then to be divided with a circular cut,
three or four fingers' breadth below  the trochanter, and after having been
moderately  drawn back by an assistant, his leaf-knife {Blattmesser)  is to
be placed as deeply as possible on the outer side close to the edge  of the
retracted skin, the leaf sunk obliquely to the trochanter,  drawn  over the
front to the inner side, so that its edge  runs along the neck close to the
   (a) Edinburgh Medical and Surgical Jour-    (c) Above cited, p. 339.
 nal, vol. iii. p. 129.  1807.                  (d) Normen zur Ablosung grosseres Glied-
   (b) Samuel Cooper's Surgical Dictionary,   masseu, p. 117.
 p. 83, 
AT THE HIP, WITH SINGLE FLAP.             691
thigh-bone, and the  cut completed in the  usual way.   If large  vessels
bleed which cannot be compressed by the  assistant, they must be tied if
not too close to the middle of the wound.   The muscles are now drawn
up by an assistant, and the fleshy parts first divided on the outside to the
very point of the trochanter, with the blade of the leaf-knife kept directly
upwards.  An assistant now turns the knee  outwards, the muscles are
divided on the inner side with the blade of the leaf-knife directed upwards
till the edge of the hip-socket appears.   The transverse ligament is then
divided with the edge of the knife  held  rather obliquely, and whilst the
assistant rolls the head  of the bone  inwards and  upwards, placing one
hand below the trochanter, and the other on the inside  of the  knee, the
operator pressing the knife firmly cuts through the capsular  ligament on
the inside.  The assistant now carries the  thigh far outwards till it forms
a right angle with the side of the body, and the operator with  one smart
stroke cuts through the outer under part of the capsular ligament and the
muscles still attached in this  region, by which the head  of the  bone is
completely freed.  After stanching the blood, the wound is to be brought
together obliquely with two  sutures and strips of sticking plaster.
                          b.  The Flap Cut.
                          * With a single  flap.
   2743. The operation of exarticulation  with one flap is variously per-
formed, according as it is a hinder (Puthod,  Bryce ;) an  inner (L'Alou-
ette, Delpech, Lenoir, Langenbeck;) a front (Plantade, Manec) or
an outer flap.
   2749. According to-Puthod, the femoral artery having been first tied,
the patient laid on his  side  and properly held, and the skin drawn up-
wards by an assistant, a transverse semicircular cut is to be made through
the skin, beginning on the inner hinder part  of the thigh, and ending at
the great trochanter.   After drawing the skin back the tendon of the m.
glutceus maximus is cut through, and by carrying the knife along the tro-
chanter all the muscles there inserted are  divided.  The  knife is now to
be thrust into the joint below the tendon of the m. gracilis, and the cap-
sular ligament cut across;  after which the thigh is drawn  upwards and
inwards so that the head of the bone may project outwards and upwards,
and then the stretched round ligament is cut through and the division of
the capsular ligament completed.  The muscles of the hinder inner side
of the thigh are now' divided, four or five fingers' breadth from their in-
 sertion, and then the  muscles on  the inside at the top of the little tro'
 chanter cut through (a).
   Hunczorsky  (b) directs the following mode of proceeding.  After  tying  the
femoral artery, the patient being laid  upon his belly, and the thigh drawn  somewhat
 inwards to render the m. glutaei  tense, the skin is drawn back, and cut through three
 fingers' breadth  below the trochanter major, and after it has been turned back, the
 m. glutaei are cut off at the trochanter; the knife is then carried  outwards to make
 one flap of flesh which is raised up, and the cut being continued quite down to the
joint, and the head twisted on itself,  the other part of the capsular ligament and the
 round ligament are divided, and  the operation completed by cutting  through  the
 muscles on the other side of the thigh.
   2750. Bryce (c) compresses the femoral artery, and makes a transverse
   (a) Morand, above cited.         (b) Anwekung  zu Chirurg. Operationen, p. 256.
                               (c)  Above cited. 
692            EXARTICULATION  OF  THE THIGH,
 cut on its inner side above the trochanter, above the highest part of the
 hip, ties the femoral artery, cuts through the capsular ligament, separates
 the head  of the bone, and at last forms the lower flap.
   2751.  According to L'Alouette, the patient  should be placed on his
 sound side, the femoral  artery compressed  with a tourniquet, the thigh
 stretched out, and an assistant draws the skin back.  With a semicircular
 cut extending from the upper  outer part of the great trochanter to the
 ischial tuberbsity, all the  soft parts are cut through to the  joint.   The
 joint is now felt for with the nail of the left fore-finger, and the capsular
 ligament  opened.   The  assistant rolls the thigh inwards, the projecting
 round ligament is divided with a button-ended bistoury, and the head of
 the  bone  dislocated  by bending the thigh towards the chest, upon which
 the  knife  being carried  round the capsular ligament, completely divides
 it, and a flap is formed four or five fingers broad, by bringing the knife
 down  on  the inside of the bone.
   2752.  According to Langenbeck (a), a transverse cut should be.made
 from the front of the thigh, not too near the femoral artery, on the outer
 side, down to the back part of the thigh, opposite the ischial tuberosity,
 which should divide the soft parts to the neck of the bone; then by turn-
 ing the knee inwards the exarticulation of the head is effected, and  the
 inner flap is formed by cutting round the inner surface of the thigh.
  2753.  Delpech {b), who has performed this operation  twice  success-
 fully, after having tied the femoral artery, thrusts a single-edged knife
 two inches  below the superior anterior spine of the ilium, between the
 m. sartorius  and m. tensor vagincefemoris, to the  neck of the thigh-bone,
 inclines the point  inwards, and pushing it well into the cavity between
 the little  trochanter and  the  neck, thrusts it through at the hinder part.
 The knife is now  drawn  down on the inside of the thigh-bone, and by
 cutting inwards a flap is formed about eight  inches long.   This flap is
 held back by an assistant, and any spouting vessel in it  tied.   The thigh
 is now inclined outwards, the capsular ligament divided  seroicircularly,
 the head  of  the bone dislocated, the round ligament  cut through, the
 knife carried behind the head, and the mass of muscle and skin divided
 by a horizontal cut.  After the vessels are tied, the flap is brought over
 the wound and  united with sutures an inch apart.  Too much skin should
 not be preserved on  the outer side, and it is better, if necessary, to make
 the  inner  flap  longer.   This method is a modification  of Larrevt's, in
 which  an  outer flap is also formed.
  In this way, Orton, Clot, Cherubini, and Well have operated, excepting that
 Clot did not tie the femoral artery first.
  2754. Lenoir (c)  compresses the femoral artery, and standing on the
 outer side of the limb, which is inclined inwards, makes a transverse cut
 on the hinder outer side, draws the soft parts back, penetrates  into the
 outer hinder  part of the joint, and ends by forming an internal flap.   An
 assistant compresses the artery in the flap till it is tied.
  2755. According to Plantade  {d), an upper or front flap  should be
  (a) Bibliothek filr die Chirurgie, vol. iv.   (c) Journal Hebdomadaire, vol. v. p. 205.
p. 512.                              1831.
  (b) Journal general de Medecine, vol. ciii.    (d)  Velpeau, Medecine Operatoire, vol. i.
 p. 429. 1828.                         p. 250. 
                AT THE HIP, WITH TWO FLAPS.             693

formed by two vertical cuts on the sides, connected by a transverse cut,
as in La Faye's mode of exarticulation at the shoulder.
   2756.  According to Manec (a), whilst the extremity is drawn outwards
and a little bent, a double-edged knife is thrust betwreen the great tro-
chanter and front iliac  spine from above downwards, and  from without
inwards, between the neck of the thigh-bone and the muscles, and as the
knife is. carried close down on  the bone, a  sufficiently long flap is cut,
which an assistant raises,  and  compresses the  artery found in  it.  The
operator now passes the knife below the joint, places it on the inner angle
of the wound, and divides to the outer angle all the soft parts to the bone.
The capsule of the joint is then opened by a smart cut on its front, the
head of the bone projected by abducting  the  thigh, the  round ligament
divided, and the rest of the capsule completely divided.  After the forma-
tion of the flap, the joint may be entered  in front, and the hind  parts
separated by a cut from within outwards.
   2757.  If the condition of the soft parts only permit an outer flap, when
the femoral artery has been either first tied  or  properly compressed, the
knife must be thrust vertically, below the middle of Poupart's ligament,
and the whole mass of soft parts cut through directly inwards.  The thigh
is now to be  carried well  outwards, the capsular  ligament opened, the
round ligament divided, the head of the bone  pressed out  of its socket,
and by passing the knife round and  drawing it down, the flap is formed.
I have performed the operation in this way upon a living person.
                         *  *  With two flaps.
   2758.  This mode of proceeding with twoflaps, varies according as it
is performed with an inner and outer (A. Blandin, Larrey, Dupuytren,
Lisfranc, von Walther), or with afore and hind flap (Wohler, Bell,
Beclard, Begin, and Sanson), and  according to the formation of one  or
other flap, and  also whether by thrusting in the knife, or by carrying it
from without inwards.
   2759.  A. Blandin ties the femoral artery first, and whilst he thrusts
the knife into the lower angle of the wound, made for tying the artery,
through the whole thickness of the  thigh, he  forms an  inner flap, after-
wards the outer one, and then proceeds to the division of the capsule and
the exarticulation.
   2760.  According to Larrey, the femoral artery and vein should first
be tied close to Poupart's ligament; then a straight sufficiently long knife
thrust in on the front of the thigh and carried between the flexor muscles
attached to the little trochanter, and base of the neck of the bone  back-
wards, so that it  may come out directly opposite the point of entrance.
The edge of the knife is now turned obliquely inwards, and with a stroke
all the muscles on the upper and inner part of the thigh cut through, and
an inner not very large, flap formed, which must be held back, and the
bleeding vessels tied.  The thigh is  now to be abducted, so that the liga-
ments may be stretched, the inside of the capsular ligament divided with
a bistoury, then the round ligament, and whilst the abduction is increased,
the head of the bone dislocated.  The edge of the large amputating knife
placed behind the head of the bone, is now carried close behind the great

      {a) Velpeau, Medecine Operatoire. 1839. Second Edition; vol. ii. p. 546.
   Vol.  hi.—59 
 694             EXARTICULATION OF THE THIGH,

 trochanter, and  the outer flap formed by cutting the muscles and skin
 obliquely.   The spouting vessels are  compressed by an assistant, and
 carefully tied, and after  the surface of  the  wound  has been properly
 cleansed,  the flaps are brought into apposition, some sutures applied, the
 union supported by strips  of sticking  plaster, covered with lint, and a
 compress, and fixed with a proper bandage.
   Larrey (a) has subsequently recommended another method, in which after tying
 the crural artery, he makes a circular cut immediately below the great trochanter,
 through the skin, to determine the length of the flap.  The inner flap must then be
 made either from without inwards, or from within outwards, according to the condi-
 tion of the parts.  The capsular ligament is divided with the same knife, the head
 of the bone dislocated inwards, the round ligament divided, and the knife being
 carried over it into the skin-cut, the outer flap is thus formed.  After tying the bleed-
 ing vessels, the ligatures are placed in the bottom of the wound, and a piece of oiled
 linen put into that  angle of the wound nearest to the hip-socket, and  then the flaps
 closed.
  Mott (b) forms the inner flap according to Larrey's method, by thrusting in the
 knife, and the outer flap by cutting from without inwards.
   2761. According to Dupuytren (c), the  operator, placed on the inner
 side of the thigh, and the artery being properly compressed, makes  a semi-
 circular  cut from the region of the upper front  spine  of the ilium, over
 the inner side to the ischial  tuberosity, through the skin,  draws it back-
 wards, cuts through the muscles in the  same  direction, thus forming an
 inner flap four or five inches long, turns  this  back, divides the capsule,
 and finishes the  operation by the formation of the outer flap.
  According to Dupuytren's (d) earlier experience, the operator should stand on the
 outer side of the limb, with his hands on the upper part of the thigh, so that by gently
 moving he can discover the situation of the joint.  From this place he makes a semi-
 circular cut  passing three inches down, over the outer hinder part, and ending half
 an inch below the  ischial tuberosity ; the skin is then drawn  back and the muscles
 divided at its edge down to the bone.  To this outer cut, the operator makes a second
 and corresponding  one over the inner side of the thigh, which joins the first at the
 points where it begins and ends.  The outer and inner flaps are separated up to the
joint, and held back by an assistant.  The capsule is divided by a circular cut, after-
 wards the round ligament, and then the head of the bone is removed.
   2762. According to  Lisfranc (e) the thigh is to be held extended by
 an assistant, and the operator, standing on the outside of the  limb, draws
 a line from the front upper spine of the ilium,  parallel with the axis of the
 thigh, and an inch in length, from the lower inner end  of which, at a right
 angle to it or transversely a second line  half  an inch long.   At the end
 of this latter line he thrusts the point of a long straight knife, with its edge
 following a line  from its entrance  to  the upper  outer part  of the great
 trochanter.   The blade of the  knife now upon the outer side of the head
 of the thigh-bone, passes round it and projects at the  middle hinder part
 of the buttock.   By some strokes upwards and  outwards, avoiding the
 great trochanter, the knife is carried along the thigh two inches, and thus
 the flap  is completed.   After  the  bleeding arteries  have been tied, an
 assistant holds, the flap  back.  The knife is now carried  round the neck
 of the bone, and again passed to the hind upper angle of the wound, the
                    (a) Clinique Chirurgicale, vol. iii. p. 611.
  (6) Above cited.                       vol. i. p. 177.—Munzenthaler, above  cited,
  (c) Lejons Orales, vol. iii. p. 363.        p. 38.—Averill, above cited, p. 158.—Stme ;
  (d) Archives generales de Medecine. 1823;  in Edinburgh Medical and Surgical Journal,
 vol. i. p. 171.                          vol. xix. p. 657.  1823.—Maingault, above
  (e) Archives generales de Medecine. 1823;  cited, pi. viii. fig. 29. 
AT THE HIP, WITH TWO FLAPS.              695
 soft parts, if necessary, being pressed inwards, to avoid the  lesser tro-
 chanter, and a flap  formed on the inner side of the bone, of the same
 length and form as the outer.   The operator then  grasps the thigh with
 his left hand, brings the edge of the knife perpendicularly upon the inner
 side of the head of the bone, which he runs round as much as possible,
 divides the capsular and round ligaments, and then cuts from within out-
 wards the rest of the capsule  and whatever muscular fibres still remain
 attached.
   2763.  von Walther {a) compresses  the  femoral artery with a com-
 pressor against the pubic bone ; thrusts a double-edged amputation knife,
 three inches below the upper front spine of the ilium, at the outer edge of
 the m. sartorius, vertically down upon the neck of the thigh-bone, carries
 it outwards and backwards  around it, and pushes  it  out two  inches and
 a half behind the great trochanter, at a corresponding height  to its point
 of entrance ; the knife now kept close to the bone,  cuts two inches below
 the base of the trochanter obliquely outwards, and  forms an oblong outer
 flap, which being drawn back, the exposed capsular ligament is cut into,
 the head of the bone dislocated outwards and downwards,  and the round
 ligament divided.   With a single-edged amputating knife he  now passes
 through the cavity  of the joint, behind the head of the thigh-bone and
 round the little  trochanter,  and  continues two inches down along the
 inside of the thigh close to the bone.   The,femoral artery and neigh-
 bouring vessels are now to be compressed, as high  up as possible, by
 both the thumbs of an assistant placed upon the surface of the wound, and
 then the edge of the knife being inclined obliquely inwards,  the opera-
 tion is completed by forming the inner flap.
   2764. According to Vohler, the  femoral vessels  should be laid bare
 by a cut on Poupart's ligament and tied, a%nd then  the patient having
 been placed on his  belly, the skin  and m. glutceus maximus are to be cut
 through two fingers' breadth below the ischial tuberosity, and  the flap so
 formed drawn up ;  the muscles attached to the trochanter are then cut
 through to the capsular ligament, which is opened whilst the thigh is slightly
 moved, and cut through forwards together with the muscles on the outer
 and fore part of the thigh,   The vessels must be in  part compressed, and
 in part tied.  The hinder flap covers the  wound.
   2765. According to Bell (b), the femoral artery should be compressed
 by a torniquet against the pubic bone, and the  thigh being bent on the
 groin,  the skin and  flesh of the thigh are^to be divided,with two circular
 cuts six inches below the joint, and every important vessel on  the surface
 of the  wound tied.  Two longitudinal cuts are now made  upwards from
 the circular, one behind from  the  head of the  thigh-bone, and another
 before, so that two  flaps are formed, one on the outer and the other on
 the inner side of the thigh.   These are separated to expose the joint, the
 head of the bone dislocated, and if broken, it must  be  pulled out with
 the forceps.
   2766.  According to Beclard (c), the thigh should be slightly bent so
 as to relax the parts on its  fore part, then in the  middle  of the space
between the upper front spine  of the ilium and the great trochanter, the
  (a) Graefe und Walther's Journal, vol.   (c) Dictionnaire de Medecine et de Chi.
vi. p. 11. 1824.                       rurgie pratiques, Article Amputation, vol. ii.
  (b) Above cited, vol. iv.               p. 278. 1829. 
696             EXARTICULATION OF THE THIGH,
knife is thrust in horizontally, carried close  over the neck and head of
the thigh-bone, and the  handle  being  raised a little,  thrust  through
opposite its point of entrance.  By drawing the knife down a flap is made
six fingers' breadth long, which an assistant raises, and at the same time
compresses the femoral artery.  The  front of the joint is now laid bare,
the capsular ligament cut into, and  afterwards  the  round ligament, the
head of the bone dislocated by moving  the thigh  backwards, and the
whole knife being carried behind the head, divides the back of the cap-
sule, and forms the hinder flap of equal length with that in front.
  [Liston's (a)  operation is the same as Beclard's, and  he  observes:—"This
mode of getting at the head and neck of the bone is much preferable to that usually
followed, and is in every respect safer, as he has more than once ascertained from
actual practice on the living body. The fore part of the articulation is fully exposed
immediately on the anterior  flap being formed.  The  capsular ligament is cut by
drawing the knife across determinedly, as if it were the intention of the operator to
cut off the head of the bone.  The round ligament and the posterior portion of the
capsule are cut, and the blade of the instrument having  been passed behind the neck
and trochanters, the posterior flap is quickly formed  so as to allow the limb to drop.
The vessels on the posterior aspect are tied fast: then  the femoral and those in the
anterior flap, which had been commanded by the assistant, are  uncovered one by
one, and secured." (p. 387.)]
   2767. Begin and  Sanson (6)  first make a semicircular cut,  with its
concavity upwards,  through the skin  and cellular tissue,  beginning from
the point of the great trochanter, carried  over the front of the'thigh and
ending at the tuberosity.   The  skin is drawn back and  the femoral
artery tied.   The front flap  is then made, either from without  inwards,
or from  within outwards, by a thrust, and  afterwards the hind  flap,
the one angle of which must correspond with the great trochanter and the
other with the tuberosity.  The operation is finished by the exarticulation
of the head.
                        * * *  The Oval Cut.
   2768.  According to Sanson, the operator, standing on the outside of
the limb, makes a cut obliquely from  below upwards and from within
outwards, beginning it four fingers' breadth below the perinceum, carrying
it over the front of the joint, and ending it at the point of the  great tro-
chanter.  This cut divides the skin and superficial muscles, and  the femo-
ral artery is now tied.   A second cut beginning from the inner angle of
the first,  is carried over the hind part of the limb and  united with the
former at the point of the trochanter; it divides the skin  and the mass of
muscles as deep as possible.  The knife  is now passed  into the first cut,
its edge  directed towards the  hip-socket, the  thigh dropped,  by which
the  head is protruded, and then  the capsular and  round ligaments are
divided.  The knife is now carried round the head from within outwards,
then backwards and afterwards inwards, care being taken that it do not
for an instant leave the socket.   This operation is very quick.
   2769.  Guthrie (c) gives  the following mode of performing this ope-
ration.   An assistant standing on the opposite side> and  leaning  over,
should compress the artery against the brim of the pelvis, with a firm hard
compress of linen, such as  is generally used before the tourniquet; he
        (a) Practical Surgery.
        (6) Sabatier, Medecine Operatoire, par Sanson et Begin, vol. iv. p. 682.
        (c) Above cited, pp. 363, 364. 
AT THE HIP, WITH OVAL CUT.
697
  should also be able to do it with his thumb, behind the compress, if it be
  found insufficient.   The surgeon standing on  the inside, with a strong,
  pointed amputating knife of a middle size, makes his first incision through
  the  skin membrane, and fascia, so as to mark  out the flaps  on cellular
  each side, commencing about four fingers' breadth, and in a direct line
  below the anterior superior spinous process of  the ilium, in a well-sized
  man ; and continuing it round in a slanting direction  at an almost equal
  distance from the tuberosity of the  ischium, nearly opposite to the  place
  where the incision commenced.   Bringing the knife to the outside  of the
  thigh, he connects the point of the incision where he left off with  the
  place of commencement, bya gently-curved line, by which  means  the
  outer incision is not in extent more than one-third of  the size of the in-
  ternal one.   The integuments having retracted, the m. glutceus maximus
  is to be cut from its insertion in the linea aspera and  the tendons of  the
  m. glutceus medius and minimus from the top  of the trochanter major.
  The surgeon now placing the edge  of the knife on the line  of the re-
  tracted muscles of the first incision, cuts  steadily through the whole of
  the others, blood vessels, &c, on  the  inside of the thigh.   The artery
  and  vein, or.two arteries and a vein of the profunda is given offhigh up,
  are to be taken between the fingers and thumb of the left hand, until the
  surgeon can draw each vessel out with the tenaculum, and place a liga-
  ture  upon it.  Whilst this is doing the assistants should press with their
  fingers on any small vessels that bleed.  The surgeon then cuts through
  the small muscles running  to be inserted between the trochanters and
  those on  the upper part of the thigh, not yet divided ; and with a  large
  scalpel opens into the capsular ligament, the bone being strongly moved
 outwards, by which its round  head puts the  ligament on the stretch.
 Having extensively divided it on the forepart and inside, the ligamentum
 teres may now  be readily cut through.   The head of the  bone is then
 easily dislocated, and  two or three strokes of the knife separate any  at-
 tachment the thigh may still have to the pelvis.  The vessels are now
 carefully to  be  secured.   The capsular ligament, and as  much of the
 ligamentous edge of the  acetabulum ought  to  be removed as  can  be
 readily taken away.   The nerves, if long are to be cut short, the wound
 well sponged with cold water, and the integuments brought together iiLa
 line from the spinous process of the ilium to the tuberosity of the ischium.
 Three sutures will in general be required, in addition to the straps of ad-
 hesive plaster to keep  the parts together.
   2770. According to Scoutetten the patient is laid across the bed, and
 upon the opposite side to that on which the operation is to be performed ;
 his head raised a little  above the pelvis, which should project beyond the
 bed, and in this  position  he is to be held by assistants, and  the artery
 compressed at the groin.   In operating on  the  left thigh, the  surgeon,
placing himself at the hinder part of the limb, assures himself with his left
hand  of the position of the great trochanter, and places his thumb or fore-
finger upon it.   With his  right hand he thrusts iri the point of the knife,
above the trochanter, vertically, sinks the blade a little  and directs it for-
wards and  inwards four  fingers' breadth below the crease of the groin
and carries round the joint, whilst pressingit as deeply as possible through
the parts.   This cut is now left, for the purpose of carrying the knife, its
                                 59* 
698    EXARTICULATION OF THE THIGH, AT THE HIP, &C.

point directed inwards and  downwards, on the inside of the thigh, into
the lower angle of the first cut; the knife is then directed obliquely back-
wards to pass into the beginning of the first  cut.  It is very rare that
in these cuts all the parts are at once divided  down to the  bone; most
commonly it is necessary that the knife  should be again entered into the
wound to complete their division.   To get  at the capsule of the joint, the
edges of the wound must be further separated and the undivided muscles
cut through; and when the  capsule is exposed, it must be cut into by
placing the knife perpendicularly upon it; the limb being then dropped
and the point of the  toe turned outwards, the head of the bone partly
protrudes from the socket, and where held by the round ligament, that
must  be divided with the point of the knife.  The operator then lifts up
the thigh in  order to throw the head out, and running the knife  round it
divides the hind third of the capsule and the muscular fibres still remain-
ing attached, and separates the limb.  In operating on the  right thigh,
the surgeon  places himself on the fore part of the limb, but the other
proceedings are the same.
   2771.  Cornuau lays down the following mode of practice.   The pa-
tient being laid on his sound side, the operator with the fingers of his left
hand ascertains  the situation of the great trochanter, from the top of
which he makes his first cut obliquely downwards and forwards to a right
angle, formed by the union of  a horizontal line from the ischial tuber-
osity  with another descending vertically from the upper front spine of the
ilium. A second cut of equal length, and forming with the first an acute
angle upon the great  trochanter, passes  obliquely backwards and down-
wards to the middle of the thickness of the  limb.  The outer, hinder and
fore  part of  the joint is now  laid bare ; the capsular ligament  must be
opened as near as possible to the edge of the socket; after  the  division
of the rest of the muscles which remain undivided by the first cut, the
head  is disloeated outwards, the round ligament easily separated, and
the knife carried round the head towards the inner side of the limb.  One
assistant on  the outside grasps the front flap  of the wound, and in its
thickness compresses the femoral artery; another draws the  skin of the
inside of the thigh upwards, whilst the operator with his left hand sup-
porting the thigh, uses the knife till it come to the lower angle of the first
cut, which finishes the division of the soft parts; rounds the inside of the
wound, and  completes the removal of the limb.
   2772. Of these several modes of proceeding which have been proposed
for the exarticulation of the thigh-bone,  I hold Larrey's with the thrust
of the knife, and the formation of an inner and  an  outer flap, {par. 2760,)
or if the condition of the parts permit the formation of a single inner flap,
{par.  2753) or of a single outer flap,  {par. 2757,)  the most  preferable in
regard to safety and  ease of performance.  It has also been, in most of
the published cases, in which the operation has had a successful result,
the way in which, with slight  deviations, it has  been performed.  As
to the objection  in  reference  to the bleeding, the artery may  be pre-
viously tied, if there  be no competent  assistant to be intrusted with its
compression.
   The wound should be brought together with sutures and strips of
plaster, a piece of oiled linen put in the  lower corner of the wound, and 
EXARTICULATION OF THE LEG.
699
the whole covered with lint  and compress  fastened with the inguinal
bandage.   Jaeger holds this dressing not always of use, recommends
cold fomentations  and applies the dressing just after suppuration has
come on.
     II.—OF EXARTICULATION OF THE LEG AT THE KNEE.

(Exarticulalio Cruris, hat.;  Ablosung des Unterschenkels im Kniegelenke, Germ.;
                     Disarticulation de la Jambe, Fr.)
  Bras dor, above cited.
  Textor, Ueber die Amputation im Kniegelenke; in neue Chiron, vol. i. p. 1.
  Velpeau, Memoire sur l'Amputation de la Jambe dans 1'Articulation du Genou;
in Archives Generales de Medecine, vol. xxiv. p. 44. 1830.
  --------, Discussion Nouvelle a. l'occasion du Rapport de M. Larrey, sur l'im-
portance et les avantages  de l'Amputation  de  la Jambe dans Particle; in Journ.
Univ. et hebdom. de Med.  et Chir. Pratiques. Novembre, 1830.
  2773. Amputation of the leg at the knee-joint, heretofore recommended
by Guillemeau in  1612, and by Fabricius Hildanus, has been consi-
dered by most writers as improper, or inferior to amputation through the
continuity of the thigh.   Brasdor, J. L. Petit, and Horn have recom-
mended it;  and Volpi, Kern,  Textor,  Langenbeck, Velpeau, and
others have shown the applicability of this mode to those cases, where, in
consequence of the extensive destruction of the front of the leg, amputa-
tion through it is not possible, though there may still remain soft parts
for covering the condyles, if exarticulation be performed.   Many sur-
geons object to  it unconditionally, as Zang, Larrey, Dupuytren, and
others.
  From Jaeger's (a) collection of the published cases of amputation at  the knee-
joint, it appears that of thirty-seven, about twenty-two have had a favourable, and
fourteen an unfavourable result.
  2774. Exarticulation at the knee-joint may be formed either with the
flap or the  circular  cut.   The patient is placed as in amputation* through
the thigh;  and the femoral artery compressed by an assistant, or with a
tourniquet.
  2775. In the amputation with  the flap cut, it is best to make the flap
from the back of the leg in the  following  manner :—After  the femoral
artery has been properly compressed, and the kg being held straight out,
the assistant who holds  the thigh, draws the skin back.  With a straight
small amputating knife, a transverse, or a semilunar (Sabatier, Textor)
cut is made through the skin, from one condyle to the  other.   The leg is
now bent to tighten the ligament of the knee-cap, and the surgeon grasp-
ing it with the left hand, cuts through with the same knife, first this liga-
ment, then the lateral ligaments, and lastly, the  crucial ligaments.   He
then takes a larger amputating knife, carries it close  to  the hind surface
of the  shin and  splint-bones, some little  distance down, and forms, in
cutting obliquely downwards, a flap sufficient to cover the exposed joint-
surfaces.  After  the vessels have been properly tied, the flap from behind
is brought  close into contact with  the front edge of the skin,  and the
dressing applied, as after amputating the leg with a single flap.
  The following modes of proceeding are less convenient:—First, According to
(a) Handworterbuch der Chirurgie, vol i. p. 363. 
700                EXARTICULATION OF THE FOOT
 Blandin (a), when the patient has been placed on his belly, and the femoral artery
 is compressed, a catlin is passed at the joint, above  the bones from one side to the
 other through the soft parts, and carried down to form a flap about six inches long.
 An assistant holds back this flap, whilst a semicircular cut is made at its base, from
 one angle to the other, over the front of the joint below the knee-cap, through the
 teguments, the joint is then opened, and by the division  of the lateral and  crucial
 ligaments, and of the ligament of the knee-cap, the operation is completed.  Second,
 The formation of  two flaps.   According to Rossi (b), a cut is to be made on both
 sides of the knee, which* are connected with each other by an arch, and the  two flaps
 thereby described, are dissected back and turned over: the ligament of the knee-cap
 is then divided, the knife carried into the joint and every thing cut through.  Accord-
 ing to Maingault (c), a narrow straight knife is to  be  thrust through  the joint, on
 the inside of the thigh, behind the knee-cap, but before and below the condyle, and
 by carrying it down the ligament of the  knee-cap, the general coverings are cut
 through to the tubercle of the  shin-bone.   This flap is  then raised, the lateral and
 crucial ligaments  cut through and by drawing the knife down, the hinder  flap is
 formed.   According to Kern, the flap should be formed by two cuts from  the outer
 sides of both condyles of the  thigh-bone towards the spine of the shin-bone,  of a V
 shape, and four or five inches  long, and after dividing the ligaments, a hind  flap of
 four inches is formed.
   2776.  In the circular cut, according to Velpeau, the leg being stretched
 out, a circular cut, three or four fingers' breadth  below the  knee-cap,
 divides the skin, which is  then dissected up and turned  back,  and whilst
 the thigh is grasped with the left hand, and a little bent, the ligaments
 are divided from  before backwards,  and  the  muscles and vessels  lying
 behind, are cut through at a stroke.   After the vessels are tied,  the wound
 is brought together vertically,  or horizontally.
  Velpeau has twice operated  in this way successfully, and has given up the method
 which he formerly recommended.  According to Cornuau, it is less advantageous
 to divide the soft parts by a circular cut at the edge of the skin, after  it has been
 turned back, and then by dividing the lateral ligaments, to penetrate into the  joint.
 Equally so is the oval cut after Baudens' method ; he makes a mark with a pen from
 the spine of the  shin-bone three fingers' breadth below the ligament of the knee-cap,
 which he carries obliquely backwards, and from below upwards, towards the  knee-
 cap, and ends only two fingers' breadth below a line corresponding to the ligament
 of the knee-cap.   An assistant draws the skin of the knee upwards, the operator
 makes a cut along the marked  line of the oval, the skin is then drawn back on the
joint, and this, together with the aponeurosis  and tendons, cut through and the lips
 of the wound united lengthwise.
  If the knee-cap be diseased,  the skin is to be separated from it, and itself from the
 tendon of  the m. rectus and the capsular ligament, which is better then making a fl
 shaped cut through the skin, as recommended by Brasdor.
  Exarticulation of the Ankle-Joint, proposed by Brasdor and others, and  entirely
rejected  by most surgeons, but in modern  times recommended  by Lisfranc,  Mal-
gaigne,  Baudens, and Jaeger, is in every respect inferior to amputation through the
leg, as it is always more difficult and dangerous, and  always forms a bad stump, and
 unfitting for the application of  an artificial foot.
   [II.*—OF EXARTICULATION  OF THE FOOT AT THE ANKLE.

(Exarticulatio Pedis, Lat.; Ablosung des Fusses im Fussgelenke, Germ.; Disarticula-
                             tion du Pied, Fr.)

  This operation was long since performed successfully in France, once
by Sedillier, de Lavall, and Brasdor ; but seems to have been given
          (a) Dictionnaire de Medecine. Article Amputation, vol. ii. p. 282.
          (b) Elem. de M6d. Operat, vol. ii. p. 227.   Turin, 1S06.
          (c) Above cited.—Froriep's Chirurg. Kupf. Taf. pi. cvii. fig. 1,2. 
AT THE ANKLE.                     701
up from a notion that the projections of the ankles below the base of the
shin-bone would prevent the scar bearing the weight of the foot, notwith-
standing Brasdor had distinctly stated that these  processes soon became
blunted, that the ends of the bones rounded, and that there was plenty of
skin to cover a great part of the wound.
  Velpeau {a) performs this operation by making two semilunar flaps of
skin, one upon the instep, and the other above the heel, twelve or fifteen
lines before and behind the joint, and meeting to form another semilunar
cut on each side about an inch below the ankles.  The tendons and liga-
ments are then to be,divided as close as possible to the joint; after which
the astragalus is easily removed from its mortise, and with it the whole
foot.  The  flaps are  brought  together transversely, so  that  the  angles
enclose the  points of the ankles.
  Baudens' operation differs from Velpeau's in a single flap being made
by carrying  a knife down to the bone, from the insertion of the Achilles'
tendon behind the heel, on each margin of the sole of the foot, nearly as
far forwards as the crease of the toes, and these are connected by a trans-
verse cut of a semicircular form like a gaiter across the whole  dorsal sur-
face of the foot, which must descend a little lower on the  inner than on
the outer edge, to  avoid including a small bundle of muscular fibres be-
longing to the plantar surface.  The flap thus marked is now taken hold
of with the left hand and firmly drawn, so that with some smart strokes
of the knife, the whole of  the soft parts, including the plantar arteries,
should be shaved off close to the bones, as far back as the points of the
ankles.   The anterior ligament is then cut through, and the  line of the
joint laid bare, but without opening it further, the saw is placed upon it,
and worked from  before backwards, so as not  merely  to remove  the
malleolar processes, but also the hind edge of the  tibial mortise, in order
to make the surface level, and leaving the joint-cartilage only in front and
in the middle, so that it hardly forms a third of the whole bony surface.
The ligaments and soft parts untouched are now to be separated with the
knife and the Achilles' tendon scraped off as  closely as possible to the
heel-bone.   The posterior and anterior tibial arteries require tying, and
the flap dropping by its own weight upon the wound is fixed with sutures.
  Syme (6) introduced the operation of amputation through  the ankle-
joint into this country, making his flaps like Velpeau, and sawing off'the
malleolar processes, as in Bauden's amputation just above the joint, but
not meddling with the base of the ^hin-bone, unless it be diseased.   The
removal  of the bony projections of the ankles was a very happy thought,
although Brasdor's observation proves that they will become blunted,
and Syme is justly entitled to the merit of having perfected  this  opera-
tion.  In his first operation he cut across the integuments of the instep
in a  curved direction, with the convexity towards the toes, and  then
across the sole of the foot, so that the incisions were nearly opposite each
other.   The flaps thus formed were separated from  their subjacent  con-
nexions, which  was easily done, except at the heel, where the firmness
of texture occasioned a little difficulty.  The disarticulation being  then
readily completed, the malleolar projections were removed by means of
  (a) Nouveaux Elemens de Medecine Ope-  London and Edinburgh Monthly Journal of
ratoire, vol. ii.  p. 497. 1832.              Medical Science, vol. iii. p. 93.  1843.
 (b) Surgical Cases and  Observations: in 
702     EXARTICULATION OF THE FOOT AT THE ANKLE.

cutting pliers.   Subsequently he thought these flaps too long (c),  and
states that a line drawn round the foot midway between the head of the
fifth metatarsal bone  and the malleolus externus, will show their extent
anteriorly, and that they should meet a little  way farther back, opposite
the malleolar projections of the tibia and fibula.   Care is to be taken to
avoid  cutting the posterior tibial artery before it  divides into the  two
plantar arteries for fear of partial sloughing of the flap.   If the articula-
ting surfaces of the tibia  and fibulahe diseased, a thin slice of these bones
should be sawn off.
  Handyside {b) imagines  that the operation can be much more easily
and readily performed by the method of antero-lateral flaps, as the  dis-
section  of the os calcis from the soft part of the heel is thus much more
easily effected,  the great bruising  and twisting  of  the soft parts, which
occurs in the other mode of disarticulation, is thus happily avoided,  and
primary union is thus more likely to take place.   The operation could,
if necessary, be still further facilitated also by incising the pad of the heel
backwards from the  point where the two antero-lateral incisions meet.
To this it may be fairly replied,  that there is no necessity for twisting
and bruising the soft parts, and that the side-flap proposal directly does
away with one  principal advantage of Syme's  operation, to wit, that " the
dense textures provided  by nature, for supporting the weight of the body,
might be still employed for the same purpose;" and on which  account it
should be preferred to the side-flap scheme.   Syme considers this opera-
tion applicable  to many diseases and injuries of the foot, in which, exci-
sion of the affected bones, or amputation of part of the foot being ineffi-
cient, the practice previously followed had been that of amputating below
the knee.   The advantages promised by amputation at the ankle-joint
instead of the operation" near the knee  are, first, that the risk of life  will
be smaller; second, that a more comfortable stump will be afforded; third,
that the limb will be more seemly and useful for support and progressive
motion.  The risk of life must be less, because the parts divided and re-
moved are not nearly so extensive as when the leg is amputated, hardly
indeed exceeding those concerned in Chopart's operation; because there
is less room for haemorrhage either immediate  or secondary, owing to the
smaller size of the vessels cut, which are merely the branches of the pos-
terior tibial,  and  the anterior tibial artery very near its termination;  and
because the cavities of cylindrical bones not beingopened, the danger of
exfoliation from the dense osseous texture  and  of inflammation in  the
medullary veins is avoided.   The  stump will be  more comfortable, be-
cause it is formed of parts peculiarly well calculated to protect the bone
from injury, and  not  disposed to contract like the  muscular tissue;  be-
cause the cut ends of the nerves being smaller will  be less apt to enlarge
and become  the seat of uneasy sensations;  and because the absence of
exfoliation ensures complete union of the integuments over the bone, and
the limb will be more useful, as well as seemly, from full play being af-
forded  to the knee-joint,  without the embarrassment  of an  imperfect
stump.   This operation has been successfully performed eight times by
Syme himself, and also by several others.
(a) Same; in same, vol. iv. p. 647. 1844.
(b) Cases in Surgery; in same, vol. v. p. 789.  1845. 
[   703  ]
       II.**-OF EXARTICULATION OF THE TARSAL BONES.
   I am rather doubtful whether this  subject should be  here  noticed, or
whether it should be referred  to excisions;  but upon the whole it may
perhaps be considered as belonging rather to  exarticulations.
   The needfulness of removing or exarticulating either of the tarsal bones
seems to be restricted  to  the  astragalus and navicular bone in cases of
compound dislocation ; but I have not known any instance in which the
latter has been removed.   In  very rare instances the astragalus may be
thrown out from all its connexions through the skin by violence;  a  case
of  this kind occurred some years since to my  late friend Hammond of
fcouthgate, in which his patient having jumped out of a gig, with which
his horse had  run away,  the  astragalus was jerked completely through
the skin on the front of the instep,  and hung only by a few shreds of
cellular  tissue, which  having  been divided, the bone was removed and
the patient recovered.
  More commonly  the astragalus is merely  detached and thrown  out
from the cup of the navicular bone, which happened in  a case of my
colleague Green's several years  since {a), the so-called head of the bone
bursting through the skin below the inner ankle.   If the bone cannot be
replaced, it must be exarticulated from the ankle-joint above and from
its connexion with the heel-bone below.   The  operation  is tedious and
tiresome, and  it is requisite  to  cut  through  the remains  of  the inner
plantar ligament and the other ligaments which connect  the bone to  the
shin- and splint-bones, in doing which the point of the knife must be kept
close to the astragalus, and if  possible, to avoid division of the plantar
arteries if they be not already torn through.—j. r. s.]
  [On removal of the Astragalus, see paper by Norris in the American
Journal of the Medical Sciences,  vol.  xx.  1837.—g. w. n.1
 III.—OF EXARTICULATION OF THE FOOT BETWEEN THE ASTRA
  GALUS AND NAVICULAR BONES, AND THE HEEL- AND CUBOID
  BONES.                                             a«w uubuijj

 (Exarticulatio per montem Pedis, Lat.; Ablosung des Fuses zwischen dem Sprung-und
  Kahnfbrmigen, und dem Fersen-und Wiirelformigen Beines, Germ.; Disarticula-
  tion Partielle du tarse, Fr.)
  2777. Amputation of the foot  through the nearly right lined joints be-
 tween the astragalus and navicular, and the heel- and cuboid bones in-
 dicated py Garengeot and Heister, was first performed by Du Viviers
 {b) and Chopart (c), but first described by the latter, whence its designa-
 tion, Chopart's excision of the  foot; and  in Germany, specially, parti-
 cular rules were laid  down for it by Walther (d) , and its great pre-
 ference to the previously grievous amputation of the leg pointed  out (e).

^T^^^TaV11 Dislocations' P- 33°- Y"L«V-P- 471—Dictionnarie des Sciences'
New Edition, 1842.                    Medicates, vol. i. p. 497.
  (6) For DuViver's Case, see Hunczovsky,   (d) Abhandlungen aus dem Gebiete drr
Medicinisch - chirurgische  Beobachtungen prakt. Medicin, u s w  p 143
auf seinen Reisen, p. 244.  Wien, 1783.      («) Langenbeck, Bibliothek fur Chirurgie
  (c) Fourcrov's  Journal; La Medecine vol. iii. p. 746, pi. i. fig  ] 3—Klein ah
eclairee par les Sciences physiques, vol. iv. cited, p. 27.—Chelius,  Be'richt uber Hi!
Paris, 1792.—Richter's Chirurg. Bibliothek, Chirurg. Klinik, p. 20. 
704      PARTIAL EXARTICULATION OF TARSAL BONES.

   2778. The diseased conditions suitable for this operation are rare, and
are only crushings and carious destruction not extending beyond the first
row of the tarsal bones, and in which the state of the soft parts permits
the formation of a flap sufficient to cover the exposed joint-surfaces.
   2779. The mode of proceeding in this operation varies acccording as
the condition of the soft parts permits the formation of  two flaps or only
one.
   2780. The patient is placed in the same position as  in amputation
through the  thigh.   The  femoral artery is  compressed above the knee
with a tourniquet; an assistant grasps the foot above the ankle, and draws
the skin as much as possible upwards.  The operator holds the front of
the foot with his left hand, placing the tip of his forefinger on the promi-
nence of the navicular bone, and the flat of his thumb behind the promi-
nent end of the metatarsal bone of the little toe; and a line drawn across
the dorsal surface of the foot, behind the thumb and forefinger, sufficiently
points out the place of the joint.  The operator in this way grasps the
right foot of the patient with his own left hand, its  palm being directed
towards himself; but in operating on the left foot, the back of his hand is
towards the operator.  This indication of the joint is by far more certain
than the direction to find it, a finger's breadth beneath the lower end of
the shin-bone, or half an inch below the outer, or an inch below the inner
ankle.
   2781. If an under flap only be to be formed, the fingers of the left hand
having been  placed as directed, a strong scalpel is to be carried immedi-
ately behind  them from the one edge of the foot, about four or five lines
above the sole of the foot, over the  instep to the opposite side, and the
skin and tendons cut through.  The first cut  generally opens part of the
joint.   The front of the foot,  then grasped with the left hand, the thumb
upon the back and the other fingers upon the sole, is borne downwards
and outwards, so as to stretch the ligaments between the astragalus and
navicular  bone, and then the knife is carried into the joint between them.
As this  is done the whole foot is drawn more downwards, and the liga-
ments between the  heel-and cuboid-bones divided.   The front of the
foot is now  much pressed down, a large amputating knife entered into
the joint,  and the inner being held a little higher than the  outer edge of
the foot, carried  down with the edge close  to the plantar surface of the
metatarsal bones, cutting the flap obliquely downwards  at their junction
with the phalanges of the toes.   In  this way a flap is formed of proper
length without any measuring being required.
   2782. After tying  the  vessels and cleansing the wound, the flap is
brought over the joint surfaces of the astragalus and heel-bone, so that its
edge  may be properly applied to that of the upper cut,  and in this posi-
tion it is to be fixed with  sticking plaster passing from the sole over the
instep, and from the one side of the flap to the other.  Four compresses
are then to be fastened with a circular bandage on the four sides of the
stump, of which two are  cleft, so that one  cleft and one not cleft are
opposite each other.  The wound is now to be covered with a pledget
and lint, the uncleft compress  passed  through the cleft one,  drawn
together diagonally and its  ends fastened by some turns  of the circular
bandage. 
PARTIAL EXARTICULATION OF TARSAL BONES.       705
  2783. If an upper and under flap be formed, the joint having been
determined as above mentioned,  one cut is made on the inner edge of
the foot, from the projection on the navicular bone, and a second on the
outer side, beginning from the junction of the heel and cuboid bone ; and
the length of these cuts is to be from two to three fingers' breadth, accord-
ing as the  lower flap is formed larger or smaller.   The lower ends of
the side cuts are to be connected  by a transverse  one across the instep,
and thus the flaps are to be separated together with all the tendons  and
muscles from the bones up to the  beginning of the side cuts, and turned
back.   The  prominence of the navicular bone is now  againfelt for, the
foot grasped, as in the former case, with the left hand, and at the edge
of the  turned-back skin, close behind the projection of the navicular bone,
the connexion between it and  the astragalus  is cut through,  and then
whilst the front of the foot is much pressed down,  the connexion between
the cuboid and the heel-bone is also cut through.   The under flap is then
formed  with a large  amputating  knife in the  way directed in the last
paragraph.
  If the above-mentioned indication  of the joint be properly followed, it cannot be
Well missed.   It may here be remarked to the little experienced, that in dividing
the connexions between  the navicular bone and  astragalus, the knife  frequently
enters behind the head of the astragalus. If the knife be passed between the navi-
cular and cuneiform bones, which is only possible by complete departure from the
wiles laid down, the mistake is soon discovered by the joint-surfaces of the cunei-
form bones, and by the obstacle which the cuboid offers to its complete separation.
  Maingault (a) begins  the operation by forming the under flap, cutting through
the tough ligaments on the plantar surface, and completing the operation by dividing
the parts on the instep.
  2784. Langenbeck, Klein,  and RicheRand consider the formation
of an upper flap useless, because the higher the scar is with a single under
flap the less injury is it exposed to, and because this flap on account of
its great toughness is more fit for  covering the wound.   Some  consider
that the  upper flap should merely  be formed by dissecting back the skin,
as the tendons are liable to a tiresome suppuration, and may be thrown off.
  Experience  has, however, proved to me  that by the  formation of an
upper flap according to Walther's method, that is, when every thing is
separated from the bones, such  adhesion of the tendons, especially of the
m. tibialis anticus, will follow ;  that the  heel cannot be so far drawn up
by the operation of the gastrocnemial muscles as in the formation of a
simple plantar flap or of an upper flap merely of skin.   If after this ope-
ration  the heel be considerably  drawn up, the foot will be little useful for
walking; and under such circumstances the  subcutaneous division of the
tendo Achillis has been recommended.
  Scoutetten's oval cut only remains to be mentioned, in which from the middle of the
line of the joint.upon the instep, a cut is made passing forwards and downwards to-
wards the roots of the metatarsal bones, and connected by a transverse cut upon the
sole of the foot in the region of the bases of those bones.  The  skin is then drawn
back, and the exposed joint divided.   Blasius recommends his oblique cut.
             (a) Bulletin des Sciences Medicales.  Nov., 1829; p. 60.
Vol. hi—60 
[   706   ]
    IV.—OF EXARTICULATION OF  THE METATARSAL BONES.

(Exarticulatio inter Tarsum et Metatarsum, Lat.; Ablosung der Mittelfussknochen
  aus  ihrer Verbindung mit den Fusswiirzelknochen, Germ.;  Disarticulation des
  Metatarsiens, Fr.)
  Hey, William, Practical Observations in SuTgery, p. 547.  Second Edition.
  Vilerme, Sur les Amputations  partielles du Pied ; in  Journal de Medecine, par
Le Roux, etc., vol. xxxii. p. 156.  1815.
  Lisfranc he St. Martin, Sur l'Amputation partielle du Pied.  Paris, 1815.
  Ficker, Ueber die Amputation des Fusses zwischen der Fusswurzel und Mittel-
fussknochen ; in von Graefe und von Walther's Journal fur Chirurgie und Augen-
heilkunde, vol. iv. p. 90.
  Scoutetten, Memoire et  Observations sur l'Amputation  partielle du Pied dans
1'articulation tarso-metatarsienne ; sur l'Amputation metacarpo-phalangienne  en to-
tality, et Reflexions sur l'Amputation phalango-phalanginienne ; in Archives gene-
rales de Medecine, vol. xiii. p. 54.  1827.
  2785. The metatarsal bones  may be removed from their  connexion
with the tarsal  bones either all  together or singly.   The flrst operation
should  always  be performed if the destruction do not extend over the
tarsal bones, and the advantage of this operation is greater than Chopart's
excision, as thereby a larger portion of the foot and the insertion of the
m. tibialis anticus is preserved, and the  drawing back of the heel pre-
vented.  But if the greater difficulty of  this  operation be considered  on
account of the irregularity of  the joints, and the impossibility of closely
applying the flap, and that by the performance of Chopart's excision,
according to the mode recommended by Walther, the drawing back of
the heel can be prevented, this preference  may seem less considerable.
  2786. Hey first makes a mark upon the back of the foot, at the con-
nexion of the metatarsal with the tarsal bones, and an inch beyond this a
transverse cut through the skin and muscles of the bones of the metatar-
sus.   From each end of this, he carries a  cut along  the inner and outer
edge of the foot towards the toes, separates the  skin from the  metatarsal
bones, and all the integuments and muscles forming the sole of the foot,
from the under part of the metatarsus, with the edge of the knife close to
the bone,  up to their  joints, detaches the four lesser  metatarsal bones at
this joint, and saws through the projecting part of the first cuneiform bone
connected to that of the great toe.  After the blood is stanched, the flaps
are brought together  with sutures.
  Scoutetten, also, directs that the  first cuneiform bone should be sawn off; the
operation of the m. tibialis anticus is not thereby  interfered with.
  2787. According to Lisfranc, the  operator, after having ascertained
the position  of the parts, grasps the fore  part of the foot with  his left
hand, and  with his right the catlin, then places, if he  operate on the right
foot, the hind part of its edge behind the projection of the fifth  metatarsal
bone, so that the edge forms  a. right angle  with the  axis of the joint; he
divides the  soft parts from without inwards, and  a little from above
downwards, and when he feels he  has penetrated into  the joint of the
metatarsus with the cuboid bone, he raises the handle of  the  knife and
passes through  the  first two. joints with the point held vertically, then
through the third joint, when he inclines it towards the toes, for the pur-
pose of getting round the outer projection  of the  third  cuneiform bone.
He then finishes the division  of the soft parts above by a cut which ends 
EXARTICULATION OF METATARSAL BONES.        707
beneath the inner projection of the first metatarsal bone.  He divides the
cellular connexion if the retraction of  the  skin be not sufficient.   The
hand of the operator is held prone, and with one cut before and another
behind, he gets round, with short strokes from before backwards,the pro-
jection just mentioned, finds the joint at about the distance of a line,
where it is distinguishable by the absence of any obstacle, and by a little
depression ; he readily passes through this by  describing a slight curve,
the concavity of which corresponds to the cuneiform bone. Without giving
the foot any other direction, and without the blade  of the knife leaving the
joint, the operator directs it, held in the same position it had in passing over
the inside of the first metatarsal bone, between that bone, the first cuneiform,
and the second metatarsal bone ; he inclines the handle of the knife for-
wards so that its point may penetrate deeper, and then raises the handle
suddenly towards  the tarsus, so as to divide the ligaments.  He proceeds
to the hinder articulation, which he dislocates a little, brings the edge of
the knife in a  transverse direction, and  ends by dividing  the connexion
of the second metatarsal bone with the third  cuneiform, by an opposite
movement to that  which had divided the connexion of the first metatar-
sal with the first cuneiform bone, taking  care  to bring  the point of the
foot slightly inwards.  Attention in using only the point of the knife  in
the exarticulation  has the advantage of not injuring the soft parts in the
sole, and of penetrating more easily between  the  bones.   The operator
continues the operation by dividing the hinder  ligaments, holding the
parts to be removed, vertically, and  not much dislocated.   He  then
carries the whole edge of the knife forwards, close to the hinder edge of
the metatarsal bones, and forms a flap from the sole of the foot, two inches
long on the outer  and  inner side, and thick in front, so that it readily
unites.   After  tying the vessels and cleansing the  wound,  the  flap  is
brought up  over the surface of the wound, kept in its place with sticking
plaster, covered with lint and compress,  and supported by a moderately
tight bandage.   The foot is now placed in a rather raised position upon
a pillow in the bed, the leg half bent and laid  on its outer side, so  that
the discharge from the wound may readily escape.
   If the operation be performed on the left foot, the operation must be
begun on the inside of the foot, and the above-mentioned directions of
the knife must  be  followed out.
   2788.  Munzenthaler (a) gives the following description of  tbis  ope-
ration.   The operator, placed  on the  inside of the limb, passes his
finger to the bone  which bounds the tarsus,  glides it from  the toes to the
ankle and acquaints himself with the projections which the connexion of
the metatarsal and tarsal bones form at some parts.  He marks the place
of the joint with the thumb and fore-finger  of the left hand, places the
edge of the knife behind the hind end of the fifth metatarsal bone, passes
over the dorsal surface of the  foot, at first  from behind  forwards,  then
from before backwards, and thus makes a  semicircular cut which ends
half an inch before the pit observed at the side of the joint of the cunei-
form with the metatarsal bone.   The knife is brought back again into the
wound from within  outwards, whilst an assistant draws  the skin back
towards the ankle, and thus the extensor tendons of the toes of both the
(a) Above cited, p. 29. 
708
EXARTICULATION OF
m. peroneus longus  and brevis, the artery, and so on, are cut through.
The operator now brings the point of the knife vertically behind the hind
end  of the  fifth  metatarsal bone, directs it inwards and forwards, cuts
through the joint of the two last metatarsal bones, and divides the liga-
ments transversely.   He now leaves this part and turns to the inside of
the foot, and here directing the  point of the knife upwards, and its edge
outwards, cuts through the ligaments from below upwards, and from be-
hind forwards, and penetrates the space between the bones, in  the di-
rection of a line running to the  middle of the fifth metatarsal bone.  To
disjoint the  second metatarsal bone, the knife performs a rotatory move-
ment, and its  edge is  diiected forwards.   The  operator brings the point
obliquely from below  upwards, between the  great  cuneiform and the
second metatarsal bone, and divides  the soft parts  near its inner edge,
then raises the handle of the  knife, cuts through the ligaments, and thus
gets to the  hind part of the mortise which the second forms with the other
cuneiform bones.   He now again,  holding the knife  as usual, directs the
point from  without inwards,  and cuts  through the dorsal ligaments with-
out penetrating the joint;  for the separation of the upper surface of the
bones thereby connected, a slight pressure of the left hand upon the end
of the foot is sufficient.  If the  fibrous parts oppose the dislocation of the
metatarsal bones they must be gradually  cut through.   The foot  is now
to be held  horizontally between adduction and  abduction, and the sur-
geon  cuts through the plantar ligaments of the joint, separates  the soft
parts from the hinder ends of the metatarsus, carries the knife round them,
cuts close to the lower surface  of  the row of bones, and forms,  by cut-
ting out obliquely, a  flap, which on its inner  side  is two, and  on the
outer side,  only one inch long.
  If the  left foot be operated on, the  operator stands on the outside of
the limb, cuts  from the tibial to the fibular edge, and proceeds with the
operation as directed.
  If the projection of the fifth metatarsal bone cannot be properly made out, a point
two inches before and below the outer ankle, will sufficiently distinguish it. The
projection on  the first metatarsal bone, if it cannot be felt, will be found nine lines
below a line supposed to be drawn from the ^prominence of the fifth metatarsal bone,
directly to the inside of the foot.
  If the operation be performed on a young person before puberty, where  the pro-
jection formed by the first cuneiform bone is still cartilaginous,.this process should
be cut through with the edge of the knife almost in the same line in which the joints
of the second, third, and fourth metatarsal bones are found.
  2789. Of the  exarticulation  of  the single metatarsal  bones, must be
considered, flrst, the exarticulation of the three or four outer  metatarsal
bones, whilst  that of the great toe is  preserved: second, the exarticula-
tion of the great and little metatarsal bones: third, the exarticulation of
one of th,e middle metatarsal bones.
  2790. The  preservation of the great toe, when the  other  metatarsal
bones are removed, is  a great  advantage to the patient.   A cut should
be made in  the space between the great and second toe, and  a  second
along  the outer edge of the foot, and  both connected  at one  or two
fingers' breadth below the  tarsal joint on the  instep;  the skin  is then
drawn back, and the joint opened from the outer edge of the foot, after
which a large  flap is cut from the sole (a).
  The outer two metatarsal bones  are removed in the same way.
            (a) Key; in Guy's Hospital Reports, vol. i. p. 244.  1836. 
METATARSAL BONES.
709
   2791.  The exarticulation of the metatarsal bone of the great toe is per-
 formed most conveniently, in the following way:—A small amputating
 knife is entered on the outer side of the great toe, at a stroke, through
 the  soft parts, between the  metatarsal bone of the great and second toe
 up to the joint of the former, with the cuneiform bone.   Then the meta-
 tarsal bone of the great toe being drawn inwards, the whole edge of the
 knife is carried into the joint, and whilst  this  is done the great  toe  is
 pressed forcibly inwards, till the metatarsal bone is completely dislocated.
 The edge of the knife is then carried round the joint-surface, and being
 kept close to the outer side of the metatarsal bone at its connexion with
 the  great  toe, forms a flap sufficient  to cover the whole surface of the
 wound.  The dressing is like that in amputation through this bone.
   2792.  If  the state of the  soft parts will not  allow the formation of a
 side flap, a lower or upper flap must be made in the same way as in am-
 putating through the bone {par. 2729) after  a  longitudinal  cut has been
 made on  the outside of the  metatarsal bone of the great toe.   Or Lan-
 genbeck's or Scoutetten's method may be adopted ; though the opera-
 tion is then  more tedious and difficult.   When the situation of the  joint
 has  been found  by feeling with the finger, and the place (par. 2788 note)
 marked, the point of the left fore-finger is put on this part, and the other
 fingers, excepting the  thumb, placed on the sole, for the purpose of sup-
 porting the foot.  A cut  is now made, beginning two lines behind the
 joint, and continued obliquely, from within outwards to the commissure
 of the toes, to the base of the  first phalanx opposite the crease of the
 joint, on the sole.  This cut is now left, and the bistoury, placed on the
 inside of  the phalanx at the lower angle of the cut, is carried up along
 the inner  side of the toe and metatarsal bone, obliquely from within out-
 wards, to the beginning of the cut.  After dividing the skin, the knife is
 carried anew into the wound, and successively cuts through  the tendons,
 muscular fibres, and skin  on  the  sole of  the  foot, leaving the two sesa-
 moid bones attached to'the joint, and separates  from the metatarsal bone
 the skin attached  to its inner side.   The  joint is now again sought for
 and opened, the point of the bistoury being held vertically, and the edge
 a little obliquely from  within  outwards, and from behind forwards.   As
 the internal ligament is divided, the knife is  drawn  backwards, and the
 undivided fibres of  the upper ligament cut through, whilst  the  edge of
 the knife is directed upwards, and the point sunk obliquely at an angle
 of 45° in the space between  the  first cuneiform, and the second meta-
 tarsal bone.  The knife, of which the point has been thrust down to the
 sole  of the foot, is raised to a right  angle, and  by this  movement, the
 fibres of the interosseous ligament are cut through, and the metatarsal
 bone, still a little attached, is to be completely separated and removed.
   If  the operation be performed on the right foot, the place of the joint
 must be found with the fore-finger of the right hand, and the left fore-finger
 placed there to point it out, and whilst with the other fingers the foot is
 held, grasping its outer edge, the first cut is made on the inside.
  2793. In exarticulation of the metatarsal bone of the little toe, the pro-
 ceeding is the same as in the former case.  That of the little and fourth
toe is performed, according  to Scoutetten, by the same method as for
removing the metatarsal bone of the great toe.
                                60* 
710
EXARTICULATION OF TOES.
  2794. The middle, metatarsal bones may be removed from their con-
nexion  with  the tarsal  bones, according  to Scoutetten, by the oval
cut, which is  preferable  to the method with two side cuts.
  In these exarticulations of the metatarsal bones, the affected tarsal bones maybe
also at the same time removed.  Key removed at once the outer four metatarsal bones,
the second and third\;uneiform,and the cuboid bones.  Dieffenbach (a) took away
the outer two metatarsal and cuboid bone; and in another case, the inner two with
the two cuneiform and the navicular bone.  Ruyer (b) in an  exarticulation of the
firsrmetatarsal, removed.also the first and second cuneiform bones.
             V.—OF EXARTICULATION OF THE TOES.

(Exarticulatio Digilorum Pedis, Lat; Exarticulation der Zehen, Germ.; Disarticu-
                          lation des Orteils, Fr.)
  2795. In exarticulation of the toes from their connexion with the meta-
tarsal bones, an under, upper, or side flap, or the oval cut, may be made
according to the state of the soft parts.
  2796. If an under flap have to be formed, after the  situation of the
joint is determined, a transverse cut should be made over its upper sur-
face, which divides the front and part of the side  connexions of the joint.
From  both angles of this cut on either side of the toe a cut descends,
dividing the side connexions of the joint*  The toe is then pressed down-
wards to dislocate it, the  connexions behind are divided, the knife car-
ried along the under surface of the bone, and the flap made through the
side cut.   After the bleeding has been stanched, the flap is  brought over
the surface of the wound, and kept in place with straps of  plaster.
  In forming the flap upon the dorsal surface, a longitudinal cut is made
on  each side,  with the knife held  horizontally, beginning from the  joint
and continued to the junction of the first with the second phalanx.  These
side cuts are connected by a transverse one across the dorsal surface, and
the flap  separated  up to the joint, into  which, whilst the toe is pressed
downwards, the knife is carried, and all the ligaments and  soft parts cut
through.
  2797. If an outer or inner flap have to be formed on the  great or little
toe, the toe must be drawn in the  opposite direction, the knife pressed
on  the outer or inner side, directly into the joint, carried round the joint
surface of the  first phalanx, whilst the toe is dislocated,  and a large flap
sufficient to cover the wound formed on the outer or inner side by carry-
ing the knife along the bone.
   With the other toes, the side flaps are formed by two semilunar  cuts
carried from the upper part of the joint  over the  side of the toe which is
turned down, and the first phalanx dislocated, after the flap has been turn-
ed back.
  To prevent the protrusion of the head of the metatarsal bone in exarticulation of
the great and little toes, Dupuytren saws off the head with a fine saw.
   2798.  In exarticulation of the second from the flrst phalanx, that which
is to be removed must be bent backwards, a transverse cut made directly
into the joint, and all the soft parts divided to its hind surface.  The pha-
lanx is now dislocated, the knife  carried round the joint, and the flap
made from the soft parts below sufficient to cover the wound.  It is, how-
   (a) Hamburger Zeitschrift, vol. i. part i.   ' (b) Revue Medicale, 1832; vol. iv. p. 187. 
EXARTICULATION OF ARM AT SHOULDER.         711
ever better when only one phalanx is to be removed, to exarticulate the
whole toe, because the remaining stump is inconvenient.
   2799. If all the toes have to be exarticulated at once, a semilunar cut
must be made on the dorsal surface from the great to the little foe, or the
contrary, through the general coverings, the joints opened and the knife
carried forwards and  downwards opposite to and through the crease  of
skin which bounds the sole of the foot in front.
   2800.  In exarticulation of the toes from their connexion with the me-
tatarsal bones, the position of the joint having been, according to Scou-
teten, ascertained by moving the toes, the point of  the bistoury  is to be
placed a  line behind the joint, and carried to the base of the toe  along
the crease in the skin there existing.   The bistoury is now again  entered
from the  other side  into the  end of the first cut, and  carried upwards
around the toe to the beginning of that cut.   It is  then passed through
the whole wound to cut through whatever remains attached, and the
tendons of the extensor muscles; and an  assistant  lifts up the plialanx,
whilst the cellular tissue surrounding the joint, and the sheath of the ten-
dons of the flexor muscles are divided ; the phalanx  is then grasped with
the fingers of the left hand, and  operation completed by  division of the
lateral ligaments.
  VI.—OF EXARTICULATION OF THE ARM AT THE SHOULDER.

(Exarticulatio Humeri, Lat.; Ablosung des Oberarmes aus dem Schultergelenke, Germ.;
                       Disarticulation du Bras, Fr.)
  La Faye; in Memoires de l'Academie Royale de Chirurgie, vol. ii.  p. 239.
  Le Laumier et Poyet, Thes. de Methodis amputandi Brachium in articulo. Paris,
1759.
  Dahl., De Amputatione Humeri in articulo.  Gottingae, 1790.
  Plattner, Ernst, Zusatze zu seines Vaters Einleitung in die Chirurgie, vol. i.
p. 432.  Leipzig, 1776.
  Haselberg, Comment, in qua novum humerum exarticulo exstirpandi methodum,
novumque ad ligaturam polyporum instrumentum proponit.  Gryphiswald, 1788.
  Seeburg, Dissert. Exstirpatio Ossis Humeri exemplo felici probata. Viteb., 1795.
  Kloss, Dissert. De Amputatione Humeri ex Articulo.   Gott., 1809.
  Schiferli ; in Hufeland's Journal, vol. xx. part iii. p. 161.
  Walther, above cited, p. 102.
  Fraser, William, Essay on the Shoulder-Joint Operation, principally deduced
from anatomical observation.  London, 1813.
  Lisfranc de St. Martin et Champesme, Nouveau Procede operatoire pour l'Am-
putation du Bras dans son articulation scapulo-humerale.  Paris, 1815.
  Emeri; in Bulletin de la  Societe d'Emulation.  1815, May.
  De Claubry, Gualtier; in Journal de  Medecine par  Leroux, &c, vol. xxxii.
1815.
  Oberteuffer, J. G., Anatomisch-chirurgische Abhandlung von der  Losung des
Oberarmes aus dem Schultergelenke.  Wurzburg, 1823.  8vo.
  Larrey, Memoire de Chirurgie Militaire, vol. ii. p. 166 ; vol. iii. p. 354; vol. iv.
p. 427.
  Guthrie, above cited, p.  420.
  Klein, above cited, p. 1.
  Maingault, above cited.
  Ammon, Parallele der franzosischen und deutschen Chirurgie, p. 235.
  2801. Amputation of the upper-arm at the shoulder joint is  the easiest
of the  extirpations from the great joints.   It was  first performed by the
elder Morand.   Of the  several modes recommended for performing the 
712         EXARTICULATION OF ARM AT SHOULDER \
 operation, the following may be considered the most important;  First,
 the formation of an upper and under flap;  Second, the formation  of two
 side flaps; Third, the circular; and, Fourth, the oval cut.
   2802.  The patient either sits on a  stool, or lies on  a table covered
 with a mattress, with  the side to be operated on turned to the light, and
 is to  be properly held by assistants.  The subclavian artery is to be com-
 pressed by an assistant standing behind the patient, either with his fingers
 or  with a compressor (Ehrlich's) against the first rib.
  The pressure upon the subclavian artery by an assistant is better than the appli-
 cation of Dahl or Mohrenheim's compressor.  When the collar-bone is considerably
 raised pressure upon the artery is often  safer beneath the collar-bone, in the  pit be-
 tween the edges of the m. delloides and m. pectoralis.  Richerand (a) thinks compres-
 sion of the subclavian artery unnecessary, and only compresses the axillary  artery,
 just before cutting through the hinder flap.
   2803. The formation of an upper and an under flap, as recommended
 by La Faye, Richerand and others, has been very carefully laid down by
 Walther.   The upper-arm to be  removed, is brought to the side  of the
 chest and there  held by an assistant.  A small amputating knife is  to be
 thrust in, at the outermost tip of the coracoid process, up to the bone, its
 edge sunk along the  inner edge of the deltoid muscle and carried  down
 to its insertion,  cutting through all  the flesh to the bone.   A  second cut
 parallel to this is carried from  the  outer upper  angle of the  blade-bone
 down also to the insertion of the deltoid muscle.  The two lower angles
 of  these  wounds are to be' connected  by a transverse  cut down  to the
 bone.  The  flap  described  by these three cuts is now  separated  from
 the bone  up  to the beginning of the two side cuts, turned back and held
 by  an assistant, who  at the same time compresses the divided circumflex
 humeral artery,  if it be not at once tied.   The upper-arm is now grasped
 with the left  hand, brought into a state of complete adduction, so that the
 tendons of the  muscles passing from the blade-bone and hind region of
 the chest  over the shoulder-joint to  the upper-arm,  and the outer side
 of the capsular ligament are  made tense.   The thumb being then placed
 on  the head of the bone, a convex  scalpel held with the whole hand cuts
 through with a smart  stroke all the  parts covering the head, which being
 rolled outwards and backwards, tightens the inside of the capsular liga-
 ment and the  tendons passing over the shoulder-joint,  and these are
 divided with repeated strokes of the knife.  The arm being now brought
 against the trunk and raised, the head of the bone protrudes out of the
joint; the  whole of the amputating knife, is then passed in behind it, and
 cutting through  the still undivided ligaments is carried, with its edge to-
 wards the bone, down on its hinder surface, and the under flap formed,
 as it cuts out obliquely downwards  about four fingers' breadth below the
joint; before  doing which an assistant grasps the flap and compresses the
 artery.
  After stanching the bleeding and  cleansing the wound, the two flaps
 are brought  together and fastened with  sticking plaster; lint and  com-
 presses are then put upon the stump and confined with a  body-bandage,
 the middle of which upon the shoulder has a hole in it through which the
 sound arm can be slipped.
  The earlier methods of Le Dran and Garengeot need only be mentioned as mat-
           [a\ Nosographie Chirurgicale, vol. iv. p. 511.  Edit, of 1815. 
WITH UPPER AND UNDER FLAPS.
713
 ters of history; the first took up the axillary artery with a straight or curved needle,
 two fingers' breadth below the armpit,'.then with a transverse cut three fingers' breadth
 below the acromion, they divided the skin and deltoid muscle, and after separating
 the head formed an under flap.                                           '
   2804. According to Dupuytren (o), the  arm should be raised and held
 at  a  right  angle with the body.   The operator placing himself on the
 inside of the arm, grasps  and lifts up  the  deltoid muscle  with the  one
 hand, thrusts a double-edged  knife through  it  from within  outwards,
 taking care that its  blade never  slips  from the head of the bone.  The
 knife with its edge towards the bone is drawn downwards,  and the upper
 flap formed by cutting obliquely outwards.   The rest of the proceeding
 corresponds with that above described, only that the operator holds the
 flap before he cuts  it through.
  Here must be mentioned Onsenoort's method.  By means of a knife curved to-
 wards its surface, a transverse cut is made an inch and a half above the insertion of
 the deltoid muscle; the knife with its  concavity on the bone is pushed up to the
 acromion, penetrates the joint, and by its concave side being drawn down upon the
 bone the under flap is  cut off,  so that by a continued stroke of the knife the two flaps
 are formed.
   2805. Lisfranc and Champesme proceed in the following manner.
 The  arm is  brought to the side and left to itself.   The operator standing
 in front of the shoulder drops the point of a narrow double-edged knife
 into the triangular space between the coracoid process and front edge of
 the acromion, and carries it from before to behind through the joint, so
 that it passes out half an inch below the part where the acromion rounds.
 The knife is then carried from above and before  around the head of the
 upper-arm bone and a flap formed from  the deltoid, as in Dupuytren's
 method.  This flap being lifted  up by an assistant, the capsular ligament
 is found opened, and the whole  knife being' carried in behind the head,
 the lower flap is formed  as after La Faye's mode.
  If the left arm be operated on, the knife  is to be  used with  the  left
 hand, or being  held with  the right hand, is thrust in at the back of the
joint, where it has been mentioned as coming out, in  the method already
 described, and out at the triangular space, by the coracoid  process.
  [Astley Cooper's (b) amputation at the  shoulder-joint "with a single flap," as
 he calls it, and which  he prefers, differs little from the last-described operation, ex-
 cept in the flap of the deltoid muscle being made from below  and up into the joint.
 "The subclavian artery is to be compressed upon the first rib, from above the cla-
 vicle,  by  an assistant.   The ring of a common key covered with some soft linen, is
 a convenient instrument for this purpose.  The  patient should be  seated on a Tow
 chair, and the arm to be removed should be elevated a little from the side by an as-
 sistant.   In making the single flap, the surgeon raises  the deltoid muscle with the
fingers and thumb  of his left hand, and  introducing the catlin through the integu-
ment,  and under  the  muscle, near  its  insertion,  he cuts upwards  close to the os
humeri, as far as the under part  of  the acromion process; the  integument1 and
larger part of the deltoid muscle are thus raised, so as completely to expose the outer
part of the shoulder-joint; the arm being then drawn downwards, the catlin is passed
into the joint, at the anterior part, so as to divide the tendon of the biceps muscle,
and afterwards is carried round the head of the bone to cut through the capsular liga-
ment.   The  separation of the limb  may be  completed either by passing the knife
over the head of the bone, and cutting downwards to the axilla, or by placing the
knife in the axilla, and dividing upwards to the joint; in either case the amputation
should be finished  by one stroke of the catlin." (pp. 429, 30.)]
              (a) Dictionnaire des Sciences Medicales, vol. i. p. 496.
              (b) Lectures, by Tyrrell, vol. ii. 
714         EXARTICULATION OF ARM AT SHOULDER )
  2806. The elder Hesselbach's (a) method differs from those already
described in forming the under flap first.   The patient  sits on a stool,
and the operator standing before him, with his left hand grasps the upper-
arm beneath the insertion of the deltoid muscle, and rolling  it outwards,
so as well to distinguish the coracoid process from the little tubercle on
the head  of the upper-arm-bone, thrusts a long, narrow, double-edged
knife near the coracoid process, obliquely outwards up to the head of the
bone, so as at once to  open the joint; the knife then carried, with its
point close  on the bone, down to the  lower edge of the  great pectoral
muscle, cuts through its tendon and that of the subscapular muscle, the
acromial  thoracic and  anterior circumflex  humeral  arteries.   He  then
rolls the head of the bone inwards, thereby rendering the hind muscles
tense, and draws  it  as  much as possible from the blade-bone, whilst at
the same time he presses the lower end of the upper-arm-bone against
the chest.   He now carries the knife between the head of the bone and
the joint-surface of  the blade-bone,  through the  joint, thrusts, whilst he
drops the handle of the knife a little, through the hinder thin part of the
deltoid muscle, below the acromion, and carrying the knife down close
to the bone, forms the under flap, the vessels in which being at the same
time compressed by an assistant.  The head of the bone is now pressed
downwards, by an assistant, out of  the opened capsular ligament, as the
elbow is separated from the  trunk,  and the whole  knife being  placed
above the head of the bone, is carried  with its edge towards  the bone, to
the end of the first flap, and forms the upper flap.
   2807. Desault (b) has given the following directions for forming an
inner and an outer flap.   A  double edged straight amputating knife is
thrust from before, into the joint, and after its point has passed  on the
inner side of the  upper-arm, through the arm-pit, drawn down close to
the bone for three fingers'breadth, and thus a flap is formed containing
the vessels, which an assistant grasps, and compresses.   The whole knife
is then carried round the head of the upper-arm-bone, and forms a cor-
responding external flap.
   Larrey  (c) forms the outer flap first penetrating from without into the
joint, and ending by the formation  of the inner-flap, so that if proper as-
sistance be wanting, as for instance, in the field, there  may be  greater
safety against bleeding.
   Larrey (d) has more recently described  his method in the following way.  A
longitudinal cut is made, beginning from the edge of the acromion, and carried down
about an inch below the neck of the humerus, which divides the deltoid muscle into
two equal  halves.   By the help of an assistant the skin of the arm is drawn back
towards the  shoulder, and two flaps, a fore and hind one, are formed by two cuts
passing obliquely from within outwards and downwards, so that the tendons of the m.
pectoralis and m. latissimus dorsi are included in the two cuts.  There is no fear of in-
juring the axillary vessels, because they lie beyond the reach the point of the knife.
The cellular connexions of both flaps are now divided, and they are drawn up by an
assistant, who at the  same time compresses the circumflex arteries.  The whole
shoulder-joint is in this way laid bare, and with a third cut carried over the head of the
bone, the capsular ligament and tendons are divided.  The head of the bone is now
moved a little outwards, and the knife carried down close to the hind surface of the bone
for the purpose of completely dividing the tendinous and ligamentous connexions at
this part.  The assistant now places the fore-finger of both hands immediately upon
   (a) Oberteuffer, above cited.             (c) Above cited, vol. ii. p. 170.
   (b) Haselberg, above cited.               (d) Above cited, vol. iv. p# 427, 
WITH CIRCULAR, AND OVAL CUT,             715
the brachial plexus for the purpose of compressing the artery ; and the edge of the
knife being turned backwards, cuts opposite the lower angle of both flaps, through
the whole bundle of axillary nerves before the two fingers of the assistant.
  Langenbfck. (a), after drawing down and  pressing the  arm  against the chest,
makes with a small knife a cut into the deltoid muscle, so that the head of the bone
may be conveniently dislocated, carries the knife behind it,  and forms  on the  inner
surface of the upper arm a sufficiently large flap, in doing which, the edge of the  knife
is carried down close to the  bone, the head of the bone grasped and drawn towards
the operator, so that the axillary artery may not be cut off too high.  Dupuytren's
(b) method corresponds with this.
   2808. The  exarticulation  of the upper  arm with the circular cut is
variously performed.  •
   Morand made a circular cut in  the skin, drew it back, and  then cut
through the muscles close to the head of the bone, exposed it and divided
the ligaments.
   Sharp proceeded in like manner, only he first laid bare the axillary
artery by a longitudinal cut and tied it.
   Nannoni and Bertrandi first  made a transverse  cut three fingers'
breadth below the acromion, through the  skin  and  deltoid muscle, and
drawing them back cut into the capsular ligament, dislocated the head of
the bone, and after tying the axillary artery, cut through the armpit  (1).
   Alanson made a circular  cut a hand's  breadth below  the acromion,
through the  skin,  and with  the edge of  the  knife directed obliquely
upwards, through the muscles, and  afterwards, for the more easy division
of the joint, he made a straight cut through the upper part of  the deltoid
muscle.
   Graefe (c) lays down the following  rules for  his funnel-shaped cut
(Trickierschnitt.)  The arm being held  nearly horizontally, the cut through
the skin is madethree fingers' breadth below the  acromion, and then the
cut through the muscles with his leaf-knife, pressed obliquely upwards to
the head of the bone.  An assistant draws  the muscular mass  upwards
with both  hands, and then, the head being rolled forwards and upwards,
the capsular ligament is  opened, first, on  the fore and upper, and after-
wards, upon the upper and back part of the head  with the leaf-knife, held
obliquely; the tendon of the m. biceps is cut through, the arm drawn by
the operator towards himself, and the  head being thereby dislocated, the
under hinder part of the  capsular ligament is divided.   The vein is  to be
also tied, and  the wound brought together in  a  vertical direction  with
one suture.
  (1) Cornuau and Sanson's  method agrees  precisely with this, only that the
former makes the semicular cut through the deltoid muscle, of four fingers' breadth,
and the latter only a finger's breadth below the acromion.  Velpeau's (d) method
is the same.
  Benj. Bell's (e) operation consists in one circular cut at  the point of the deltoid
muscle through the  skin, and a second through the muscles, and tying the artery;
then two longitudinal cuts, in  front from the  acromion  and behind from the  top of
the shoulder,"run down into the circular cut, after which the flaps thus formed are
separated from the bone and its head set free.
   2809. In exarticulation of the upper-arm with the oval cut, Scoutet-
ten (f) proceeds in the following manner:—The operator, having satis-
  (a) Bibliothek fur die Chirurgie, vol. iv.   (d)  Medecine Operatoire, vol. i. p. 39.
p 5Q5.                                 (e)  Above cited, vol. vi. p. 417.
  (6) Lecons Orales, vol. iii. p. 328.          (0 Above cited,  p. 15, pi. i. and ii.
  (c) Above cited, p. 110, pi. ii. and iii. 
716         EXARTICULATION OF  ARM AT SHOULDER.'
 tied himself of the situation of the acromion, grasps, if operating on the
 left arm, the middle of the upper-arm with the left hand, brings it about
 four or five fingers' breadth away from the trunk, and thrusts a pointed
 knife, immediately below the acromion, up to the head of the humerus.
 The edge of the knife is now sunk  deeply, carried  downwards and in-
 wards, and thus the first  cut  is completed, which stretches down four
 fingers' breadth from the acromion, and upon the bone divides  the hind
 third of the deltoid muscle, and the greater part of the fibres of  the long
 head of the m.  triceps.  The operator now places the knife,  with  its
 point downwards, on  the inside of the arm, and beginning the second
 cut upon the other side of the m. triceps, at the  same height as the end
 of the first cut carries it inwards and upwards  to the acromion where it
 meets with the former.   In order to lay bare the joint better, that part of
 the deltoid muscle attached to the humerus maybe a little separated, and
 the edges of the wound drawn apart by an assistant.  The upper-arm is
 now to be moved about in different directions, and the tendons and cap-
 sular ligament, being divided together, the head of the bone is lifted out
 of the joint, and the  arm being pressed  towards the body, the whole
 knife is carried round it close to the bone, the humeral artery compressed
 in the wound by an assistant, and the  still undivided parts, containing
 the vessels, cut through.
  When the right arm is operated on, the first cut must be  made from
 the inside of the joint up to the acromion, but in other respects, the ope-
 ration is the same.
  In like manner Dupuytren and Beclard proceed.  They form from the middle
 of the top of the shoulder two  semilunar cuts running downwards, and ending be-
 fore the plexus.  The flaps thus formed are turned back, the joint opened, the knife
 carried behind the head downwards, and the flap containing the vessels, which are
 compressed by an assistant, divided.
  Bonfils (a) begins his first cut between the coracoid  process and the acromion,
 and the *scond, not in the beginning of the former, but two  inches lower, so as to
 form a larger  hinder flap, with which the joint-surface can be better covered.
  Blasius's oblique cut may also here.be mentioned.
  2810. As regards the choice of the above-mentioned methods for ex%
 articulating  the  upper-arm-bone, the following circumstances must^be
 attended to.  It must here be considered,  as in every other  exarticula-
 tion, in what way the soft parts are injured, whether the bone be broken,
 and whether the arm be more or less moveable.   The method^of opera-
 tion must be directed by these circumstances, and the formation of the flaps
 undertaken in such way as the condition of the soft parts allows,  and, as
 is necessary to cover  the wound properly.   The  modification  of La
Faye's method  by Wa£ther and Dupuytren is, in general, most fit-
 ting ;  at least,  in certainty and readiness of execution it surpasses all
 other.   The objection  of the more tedious  and difficult healing,  on ac-
count of the flaps, the  base of which corresponds to the greater diameter
of the joint, not fitting well; on account of the obstacle to the escape of
the pus, and so on is contradicted as  well by my own experience as by
that of others, and is no reason for preferring the. vertical wound with an
outer  and inner flap.
  The quickness in performing Lisfranc's and Hesselbach's operations
is not, indeed to be denied; but in living persons  where the parts about
               (a) Journal de Medecine, vol. xcvi. p. 192.   1826. 
EXARTICULATION OF ARM AT SHOULDER.         717
 the joint are often swollen and variously altered, the arm little  or  not at
 all moveable, and the head of the upper-arm-bone firmly drawn into  the
 socket by the contraction of the muscles, this  method is, for beginners
 especially, in most cases unsafe.   The point of the knife is easily caught,
 must be carried  inwards and  forwards in various ways, and the like.
 Beginners  find out that here, as in many other of the modes of exarticu-
 lation proposed in modern times, sleights of hand,  which are readily per-
 formed upon the dead body, are unavailable in cases of necessity.   Lan-
 genbeck {a) has  already justly objected  to Graefe's method, that  the
 knife with  its edge turned  outwards is not fit to  be  rolled  about, and,
 especially in  the extended position of  the arm, that the much-stretched
 axillary artery would  be cut through  too  near the shoulder-joint, and
 might retract so greatly as to cause great difficulty  in tying it.
   2811. When, after exarticulation of the upper-arm-bone, the acromion
 or the glenoid cavity is in any way injured, so that its removal may be
 considered necessary, it is easily done with the saw (&)._  Brown  sawed
 off the  projecting acromion, for the  purpose  of making an insufficient
 quantity of  skin  better  cover the wound.  Robinson (c) recommends
 removal of the  acromion and the glenoid cavity, so that the stump may
 be  made  rounder and more, regular.   Fraser {d)  also  proposes  the
 removal of a portion of the acromion and coracoid  process, together with
 the whole  glenoid cavity, because they hinder the quick union  of  the
 parts by the  adhesive inflammation (1).
   Supported by the law of the formation of the bone,  in consequence of
 which the  top of  the acromion remains cartilaginous to the  age of from
 eleven to  fifteen  years,  Lisfranc (e) recommends, for persons of this
 age, the following practice:—Be  the position of the  arm what it may,
' the operator  places the heel  of the amputating knife upon the outer side
 of the top of the coracoid process, and carried  it up to the hind edge of
 the arm-pit.   The flap thus  formed is lifted up, the cartilage  of the acro-
 mion and  collar-bone cut into, the joint readily entered, and the  under
 flap  formed in the usual way.
•  When the upper-arm bone has been shot through by a ball close under its head,
 the, appearance of the wound  does not point  out its importance, as the shoulder re-
 tains'its form; and it can only be ascertained, when the arm-bone is  examined
 throughout its whole length with  the fingers, when a deep  pit is found, which
 points out the  solution of continuity.  Enlargement of the  shot wound is insufficient
 for the removal of the head of the bone, and if it be left it causes inflammation, sup-
 puration, and destruction  of the bone, which render  the exarticulation  of the  arm
 necessary.   In such cases these symptoms  must be guarded against, by the early
 removal of the head of the bone, or of the broken pieces.  Larrey (/) made a cut
 in the middle  of the deltoid muscle, parallel to its fibres,  carried it down as far as
 possible, divided the edges of the wound on the sides, so  that he laid bare the joint
 of which the capsular ligament is generally opened.  With a curved, blunt-pointed
 bistoury the insertions of the m. supra-spinatusy infraspinatus, teres minor, subscapu-
 lars, and the long head of the  m. biceps were divided, the head of the bone freed
 and removed with the fingers.  The arm was then brought up to the shoulder,  and
 kept  in that position by proper  bandages and a sling.  Either anchylosis between
 the arm and shoulder-blade, or an artificial joint, which permits certain motions, is
 the result.
   (a) Above  cited, p. 504.                  {d) Above cited.
   (b)  Faur ;  in Memoires de l'Academie de    (<•) Averill, above cited, p. ISO. Edit.
 Chirurgie, vol. ii. p. 463.                 of 1823.
   (c)  New England Journal, vol. iii.  Bos-    (/)  Memoires de Chirurgie Militaire, vol.
 ton, 1814.                            ii. p. 173.
   Vol. hi.—61 
718         EXARTICULATION OF FORE-ARM AT ELBOW.
  Guthrie (a) says that " a wound from a musket-ball, causing a fracture beneath
and exterior to the capsular ligament, although in its  immediate vicinity, by no
means demands amputation, from this cause alone.  With a wound from a musket-
ball passing through the soft parts and the bone, in the same situation, without de-
stroying its substance to any great extent, the arm has frequently been preserved."
  [(1) Unless disease of the acromion, glenoid cavity, or coracoid process, impera-
tively require their removal, when amputation at the shoulder-joint is performed, or
when by accident the skin is not of sufficient length to cover the joint, the proposal
of removing these processes, or either of them, is not to be entertained; no real ad-
vantage is to be gained from it;  and if it be believed, that the continuance of the car-
tilage upon the glenoid cavity offer any bar to union in the ordinary time, which,  so
far as my own personal experience, and the observations I  have made in the practice
of others, is certainly not proved, the surgeon may scrape off the cartilage, if he have
a fancy to do so, but it is matter of no consequence at all.
  Amputations at  the  shoulder-joint are not very frequently needed, as it appears
from Liston's reported cases, he had but one in University College Hospital during
five years, and myself only one  in six years at St. Thomas's,  both secondary to ac-
cident, and both recovered.   Astley Cooper says :—" In  every  instance  in which
I have performed the amputation through this joint, and every case in which I  have
seen it done, the recovery of the patient has been speedy and perfect."  (p. 432.)]
Amputation through Shoulder-Joint.
	Accident or Disease.	Operated on.	Remarks.	Dis-charged.
1840 John Bateman, aged 39 (coal-car-man,) admitted July 25.	Compound fracture, with comminution and small wound in skin, but not much bruising; conse-quent on cart-wheel passing upon, but.not over the arm. On the fourth day irritative fever set in; the whole arm much swollen. On the sixth day some bloody oozing, which continued through the day, and reduced him much. Bleeding came on again on morning of twelfth day, to the amount of six ounces; said to have been in a jet, but seemed to me to be venous; but it brought him very low. Was easily checked by pressure; and when he was revived by stimu-lants,the operation was performed.	Aug. 6. Twelve days after.	With flaps of m. deltoides by piercing from*efore. The artery held as the second cut was being made. Six arteries tied, and three hours after two more. The flap was dropped down, and covered with a wet cold cloth. He became very restless soon after the operation, and so con-tinued for nine hours, till the opium given sent him to sleep. At twenty-two hours the fla p was 1 igbtly applied with straps of plaster. Went on very steadily improving; but the discharge from the wound was very profuse.	Nov. 10.
VII— OF EXARTICULATION OF THE FORE-ARM AT THE ELBOW.

(Exarticulatio Antebrachii, Lat.; Ablosung des Vordernarmes in Ellenbogengelenke,
                Germ.; Disarticulation de VAvant Bras, Fr.)
 Brashor, above cited.
 Moublet ; in Journal de Medecine, vol. xi. p. 240.
 Mann; in New York Medical Repository, vol. vii.  1821.
 Textor; in Neuer Chiron, vol. i. part. i.
 Dupuytren; in Sabatier Medecine Operatoire, vol iv. p. 524.   New Edition.
 Rodgers; in New York Medical and Physical Journal, vol. vii. p. 85.
  2812.  This operation, first performed by Pare, and  more  fully deter-
                           (a) Above cited, p. 424. 
            EXARTICULATION OF FORE-ARM AT ELBOW.         719


mined by Brasdor, is  objected to  by nearly all writers, and amputation
through  the  lower  third  of the fore-arm is preferred to  it.   Mann,
Textor, Dupuytren, and others have, however, performed it  success-
fully.
   2813.  The operation is best performed according to Textor's direc-
tions :—After making provision against the bleeding during the operation,
and the arm being straightened, a long double-edged amputating-knife is
passed in at the top of the outer condyle  of the upper-arm-bone, carried
flat before  the bend of the elbow,  and  thrust through before and above
the inner condyle, at corresponding height to the point of entrance, and
then being drawn down, a flap is formed of three or four fingers' breadth
long.   The vessels found  in this flap may be at once tied.  A cut through
the skin is next made on the opposite side of the arm, two fingers' breadth
below  the  entrance of the former, extending from one end  of the exist-
ing wound to the other, and  the skin is  dissected back to set the ole-
cranon free.   The external ligament is now cut through, the knife carried
between  the upper-arm-bone and the radius, and the fore-arm being bent,
cuts through  the tendon of the m. triceps, and lastly, the  internal lateral
ligament.
   According to  Brasoor,  a transverse cut  should be  made through the skin and
tendon of the m. triceps on the extending side of the arm; the ligaments are then
divided, and the whole knife, the  arm being bent, is carried through the  joint, and
forms from the inside of the arm a fleshy flap.
   Jaeger favours  this method.  The fore-arm being bent at a  right or an oblique
angle, he makes a semicircular cut through the skin with a small convex amputating-
knife, two fingers' breadth below the point of the  olecranon, from the head of the
radius, to the outer edge of the ulna.  The skin is drawn back by an assistant above
the olecranon, and  the tendon of the m.  triceps  cut through, by which the joint is
opened. Whilst the fore-arm is bent still more, the lateral ligaments between the up-
per-arm-bone and the olecranon and the ulna and radius are opened, the knife is carried
over the coronoid process upon the front of both bones, the arm  being slightly bent,
and by cutting from within outwards, a flap of three fingers' breadth is formed, which
the assistant grasps before its complete division, and compresses the brachial artery.
   Hager  makes two longitudinal cuts of three inches length, down from the con-
dyles to the ulna and radius, by which he marks out the front flap.   An inch below
the upper angle he makes a semicircular cut through the skin and muscles behindr
separates the little flap upwards, passes into the joint from behind, and  forms the
front flap,  two inches or two inches and a half long.
   Rodger forms the front flap with a semicircular cut, from the head of  the radius
to the- inner condyle, and by separating the skin he forms the  hind flap.  After
which the joint is  cut through.
   Dupuytren's (a) agreed with Textor's method, except that he  sawed off the ole-
cranon.  He performed this operation eight or ten times successfully, and preferred
it as giving a greater length  of the upper-arm, and leaving the m. triceps attached,
by sawing off the olecranon.   When the soft parts are not sufficient to form a front
flap, Dupuytren made a circular cut through the skin and aponeurosis, the fore-arm
being half bent, three fingers' breadth below the condyles of the upper-arm-bone.
These  parts are drawn back by an assistant, and the muscles cut through at their
edge down  to the bone.   Whilst the  operator separates them upwards from the
bones, he reaches the joint,  which is  opened by dividing the lateral  ligaments
and the capsular ligament on the front.  The knife then easily passes between the
bones and the operation is completed.
   Velpeau and Cornuau proceed in like manner with the circular cut, only they
do not saw through but exarticulate the olecranon.
   Textor (b) proposes  the oval cut, which however, is  more difficult and not so
advantageous as the flap, in the following way.  The arm being brought horizontal,
  (a)* Lecons Orales, vol. iii. p. 318.                 (b) Jaeger, above cited, p. 365. 
720         EXARTICULATION OF HAND AT THE WRIST.
 the fore-arm straightened, and the hand prone, the surgeon standing on the outer
 side makes, with a small amputating knife, onecutabout four inches long and pene-
 trating to the bone, from the head of the radius obliquely upwards and inwards to
 above the tip of the olecranon, and then a second on  the ulnar side from the upper
 end of the ulna, to the same height.  He then dissects back the flaps to their base,
 passes between the upper-arm-bone  and radius, upon and around the olecranon, and
 cuts through the tendon of the m. triceps, whilst the fore-arm is bent and supine.
 He now cuts forwards and downwards over the coronoid process of the ulna, above
 the head of the radius and along both bones so far upwards as necessary to form a
 flap three fingers' breadth long.  The wound is brought together lengthways.
  Baudens proceeds in another way.  The fore-arm being rendered supine and the
 brachial artery compressed, the surgeon, standing on the inner side if he operate on
 the left, and on the outer if upon the right arm, marks with varnish an oval, which
 begins on the  outer edge of the  radius four fingers' breadth below the bend of
 the elbow, and terminates  on  the  hind edge of  the ulna three fingers'  breadth
 below the bend of the arm.  Following this mark he cuts through the skin, which,
 by dividing its connexions and drawing back with his left hand, he separates to the
 extent of eighteen lines.  He then cuts through the muscles down to the bone, holds
 back the fleshy parts like a ball and  divides the deep muscles circularly, at the same
 time passing between the joint surfaces of the upper-arm bone and radius, and com-
 pletes the exarticulation by division of the ligaments, and of the tendon  of the m.
 triceps near the tip of the olecranon.  The soft parts by their own weight  drop over
the  joint surfaces and form a hollow globe in the point of which the joint surface
of the humerus is found.  After tying the vessels the wound is brought together
lengthways.
   VIII.—OF EXARTICULATION  OF  THE HAND AT THE WRIST.

 (Exarticulatio  Manus,  Lat.;  Ablosung  der  Hand^  Germ.;  Disarticulation  du
                               Poignet, Fr.)
   2814.  The brachial artery is  to be compressed with the tourniquet;
one assistant holds the fore-arm and draws the skin back, a second holds
die hand.   The operator, standing on the inner side for the left, and on
the outer for the  right hand, makes a circular cut. through  the skin half
an inch from the spinous process  of the radius.   The skin is next dis-
sected up, without the tendons, to the wrist, turned inside out, and held
by the assistant.   The hand is  now put between  pronation and supina-
tion, the knife placed  before the spinous process of the radius, and whilst
the hand is  pressed down, the whole knife is carried into the joint,  ob-
liquely towards  the ulna, and  divides  all the  ligaments and tendons.
The edges of the wound, after tying the vessels, are brought together in
the oblong direction of the joint.
  Instead of the semicircular cut, a flap  maybe made upon the back and front of the
wrist.  It may be necessary on account of some peculiar kind of accident which af-
fects the exarticulation to form a large upper or under flap; for this purpose the skin
of the thumb and the like may Tie saved.
  The above-described mode of proceeding is  better than by dividing the skin  and
tendons on the back  of  the hand by a semicircular cut to pass  into the joint, and
drawing down the knife to form a flap on  the  front  of the hand.   Or, according to
Lisfranc, the hand being held between pronation and supination, a narrow knife is
thrust through the soft parts opposite the joint on the palmar  surface from one  side
to the other, and then being drawn down forms a flap ; after which  a semicircular
cut is made through the skin upon the dorsal surfaces the flap turned back and the
joint divided from the radius.
   [If amputation through the wrist-joint be performed with flaps, special care must
be taken to avoid,  in forming the front flap, the pisiform bone, which often catches
the knife, and unless well cleared, spoils the edge of the skin-cut.—j. f. s.] 
[   721   ]
  IX—OF EXARTICULATION OF THE METACARPAL BONES AT
               THEIR JUNCTION WITH THE CARPUS.

 (Exarticulatio inter Carpum et Metacarpum, Lat.; Ablosung der Mittelhandknochen
  aus ihren  Gelenken mit der  Handwurzel, Germ.;  Disarticulation  des Mita-
  carpiens, Fr.)
   2815. The exarticulation of the metacarpal bone of the thumb, of the
 fore- and of the little-finger, and of all the fore-fingers together, the thumb
 being still preserved, is now to be considered.   The exarticulation of the
 middle  and ring metacarpal bones is not to be recommended.   The dis-
 ease being  rarely confined to any one of these bones, the  operation is
 attended with much difficulty.   Collections of pus take place in the car-
 pal joints, and the exarticulation of the hand afterwards becomes neces-
 sary, as I have seen in two  cases.  It is better therefore under such cir-
 cumstances, to amputate through the  continuity of the metacarpal bones
 of the middle and ring-fingers.
   2816. In exarticulating the  metacarpal bone of the thumb, if the soft
 parts permit the formation of a side flap, it must be thus performed.  An
 assistant, who holds the fore-arm, compresses the radial and ulnar arte-
 ries.  The  operator holding the thumb with one hand abducts it strongly,
 so as to render the fold of skin between it and4he fore-finger tense.  He
 now carries a straight bistoury in this fold to the connexion of the first
phalanx of the thumb with its metacarpal bone, and along the side of the
 metacarpal  bone to the joint.   The thumb is now violently  abducted  to
 stretch the ligaments, the whole knife carried into the joint, the metacar-
 pal bone dislocated, the knife carried  up on the other  side of the  bone,
 and along it, to its junction with the first phalanx, where, by cutting ob-
 liquely out, the  flap is formed, which corresponds precisely to the first
 cut.  After tying the vessels the flap is properly  applied and fastened with
 strips of sticking plaster, and a bandage.
   Where the formation of a side flap is not possible, and only an upper
 or under flap can be formed, the  same mode must be employed  as de-
 scribed  in exarticulation of the metatarsal bone of the great  toe.
  2817. In precisely the same way  may the metacarpal bones  of  the
 ring- and little-fingers be separated from their connexion with the carpus,
 only that these exarticulations are more difficult than that of  the thumb.
  2818. Langenbeck's method of shelling out  the bone from the soft
parts by carrying forwards a £ shaped  cut from the junction of the me-
tacarpal bone of the thumb with the trapezium,  and then cutting through
the joint, is  more troublesome and tedious than that described.
  Scoutetten (a) has also applied his method to the metacarpal bone of
the fore-finger, of the ring- and of the little-finger, according to the rules
given for exarticulation of the metatarsal bones.
  2819. The oval cut of  Scoutetten is most convenient for exarticula-
tion  of the  middle  metacarpal  bone.   The knife  is placed  at the joint,
above the bone at the crease of the finger in front, and carried round cor-
respondently to  the  first phalanx; then placed on the other side  in this
cut, and carried back,  and in the same direction as the first cut to its be-
ginning.  The soft parts are separated by short strokes from the bone to
                        (a) Above cited, pi. iii. iv. v.
                                61* 
722    EXARTICULATION OF THE METACARPAL  BONES, &C.

the joint, which is best entered on the under side.   The wound is united
by bringing the neighbouring metacarpal  bones together.  The practice
of making  two  side  cuts  in the  interspace  united on the dorsal,  and
palmar  surfaces by an oblique or  A shaped cut, keeping close to the bone
to be removed, and avoiding the  extensor tendons of the next fingers
is inconvenient.  The extensor tendon of the finger to be removed is di-
vided with the point of the  knife, the metacarpal bone pressed down, and
the connexions of the joint cut through.
  If both middle metacarpal bones are to be exarticulated, the fore-  and
little-finger being well adducted, one cut between the bones  is to be made
close on the radial side of the middle finger, and another on  the ulnar  side
of the ring-finger to the carpus.  These two long cuts are then to be con-
nected  on the volar and dorsal surfaces by transverse cuts close down to
the bone, the soft parts turned back and the joint cut through.   After the
bleeding is  stanched the flaps are to be brought together (1).   The exar-
ticulation of the  last two or three metacarpal bones  may be performed in
like manner; the cut  between the  bones being first made, and then a  lon-
gitudinal cut along the ulnar side  of the fifth metacarpal, both  these con-
nected  by a transverse cut on,the back of the hand nearer or farther from
the carpus, the soft parts dissected back, the joint divided  and the volar
flap made (2).          *
  (1) von Walther (a) proceeds in the same way in extirpation of the middle and
ring-finger, together with removal of the hind part of the  metacarpal  bone of the
fore-finger.  Astley Cooper (b) also operated successfully in  the same way.
  (2) Riadore, Guthrie, von  Graefe, von Walther, and Jaeger have removed
in this manner the last two, and Astley Cooper the outer three and the first meta-
carpal bone with the thumb, so that the fore-6nger alone remained,  and served as a
very useful  hook.  Larrey and Riadore  removed  the  second, third, and fourth
metacarpal bones, preserving the thumb; and Tyrrell took away successfully the
fourth and fifth metacarpal bones with the pisiform and unciform bones, and the half
of the first, second, and third metacarpal bones.   Benaben (c) extirpated, instead of
the whole hand, the first and  second  metacarpal  bones, the  scaphoid, great, and
trapezial bones, and cut off the upper part of the third metacarpal bone, preserving
the outer three fingers.
   2820. In exarticulation  of the four metacarpal bones, but preserving
the thumb,  a double-edged knife is passed in, whilst the hand is  supine,
on the ulnar side, at the junction of the metacarpal bone  of the little finger,
thrust between the other metacarpal bones and the soft parts of the palm
to the junction of the  metacarpal bone of the fore-finger, where it is thrust
out, whilst the thumb is abducted.  By cutting obliquely outwards a  flap
is formed;  then a  semicircular cut is made on  the back of the hand,
through the skin and  tendons, and the joints opened  on the palmar  sur-
face of the hand.   After tying the vessels, the flap is brought over the
wound and fastened {d).
   Troccon  {e) makes first  the cut on the back of the hand, cuts through
the joint, beginning on the radial  or ulnar side, and forms a palmar flap,
whilst the knife  is carried into the opened joint and drawn forwards  and
downwards.
   (a) Journal fur Chirurgie und Augenheil-    (d) Maingault, above cttcd, pi. ii.—Cht-
kunde, voL xi>i. p. 352.                  rurg. Kupfertaf., pi. lixiii.— Gensoul; in
   (b) Lectures onSurgery, by Tyrrell, vol. Revue Medicale. 1827; vol. ii. p. 143.
 ii, p. 423.                               (e) Nouvelle  Methode pour l'Amputation
   (C) Revue Medicale.  1825; vol. i. p. 371.  du Poignet, dans son Articulation carpo-
 March.—Jaeger, above cited, p. 334.        metacarpienne, Bourg, 1926. 
EXARTICULATION OF THE FINGERS, &C.
723
  When the disease is confined to merely one or other metacarpal or metatarsal bone,
it is very advantageous, according to Blandin (a), to remove.that one alone, and to
preserve all the others ; with which opinion Jaeger also agrees.
  In removing the first metacarpal bone, the  hand is placed on its ulnar edge
upon a table, and held firmly by an assistant, who grasps on the one side the thumb,
and on  the  other the four-fingers.  The operator makes, along the muscles of
the thenar eminence, a cut  four fingers' breadth long, which must extend a little
beyond  the carpal and finger-joint of the first metacarpal bone.  The edges of the
wound are drawn asunder, and the attachments of the m. opponens pollicis and of the
first m.  interosseus are cut through.   During the latter act the knife rests close above
the first metacarpal bone, so as not to wound the radial artery, which lies close to
the second bone.  The tendons of the flexor and extensor muscles of the thumb are
drawn back, the tendon of the great m. abductor pollicis cut  through at its insertion,
and thecarpo-metacarpal joint of the thumb divided  from  without inwards;  after
which the bone is lifted  out with strong forceps, and  separated from all the fibrous
parts which connect the metacarpal bone to the undermost phalanx.
  In removing the other bones the method is the same, with but little variation.  In
removing the second metacarpal  bone, wounding the  radial artery is unavoidable.
As to the rest, the part of the inner  transverse  ligament of the metacarpus, corres-
ponding to the phalanx, must be left, the joint must be opened from behind forwards,
and when this is half done,  and the bone half dislocated, the knife must be lifted up
before the head of the metacarpal bone, for the purpose of cutting through the ante-
rior ligament from above, so that it remains attached to the phalanx,  together  with
the transverse metacarpal ligament with which it is connected.
   In extirpating the first metatarsal bone, the foot must be so placed as to rest on its
outer edge; the operator then thrusts a long  narrow bistoury on the inner side of the
m. extensor longus pollicis, so that its point may come out at  the inside of the tendon
of the m. flexor pollicis, and then cuts out a flap, the base of  which corresponds to
the hind joint of the metatarsal bone, and its tip to the front joint of that bone ; the
rest of the operation is performed as on the metacarpus.
X.—OF EXARTICULATION OF THE FINGERS, AT THEIR JUNCTION
  WITH THE METACARPAL BONES, AND AT THEIR OWN JOINTS.

(Exarticulatio Digitorum Manus, Lat. ; Ablosung der Fingerglieder aus ihrer Verbin-
dung mit den Mittelhandknochen, unduntersich, Germ.; Desarliculationdes Doigts, Fr.)

   2821.  All that has been  said in  regard  to  exarticulation  of the toes
from the  metatarsal bones,  applies  to amputation  of the fingers  at  their
junction with the metacarpus.
  In exarticulation of the middle and ring-fingers, Dupuytren (b) cuts off the head
of the metacarpal bone obliquely with a saw.  In younger  persons, in whom ossifica-
tion is  incomplete, the head of the bone may, according to Lisfranc, be cut off
with a knife.
  Barthelemy (c) thinks  that inflammation, gangrene, and suppuration occur after
exarticulation of the fingers from the metacarpal bones, in consequence of the strangu-
lation of the underlying cellular tissue by the palmar aponeurosis, and therefore pro-
poses, after extirpating the finger, to separate the  processes of the  aponeurosis, which
is easily done ; and by which, whilst the tension of the aponeurosis is got rid of, these
bad symptoms are more certainly prevented.
   2822.  In exarticulation of the joints of  the fingers, from each other, if
the state  of the parts permit, the following is the best mode of proceed-
ing:—-An assistant draws out the diseased  finger from the healthy fingers,
held in a state of pronation, and  holds them firmly.   The operator, with
his left thumb and finger, grasps the diseased joint and bends it, whilst
             (a) Gazette Medicale de Paris, vol. ii.  p. 152; 1831.
             (6) Sabatier,  above cited, p. 534.
             (c) Journal Universel des Sciences Medicales.  1829; p. 211. 
724                     IMMEDIATE AMPUTATION.
with the  other hand he carries  a straight narrow bistoury, holding it as
in making a longitudinal cut, a line below the projection which Is formed
by the head of the upper phalaltx,  in a horizontal direction from the left
to the right side, with  a stroke  into the joint.   The  lateral ligaments are
then divided, the diseased phalanx pressed much downwards, the blade
of the knife carried to the  palmar surface, forwards, and close to the bone,
where by cutting obliquely a flap is formed.
   If two flaps have  to  be  formed, a semilunar cut is to be made on the
dorsal surface of the joint, the  skin drawn back, the joint cut into, and
the lower flap formed as in the  former case.   This  mode of proceeding
is, however, unsatisfactory, because the  upper flap  is very thin,  its dis-
section painful, and after the cure the scar is in the middle, and thus most
exposed to external violence.
  Less suitable is Lisfranc's (a) method of forming the flap, by thrusting the knife
through the palmar surface, cutting into the joint frorrrabove downwards, and through
the skin on the dorsal surface.
  For the purpose of producing, by adhesion of the tendon of the flexor muscle, the
mobility of the firstphalanx, after the removal of the second, Lisfranc (b) previously
makes a longitudinal cut of half an inch on the palmar surface, which wounds the
tendon, the wound heals  by  suppuration, and  then the  extirpation  is  performed.
This practice is objectionable, because  thereby inflammation of the sheath of the
tendon may be set up; it  is also  unnecessary, because the  tendon unites with the
scar (c).
   [I take the opportunity, in concluding the subject of amputation through the shaft
or in the continuity of bone, and through the joint or in the contiguity of bone, to
add Liston's cases to my own for the purpose of making a better average of the re-
coveries and deaths after the operation for amputation.
    Of Liston's cases  -  - 52    Recoveries  -  - 45    Deaths   -  -   7
    Of my own cases  -  - 54               -  - 42             -  -  12

                         106                    87               19—106
Making a per eentage of 82.075 recoveries, and 17.925 deaths to the whole number
of cases operated upon.
                      IMMEDIATE AMPUTATION.
  The question of Immediate Amputation has been already discussed (d) in treating
of compound fracture, and to this  the  reader will refer.   From the reports  of the
amputations which I have given, it is proved, as I there stated, that primary ampu-
tation is more serious in its effect on the constitution, when performed on the lower
than on  the upper  limbs, and more  especially when the  thigh is the part  of the
member subjected to that  operation.  If, however, a much-injured  thigh be not at
once removed, the patient almost invariably has a fearful struggle with irritative or
with hectic fever, if he escape the former, but more commonly he has to pass through
both, and dies in consequence of his powers being completely worn out.  The sur-
geon is therefore placed in a most difficult situation in determining whether he shall
amputate the thigh, or through it at once.   The danger to the patient is great if the
operation be performed, as my reports prove;  the danger is as great and the patient's
sufferings severe, protracted, and without good result, if the operation be not per-

  (a) Memoire sur un Nouveau Precede pour  pour pratiquer l'Amputation dans les  Articu-
1'Amputation dans  les Articulations  des  lations du Metatarse et du Metacarpe avec
Phalanges; in Revue Medicale.  1823;  vol.  les phalanges; in Revue Medicale.  1823;
i- P- 233.                               vol. i. p. 382.
  (b) Ibid., above cited, p. 236.               {d) Vol i. p. 569-74,par. 590, note.
  (c) Memoires sur de nouvelles Methodes 
IMMEDIATE AMPUTATION.                   725
formed, as I have witnessed again and again.  On the whole, I am inclined to believe
that primary amputation of or through the thigh, is to be preferred.  But with regard
to the leg, the danger is very much less, and in the several parts of the upper limbs,
comparatively trivial, and therefore, according to my experience, amputation in these
cases should not be deferred.
   John Hunter indeed thought differently, and  preferred secondary amputation in
case of accidents; and his opinion is too important to be passed by unnoticed.  He
says (a) :—" If a man gets a very bad  compound fracture in the leg, or has his leg
taken off, either for this fracture, or in consequence of any other accident, he stands
a much worse chance of recovery than  one who has been accustomed to a local dis-
ease ; even the man with the compound fracture will  do much better, if his leg is
not taken off till the first symptoms are over; or at least we may be certain  that the
symptoms arising from the amputation will not be nearly so great as those that arise
at first from the fracture, or would have arisen from the immediate amputation.  *
*   *  For, first, I do  not look upon full health as the best condition to resist disease;
disease is a state of body which  requires a medium.  Health brooks disease ill, and
full health is often above par;  persons  in full health are too often at the full stretch
of action,  and  cannot bear  an  increase, especially when  diseased ; and, as I have
before observed, it is a new impression on the constitution, and till it be in some
degree accustomed to  local disease, it is less able  to bear such  as is violent; besides
the removal of a diseased part which the constitution has been accustomed to, and
which is rather fretting the constitution, is adding less violence than the removal of
a sound part in perfect harmony with the constitution."   (p. 233.)
  Notwithstanding Hunter's  great authority, however, I must still agree with
Astley Cooper (b), that "if  it will be necessary to amputate in a few days after
the accident, then the sooner it is done the better.  *  *   *   For if you amputate
immediately, the constitution has  but one  shock to sustain, and  in general rallies
much better than when the amputation is delayed." (p. 680).—j. f. s.
  Rutherford  Alcock, in  his very able  Lectures  (c), which I regret my limits
have not permitted me to make use of; but which are of such deep interest and im-
portance that I  would recommend them  for careful perusal, and  specially to Army
and Navy  Surgeons, as they are more  particularly concerned  with the cases which
form the principal subject of his consideration,  observes :—" That  the injuries of
civil life, and the amputations for them, especially those performed in the  primary
period, are followed by more unfavourable results than equally grave injuries occurring
in the field.  If we reflect for a moment upon the mode in which the two classes of
injuries are inflicted, I think an adequate reason will suggest itself.   A man em-
ployed in some agricultural or manufacturing occupation, if he becomes the subject
of a grave injury, it must be under circumstances for which his mind is totally un-
prepared, under circumstances the  most calculated to cause terror and a great shock,
mental and physical.  *  *  *  In  military life, the injuries inflicted are under
very different circumstances; it is true,  men but the moment before with sound limbs
and in full  health, fall with bones  crushed and broken, with  limbs torn from  their
bodies.   But every man goes into action knowing his liability to  such occurrences;
he sees his comrades fall on every side; many he sees besr  it almost gaily—the
majority with good courage; he has known  hundreds to whom the same lot has
fallen, recover, and either return to their duty or pass the rest of their lives, not un-
happily with a pension.   He is excited at the moment; the onward rush, the shouts
of  the victors and the vanquished  mingling with the roar of artillery, the  flashing
peals of musketry, all tend to make him reckless of any feeling but one of wild ex-
citement or enthusiasm.  *  *  *  The immediate shock of the injury is often,
therefore, trifling in some of the  worst injuries."  (pp. 850, 51, vol. ii.)]
  (a) On inflammation,  &c.                nature, progress, and terminations of the
 (b) Lectures.                           Injuries for which it is required ; in Lancet
 (c) Lectures on  Amputation, and on the  1840-41; vol. i. and ii. 
[   726   ]
         Fifth Section.—OF EXCISION OF THE JOINTS  (a).

   (Excisio Arliculorum, Lat.; Ausrottung der Gelenklheile der Knochen, Germ.;
                Resection des Extrimitis Articulaires des Os, Fr.
  White, Charles, Cases in Surgery, &c, p. 1.  London, 1770.  8vo.
  Sabatier, Seances Publiques de l'Academie de Chirurgie, p. 73.   Paris, 1799.
  ---------— Memoires de l'Institut National, vol. v. p. 366.   1805.
  Park, H., an Account of a New Method of treating Diseases of the Joints of the
Knee and Elbow.  London, 1733.  8vo.
  Moreau, Observations pratiques relatives & la Resection des Articulations affectees
de Carie. (Diss. Inaug.)  Paris, an xi.  (1803.)
  Park, H., and Moreau, Cases of the Excision of Carious Joints; with Observa-
tions by J. Jeffray.  Glasgow, 1806.
  Chaussier ; in Magasin Encyclopedique, cinquieme annee.
  Wachter, Dissert, de Articulis exstirpandis, inprimis de Genu exstirpato. Gron-
ing., 1810.
  Roux, De la Resection ou de Retranchement de portions d'Os Malades, soit dans
les Articulations, soit hors des Articulations.   Paris, 1812.
  Syme, James, On Excision of Joints; in Edinburgh Medical and Surgical Journal,
vol. xxxi. p. 256.  1829.
  ------------, A Treatise on the  Excision of Diseased  Joints.  Edinburgh,
1831. 8vo.
  Crampton, Philip, On the Excision  of Carious Joints ; in Dublin Hospital Re-
ports, vol. iv.  p. 185.  1827.
  Jaeger,  M., Article Decapitato;  in Rust's Handbuch der Chirurgie, vol.  v.
p. 559.
  ----------, Operatio Resectionis conspectu chronologico  adumbrata.  Erlang.,
1832.
  Meyer, G., Ueber Resection und Decapitation.  Erlangen,  1829.
   2823. Although Paultjs .ZEgineta and Heister had previously pointed
to the  extirpation  of diseased joints, yet was  it only  first performed  by
Filkin of Liverpool, on the knee-joint, in 1762, and the removal of the
head of the  shoulder-bone was undertaken  by Vigaroux, David and C.
White (1),  alout the same time.  The successful result which White,
and afterwards Bent (b) and Orred (c), had of this operation led to its
further extension to other joints.   Park applied it  to  the knee-and pro-
posed  it for  the elbow-joint.  Moreau, father  and son, performed  it on
the  latter, and  at the  ankle and wrist-joint; White, and  afterwards
Mulder (2), pxoposed it for the  head  of  the thigh-bone;  von Graefe
{d) undertook it at the jaw-joint, and Davie {e) on the collar-bone*   It
was subjected to the closest examination by  Sabatier, Percy (f), Roux,
Moreau the son, Larrey {g), and Guthrie (h), and much valuable ex-
perience  in  reference  to  it  has been  published.  But the  many and
favourable results obtained by the English and German  Surgeons, Syme,
Textor, and Jaeger, have contributed to extend the employment of this
practice and by their successful issue have contradicted many of the ob-
jections to it.
  (a) I  have  here slightly deviated from    (d) Bericht iiber das Klinisch-chirurgisch
Chelius, distinguishing Excision from Re-  Institut. 1821.
section, and placing them in two distinct    (e) Cooper, Astley, Lectures on Surgery,
sections; to  which they seem to me as fully by Tyrrell, vol. iii. p. 297.
entitled as Exarticulation and Amputation,     (/) Eloge historique de M. Sabatier.
and for the same reasons.—j. f. s.             (g) Memories de Chirurgie Militaire, vol.
  (6) Philosophical Transactions, vol. lxiv. p.  ii. p. 171.
353. 1774.                              (JK Above cited, p. 470, p. 521.
  (e) Same, vol. Ixix. p. 6.  1779. 
EXCISION OF THE JOINTS.
727
  (1) White (a) performed this operation in the year 1769.  It had been previously
done by Vigaroux and David  (6), although their operations were only published at
a later period.
  (2) Wachter (c), Vermandois (d) Kohler (e), Chussier (/), and more re-
cently Heine have performed experiments on animals which have supported the
proposition.
  2824.  In regard to  the  fitness of this operation, and in comparing it
with amputation, the following have been specially stated as objections;
the  difficulty of its performance, especially on  large  ginglymoid joints,
the danger  of violent inflammation and wasting suppuration, the tedious-
ness of the  cure, and, particularly, that after the removal of the joint-ends
of the bones of  the lower extremities in consequence of the shortening
and stiffness of the limb which remains, it is  only retained in a condition
far  worse than the use of an artificial limb   after  amputation, which is
much less dangerous.   According to the  cases as yet published, many of
these objections have lost  their importance, and are contradicted by ex-
perience.   It must, however, be admitted that the removal of the ends
of  bones is  more  difficult than amputation or exarticulation, yet  the
danger during and after the operation is not greater than in amputation,
and the  symptoms are not usually severe ; the  cure, indeed, is more
tedious but accompanied with fewer inconveniences, (Syme, Jaeger,) and
with the preservation of the limb the patient finds it  generally in a very
useful condition.   As  regards the removal of the joints of the upper  ex-
tremities, these circumstances are no doubt  of the greatest importance,
and to a certain extent influence its preference to amputation, as the pre-
servation of the arm, even with confined motion, is not  to be compared
with its artificial  supply after amputation, and  experience of the conse-
quences of  the  removal of the  joints of the upper limbs points to  the
most favourable  results.   This  operation on the lower limbs  cannot,
however, be  considered  so  advantageous;  it  is here  manifestly more
dangerous, the after-treatment more tedious and difficult, and the result
as to the capability of using the preserved  limb,  in many instances, in-
complete ; so that only under peculiarly favourable circumstances should
the removal of the joint-surfaces be here  performed.
  These statements are founded on the cases hitherto published.  Of Jaeger's col-
lection of fifty-three cases of excision at  the shoulder-joint but two had an unfavour-
able result;  of thirty-four at the elbow only four; arid in three at the wrist all were
successful.  In regard to excision at the wrist it is  remarkable that Syme (g),
otherwise so warm an advocate for the operation, gives a most unfavourable opinion,
that it is very difficult to perform, that relapses easily recur, and that it leaves a
stiff and unusable limb.   He, however, admits that these objections are supported
only by theory, and that experience might, perhaps, show them to be of less impor-
tance.  Of thirteen excisions  of the knee-joint, upon careful observation six were
perfectly successful, three imperfectly  so, in reference to the capability of using
the limb,  and three  were fatal; a  proportion decidedly less favourable  than in
amputation, but not so bad that excision of the knee-joint should be unconditionally
rejected.  Upon this  point Syme (h) observes, that excision  must always  be  con-
  (<*) Philosophical Transactions, vol. lix. p.   (d) Journal de Medecine, Chirurgie, et
39.  1769.                            Pharmacie, vol. lxvi. p. 200.
  (6) Pavid  (fils), Dissert, sur l'lnutilite   (e) Experimenta  circa Regenerationem
de l'amputation des Membres dans la plupart Ossium. Exp. 14,15,16, p. 84-98.  Gotting.,
des Maladies de la contiguite des Os.  Paris, 1786.
an xi.                                 (/) Above cited.
  (c) Above cited.                        (g) Above cited, p. 119.
                         (h) Above cited, p. 131. 
728
EXCISION OF THE JOINTS.
 sidered more dangerous than amputation when the patient is very weak or has been
 wasted by previous  disease; but if he possesses moderate powers, it is not to be
 supposed either from general circumstances or from the results of experience that
 excision is attended  with greater danger than  the removal of  the limb.  It must,
 however, be mentioned that a larger number of cases would give us a more decided
 opportunity of comparing excision of the knee-joint with amputation.  In five cases
 of excision at  the ankle-joint the result  was successful, and in twenty-four cases
 where it was performed for compound dislocation but one patient died.   Syme (a),
 however, says, that although excision of the ankle joint has  not the objections to it
 that that of the wrist has, it cannot be extolled as of any  great use.  It affords,
 indeed, a support for the body, and it may be questionable in how far the foot, after
 the excision, is better than an artificial apparatus.  Moreau's experience also shows
 that anchylosis  generally occurs after, the  operation ; and although, as he observes,
 the other joints of the foot become more moveable, so as in some measure to make
 amends for this stiffness/, there can still be no doubt that the foot loses much of its
 elasticity (b).
   [Upon the excision of joints Crampton (c)  observes:—" It is impossible not to
 be struck by the fact, that the constitutional disturbance succeeding to the excision
 of even so large an articulation as the knee-joint, bore no comparison in kind or in
 degree, with that which experience has proved to be the invariable attendant upon
 simple penetrating wounds of a joint, when union is not effected by the first inten-
 tion.   This difference in the'symptoms may, I think, be referred to that well-known
 principle of the animal economy, which disposes the system generally to suffer in
 proportion as the injured part is possessed  of a higher or lower degree of sensibility,
 and as the injury  is more or less difficult of cure by the proper  forces of the consti-
 tution.  Now,  although it be true that when  in  a healthy state the parts which
 enter into the composition of a joint'are possessed of but a low degree of sensibility,
 still it is well known that  when suffering under disease there are no parts in which
 inflammation  is attended  with more exquisite pain, or in which the actions which
 tend to recovery  are  more slowly or imperfectly performed.   It is not surprising,
 therefore, that a penetrating wound of a large articulation should be succeeded by a
 train of the most painful and dangerous symptoms.   By the total  excision of the
 joint, however,  all those parts, which when diseased, influence the constitution so
 unfavourably are removed from the system, and the injury is resolved into a case of
 clean incised wound, with a divided but not fractured or diseased bone at the bottom
 of it."  (pp. 207,208.)]
   2825. All  the cases in which excision of the ends  of bones is to  be
 preferred to amputation of the limb, may  be thus considered :—
   * Caries and necrosis of the joint-ends, of tubular bones, which does
 not spread further.
   £ Crushing of one or several joint-ends, without  further considerable
 splintering of the bone towards its body,  without injury of the  principal
 artery and nerves,  and  without great destruction of the  soft parts.
   y When, under like  circumstances, a  musket-ball  remains sticking in
 the spongy structure of a joint-end, and cannot be withdrawn.
   <? When,  in compound dislocation, a joint-end protrudes from the soft
 parts,  and cannot be  replaced.
   t Degeneration  of the whole joint, from spina ventosa or osteosteatoma,
 when  the boundary of the joint is not decided.
   £ Anchylosis  vera, when the limb is thereby rendered useless, or very
 considerably restricted.
   jj Old dislocations, with impossibility of using the limb.
  The  condition of the patient's powers deserves particular attention in considering
the indications for excision.  Much sunken condition of the patient is always to be
 held as a contraindication, and amputation is  here preferable, as with the removal
  (a) Above cited, p, 141.                  in Rust's  handbuch der  Chirurgie, above
  (b) Jaeger. Wurdigung der Resectionen;   cited.
                                  (c) Above cited. 
OF EXCISION OF JOINTS.                  729
of the source of the wasting suppuration, a relatively increased quantity of blood re-
mains in the body upon which depends the frequently and  so quickly favourable
change in the general condition after amputation, whilst in excision, especially the
knee-joint, a greater call on the powers is necessary.
  The state of the soft parts may contraindicate excision, if they be largely de-
stroyed or changed by disease.  According to Moreau, the degeneration of the soft
parts  depending alone on disease in the joint-end, should by no means forbid the
operation ; fistulous openings, consequent on affections of the bone, generally heal
after their removal; the damaged part of the skin might very possibly also be in-
cluded in the cut necessary for the exposure  of the end of the joint, but a greater
degree of destruction of the soft parts must always be considered a contraindication.
   2826. The operation of decapitation includes  the  following  acts :—
 The cut through the skin and muscles, and the exposure of the joint-ends;
the cutting off the bone,  the union of the wound by proper dressing*
   2827.  When  the patient has  been  properly placed and held by as*
sistants, a competent person  must be intrusted with  the compression of
the principal  artery, which is  preferable to  the tourniquet, as  the bleed-
ing is in general trifling, and by application  of the tourniquet the great
venous bleeding is rendered more serious.
   The direction and extent of the cut  depend on the condition of the
joint and soft parts.   A sufficient, but  not  very large cut must be made
according to  JjEGER(a), from  the simplest to the most complicated form,
in about the following scale.  First,  the  simple longitudinal  cut  — ;
second, the +  or|—|  or ++ cut; third, the ]/ cut; fourth, the "]"
or  J_ or -f—■ cut,fifth, the J_ or  I, shaped cut; sixth,  the  L.—I cut;
seventh, the  LJ  or  13  cu*>  eighth, the |—{ cut; and ninth,  the £""7^
or elliptical cut.
   For making these cuts, a pretty  strong knife should be used ;  the flaps
therewith  made separated from the bone, turned  back, and held with a
blunt hook, or by the fingers of an assistant,  the  ligaments cut into and
divided, the  head of the  bone dislocated, and  separated from the  soft
parts to the extent of the disease,  and  the periosteum there cut through.
If possible, the joint  should be at once opened in  making the cut through
the skin, and the ligaments lifted up with the flaps, as thereby the whole
operation is shortened, the pain diminished, and  the  cut has more posi-
tive direction.  After the spouting vessels have  been tied, a wooden  or
horn  spatula, a  plate of lead,  or a strip of leather or of linen,  should be
passed  between the  soft parts and the bone, to separate them  from each
other, and then the  edges  of the wound are brought together with the
assistant's  fingers or with a blunt hook.
   2828. Close upon the spot  where the periosteum has been divided, the
bone must be cut through with a moderate-sized saw, or if it be not  very
strong and hard, with the bone-nippers, and every splinter removed  with
a little saw, the nippers, or the file.  The still spouting arteries must be
tied, the thickened  ligaments, and capsule  of the joint, together with all
superfluous skin, removed, the whole wound cleared  of blood, and care-
fully examined both with the  finger and the eye to ascertain whether any-
thing hurtful  remains, that it may be removed.
  In determining the boundary of the diseased bone, not merely must the extent of
the caries be considered, but also the extent to which it has been separated from the
periosteum, for if that part be left, caries  or necrosis is quickly  set up on it.  In  such
              [a)  Rust's Handbuch der Chirurgie,  above cited, p. 582,
   Vol. iii.—62 
730
OF  EXCISION  OF JOINTS.
cases the cut must, therefore, be extended into the firmly-attached periosteum, and
the bone must be sawn through there.  If the caries run into the spongy end of the
bone, a plate of bone of corresponding depth to the caries must be sawn off, in which
case the application of the white hot cautery-iron, according to Moreau, generally
increases the necrosis, and delays the cure (Jaeger.)  If the bone be diseased more
extensively than was  supposed, amputation was generally required; however, in
regard to this, every thing depends on whether a large piece of bone can be removed
from each or from only one of the bones of a joint, as well also as on the condition
of the joint; thus, for  instance, at the shoulder, five or five and a half inches of the
upper-arm-bone have been successfully  removed.
  Of the numerous instruments which  have been recommended for removing the
ends of bones '(a), the  most convenient and applicable for all cases are, the common
large and smalt bow saw, the knife saw, Hey's saw of different sizes, Jeffray's,
(Aitkex's,) B. Heine's chain saw, the bone-shears and nippers, variously-formed
chisels, which although they jar both the bone and  the neighbouring-joint, and in-
crease the pain, are often indispensable.  Sometimes it may be convenient to divide
the bone partially with the saw, and then to use the nippers, with which the piece
of bone can be easily removed.
  The trickling of the  blood from the wound is commonly stopped by exposure to
the air, or with cold Water;  but if it come from a spongy and thickened tissue, this
must be removed, and cold water or some other styptic must be applied.  Bleeding
from a bone, when it cannot be checked by pressure with a sponge dipped in cold
water, requires pressure with German tinder, with lint dipped in spirit of wine, or with
little balls of wax.  Severe venous  bleeding, if it do not cease after the removal of
the tourniquet, and after repeated inspiration and expiration, requires the application
of cold water, or some  other styptic.  If the principal trunk of the artery or vein be
wounded, which can only be done by awkwardness or carelessness, it must be tied;
but, in-general, amputation will be necessary.
   2829. In  applying the dressing, which according to Jaeger, is best
done after the patient has got to bed, the limb  must be laid  on a pillow
covered with oiled  cloth, the ends of the bones put into proper, place,
either touching or not, and  the  edges of the wound brought together with
the interrupted suture.   Only when  the teguments are so very thin that
they would be cut through by the pressure of the suture-threads, should
compresses of lint be applied to support them (Syme.)  The most de-
pending part of the wound  must be  left open for the escape of the dis-
charge.  The wound must be covered with lint, the part  carefully raised,
and another oiled cloth with  the Scultetus's bandage, compresses, and
lint, laid upon  the  pillow, the  limb placed  on  it in  the position  most
proper for its future  use, the several parts of  the  dressing applied, and,
if necessary, secured with a  suitable splint.   Jaeger's practice, however,
of surrounding  the  limb with  compresses  dipped in cold  water and
simply laid on1 a pillow till suppuration come  on, seems to be best, as
at this  time Scultetus's bandage can  never be applied  so firmly as to
give hope of keeping the bones together.
  Syme's assertion that, after putting the  limb in proper position, to swathe  it in a
long roller affords the  necessary support better than splints, or stiff pieces of tin or
pasteboard,  is manifestly incorrect.
  2830. The  after-treatment must be  conducted according to the usual
rules for wounds and amputations.   The traumatic reaction is, according
to the  concurrent testimony of most observers, not great, and requires,
at first, besides keeping the patient quiet, strict diet, mucilaginous drinks,
and the use of  cold applications.  If there be little reaction and a cold
cedematous state of the parts, warm aromatic fomentations should be em-
ployed, and a  more nourishing and exciting diet.   When suppuration
(a) Jaeger, above cited, p. 584. 
OF EXCISION AT THE SHOULDER-JOINT.          731
begins the  cold applications must be given up, and the wound dressed
with lint and sticking plaster and bound up with Scultetus's  bandage,
to check any unnecessary movement of the arm.   On the fifth day, those
stitches which are most stretched must be removed, and the others ac-
cording to circumstances from the  sixth  to the ninth day.'  When the
fever subsides, more nourishment must be  allowed, and the patient, usu-
ally about  the eighth day, will have  returned  to his  ordinary diet and
drink.   The scarring, in general goes  on quickly, and only now and
then does the wound remain open longer {a).
   2831. Among the untoward  circumstances which  may occur during
the after-treatment, the following may be specially noticed, after-bleeding,
abscesses, fistulous passages, and ulceration of the scar.
   If after-bleeding come on soon after the operation, the dressing  must
be removed and the bleeding vessels tied.   If there be trickling from the
whole wound, cold applications and  styptics must be used.  During sup-
puration, if large bleeding come on,  amputation  will be necessary, as
tying the great  arterial trunk does away with the least hope of a favour-
able result.
   Abscesses which  are formed by extension  of the inflammation, or by
the burrowing df the discharge into  the neighbourhood of the operation,
require poultices and to be opened with the knife.
   Fistulous passages depend either on the continued secretion of synovia
from a still remaining portion of the joint-Surface, or on sluggish granula-
tions of the thickened callous tissue, or on some carious part remaining,-
or on superficial necrosis of the edges of the bone, and  require the con-
tinued use of aromatic applications until, in the latter case, small splinters
of bone be thrown off.
   JVecrosis  after decapitation, according  to Jaeger, rarely  or never af-
fects the medullary cavity.   Any remaining carious part, if it do not heal
after the above-mentioned treatment,  requires  a second  excision, or if it
spread, amputation.
   2832. The mode of  dressing the sawn-off ends of the bone  requires
particular attention  in the after-treatment..  In the upper extremity  the
formation of callus  should never be the object.  On the contrary, how-
ever, in the lower limbs, a!nd specially at the knee-joint,  every thing must
be directed towards its production,  and attention  paid to the  motions it
will have to perform, or that state of rest in which it is to remain.  If no
callus form, a tough fibrous tissue which grows and connects the ends of
the bones affords the limb sufficient firmness.  If no firm union take place,
if the limb be thereby rendered useless and not fixable by a firm enclosing
bandage, it must be amputated.
           I.—OF EXCISION AT THE SHOULDER-JOINT.

(Excisio Scapulo-humeralis, Lat; Ausrottung  im  Schultergelenke, Germ ; Resection
                         Scapulo-humirale, Fr.)

  2833.  The most important  proceeding in excision of the head of the
upper-arm-bone is to form an upper flap, as in La Faye's exarticulation,

                      (a)  Jabger, above cited, p. 394. 
732           EXCISION AT THE SHOULDER-JOINT.
{par. 2810,) to divide the connexions of the joint, to lift out the head of
the  arm-bone, and whilst a wooden spatula is  passed beneath it for the
protection of the  soft parts, to saw if off.   When  the  bleeding  vessels
have been tied, the sawn surface of the bone must be brought near  the
lower edge  of the glenoid  cavity,  the flap  laid  down and fixed with
sutures and strips  of plaster, covered with lint  and compresses, and the
arm kept in proper position, by means of such bandages as Desault has
described for  fractured  collar-bone.   The  after-treatment  must be con-
ducted in the same way as that of amputation, and bagging of pus must
be  especially prevented.
  C. White, Orred and others, operated with a longitudinal cut from the socket of
the  shoulder-joint down to the insertion of the m. deltoides, and then having divided
the  tendon of the long head of the m. biceps, lifted out the head of the bone and
sawed it off.  This method seems most preferable in all cases where only fragments
of the crushed head are to be removed. In chronic affections of the joint it must be
presumed that dislocation of the head of  the bone is easy under particular circum-
stances, that the ligaments are not very thick, and the like.
  Bent formed a flap from the outside of the joint by one vertical and two horizon-
tal cuts, running outwards from it.  Sabatier made a V flap from the deltoid muscle.
  Moreau thrusts in a scalpel, at the most prominent part of the coracoid process,
to the bone, aud cuts the skin and deltoid muscle directly downwards to the length
of three inches; next makes another cut parallel to it, beginning from the back part
of the lower edge of the acromion, then connects both with a transverse cut across
the  acromion, separates the flap and turns  it down.   The tendons and capsular liga-
ment are now divided, the head of the hone lifted out, a long pad introduced between
it and the soft parts, and then the head is  sawn off.  If the caries affect the glenoid
cavity and the acromion,  Moreau lengthens the front cut over the outer end of the
collar-bone and the hind one to the spine of the blade-bone; separates this new flap,
removes the carious part with  the  bone-shears or  the chisel, and then fixes  the
upper to the under flap.  Especial care must be taken that as much as possible of
the  capsular ligament should be cut off to prevent inflammation and profuse suppu-
ration.
  Syme makes a vertical cut from the acromion through the middle of the deltoid
muscle, nearly to its  attachment, then a shorter one from the lower edge of the for-
mer upwards and backwards, so that the outer part of the muscle is cut through.
After this flap has been dissected up, the joint comes in sight, and when the capsular
ligament, if existing, has been divided,  the surgeon  passes his finger around the
head of the bone, so that he may feel the attachments of the m. supra-spinatus, infra-
spinatus, and subscapularis, which he easily cuts through by turning the knife first
towards one and then to the other side.  The movements of the arm should be pre-
vented, to guard against irritation and displacement, and the latter by putting a pad
in the armpit.
  2834.  After this operation the motion of  the arm may remain under
various circumstances:—-first, the upper end  of the remaining, part of the
upper-arm-bone may be drawn back  to the glenoid cavity ;  second, it may
be  drawn from the outer edge  of the blade-bone to the trunk; or, third,
separated from it, may remain isolated in the soft parts.   In the first case,
a new perfectly free joint takes the place of the old one; in the second,
an  imperfect joint  is formed without much motion ; and in the third, the
lever of the arm remains  without any fulcrum, which, however, does not
offer any obstacle  to the  direction and freedom  of the movements pre-
served (a).

  (a)  Moreau, above  cited, p. 31.—Textor, Ueber das Absagen des oberen Endes des
Humerus; in Neue Chiron, vol. i. part. iii. 
[   733   J
             II.—OF  EXCISION OF THE ELBOW-JOINT.

(Excisio Humero-cubitalis, Lat; Ausrottung im Ellenbogengelenke, Germ; Resection
                          Humero-cubUali, Fr.)
  2835. Moreau's (a) method of sawing off the elbow-joint is as follows;
The patient lies  on a table covered- with a mattress, upon his belly, so
that the ailing arm  may be  put  at a right  angle  with the trunk, at the
edge of the table, in the strongest light, and/the hind part of the half-bent
elbow may be opposite to the operator.   One assistant holds the upper
and another the lower  end of the limb, and the brachial artery is com-
pressed with  a tourniquet in the upper third: of its course;  A cut of three
inches length is now  made, with a single-edged  scalpel, on each side  of
the lower end  of the upper-arm, to the pit of the  condyle, and both are
connected  by cutting through the skin and tendon of the m. triceps; the
flap is now dissected upwards  from the bone  and held by an assistant. ,
The fibres of the m. brachialis internus are  next separated  on the inner
and outer  side,  from the: bone,  and an ivory  spatula-shaped  retractor
passed between  it and the soft parts.  The elbow is held fast with the
left hand, and that part of the upper'arn>bone to be removed is sawn off
with a large saw by the right hand.  The fore-arm is then dropped, the
upper end of the sawn-off piece of bone lifted up, the knife  carried  in
front of it, its connexions separated, and as  it is set  free,  it  must be
decided how it can be removed  without violence.    If both  ulna and
radius, at their connexion, with the upper-arm-bone j. be deeply affected
with  caries, the  fore-arm  must be  lifted  up, a cut, an inch and  a half
long, made on the outer edge qf the upper end of the radius,  and a like
one on the hind-edge of the ulfia.   The flap between the two cuts is now
separated downwards, the head of the radius freed from its connexions,
a fold of linen, in place  of a retractor, passed between it and the soft
parts,  and the diseased part cut off with; a small  saw, in such a way as to
preserve the  insertion* of the m. biceps.  In like manner the upper end  of
the ulna is laid bare, protruded by raising the fore-arm, the carious part
sawn off, endeavouring* to keep the whole or part of the insertion of the
m.  brachialis internus.
  After tying  the vessels and cleansing the  wound, the two flaps are
brought into  place and fixed  with five sutures, the wound covered with
lint and compresses,  and a Scultetus's bandage.  The arm is to be laid
half bent upon a pillow.
  Dupuytren  (b) forms, like Moreau, two flaps on the hind partof the joints then
draws out the olechranon so that the ends of the bone may be better protruded.
  Syme also first removes the olechranon, cuts  through  the lateral ligaments for the
purpose of freeing  the lower end of the- upper-arm-bone and then cuts  it off.  He
then takes hold of the head of the radius with  the cutting forceps, and removes the
remaining part of the sigmoid' cavity.   The reason he gives for not at once remov-
ing  the whole  piece of the ulna is, that if cut through below the attachment of the
m. brachialis internus, its removal is very difficult.
  According to Moreau, the ulnar nerve must  be cut through, by which sensation
and motion is partially destroyed.  Dupuytren recommends saving this nerve, by
dividing the fibrous sheath in which it  is contained, and lifting the nerve with a
spatula over the inner condyle, where  it is to be held whilst the bone is sawn off.
Crampton and  Jaeger are of the same opinion.   Syme also preserves the  nerve,
which lies close to the inner edge of the olechranon, and will certainly be cut through
(a) Above cited, p. 42.
62*
(b) Sabatier, p. 451. 
734
OF EXCISION OF THE WRIST-JOINT.
if the transverse cutbe made beyond the olechranon towards the inner condyle. The ole-
chranon must therefore  be felt for and the knife thrust into the joint, with its back
towards the inside, close along the upper surface of the olechranon, but a little near-
er the radial side, and then cut transversely with a sawing movement, for the pur-
pose of dividing completely the tough  tendinous parts till the radial tuberosity is
exposed.
  Jaeger, in the absence of fistulous passages, always lays bare the ulnar nerve: he
ascertains its position by feeling  on the inner condyle, and then carefully makes a
cut two, or two and a half inches long, upon it, of which the middle is upon the
condyle; then opens the sheath of the nerve, takes hold of and lifts it up with a blunt
book, separates it from  the soft parts, lifts it over the inner condyle, and there has
it held fast, with a blunt hook.  With the left hand he now grasps the fore-arm, and,
by bending it towards the upper, renders the m. triceps tense, cuts through it with
a strong scafpel,a quarter of an inch above the olechranon from  the inner to the outer
condyle, and opens the joint, the bending of the arm being still  increased, the  lateral
ligaments and skin upon the condyles are still further cut through.  The further
progress of the operation depends on the extent of the caries; if but one condyle
be affected on its joint surface or on its outer side, the longitudinal cut must be con-
tinued upwards to the extent of the caries; in paries of the whole cubital process, a
longitudinal cut of an inch and a half or two inches length, must be carried from
each side to the pit of the condyles, the flap dissected back to the part where' the
bone is to be sawn through, and the operation finished according to Moreau's method.
If  the cubital process be healthy, the lower longitudinal cut of from one and a half
to two inches, must be made from, the inside of the olechranon and the outer part of
the head of the radius.  If the  upper cut be already made, it must be continued
downwards to the  requisite extent, and the lower flap dissected from the ulna.  If
the radius be carious, a simple cut must be carried over its condyle to the extent of
the caries..
  After excision of the  elbow-joint the radius and ulna always  remain separate, al-
though they are near together and held by the soft parts.  The hand retains its power
and mobility, and the fore-arm its most important motions.  Every thing, however,
depends on  the circumstance, whether the insertion of the m. biceps to the radius, and
of the  m. brachialis internus to the ulna can  be preserved.   Jaeger's  case, how-
ever, shows that  motion of the fore-arm is possible, when even the insertion of the
m. biceps has been destroyed..
  [Crampton first performed this operation in Dublin, in February, 1823 ; but no
account of it was published till 1827.   Syme  gave (a) an account in 1829 of three
cases in which he had performed it.—j. f. s.]
                III.—EXCISION. OF THE WRIST-JOINT.

  ([Excisio RadiO'Carpalis, Lat; Ausrottung im Handgelenke, Germ,; Resection du
                               Poignet, Fr.) ,
  2836. For the excision of the lower part of the radius and ulna, first
performed by Orred and Moreau, Roux  {b) gives the following direc-
tions.   Two longitudinal cuts are made, one along the outer edge of the
radius and the  other along the inneE edge  of the ulna, as near as. possible
to its inner, edge, to the wrist-joint, without injuring the vessels or nerves;
a transverse cut is  then made across the  palmar and dorsal surfaces of the
arm, avoiding the  tendons.   The lower end of the radius and ulna are
then laid bai;e, sawn through, and the diseased carpal bones removed.
  According to Jaeger (c), in excision  of the ulfia at the wrist-joint, the
arm must  he placed on its radial side, so that its ulnar side be before the
operator, the hand bent in the  opposite direction, the skin  made  tense

  (a,) Edinburgh Medical and. Surgical Jour-    (b)  Above cited, p. 54,
nal, vol. xxxi. p. 256.   1,829.                  (c)  Above cited, p. 67.8.. 
OF EXCISION OF THE HIP-JOINT.              735
with  the left  thumb  and fore-finger, and a cut begun  upon the styloid
process, and carried up two inches on the outer side of the ulna.  From
the lower end of this another cut is made, from three-quarters to an inch
long, through the skin on the dorsal surface  of the joint, the flap dissected
off and the tendon of the m. extensor carpi  ulnaris lifted up with a blunt
hook.  The ulna is now laid bare on the upper  and under  surface, the
joint  cut into  above and on the side, whilst the hand is bent rather to the
other side.   The  skin and tendons are then  held back with a blunt hook,
and either a small Hey's saw or a phalangeal saw applied at the upper
sound part of the  bone, which is then  sawn through.  The piece of bone
is now taken  hold of with the forceps, drawn out and rolled downwards,
and its inner  connexion  with the  radius divided.  The end  of the ulna
is then seized with, a sharp double hook, drawn forwards, and its con-
nexion with the radius at the joint divided.
   In  excision of the radius, the  arm is placed on its ulnar side, a cut two
inches long is made upon the inside of the lower part of the radius from
above downwards to its styloid process, and from the lower angle of this
wound a transverse cut, an inch and a half long, upon the dorsal side of
the wrist.   After  the flap of skin has been dissected up, the sheath of the
tendons is cut into, the tendons separated on both sides from the radius,
and held by a blunt hook.   The ligaments  are  made  tense  by bending
the hand in the opposite direction, cut through from  above and on  the
side, the radius dislocated, and as  much of it sawn off with the phalangea
saw as had been  sawn off the ulna.
   After cleansing the wound the fore-arm and hand are laid upon a pil-
low,  the ends of the bones brought together, the longitudinal and trans-
verse cuts united  with, sutures and  the angles of both wounds left open.
The joint is surrounded with, oiled cloth  and compresses dipped in cold
water applied ; when suppuration  has set in Scultetus's bandage is to
be put on.
   Dubled makes a longitudinal cui on the ulnar side of the wrist, draws the edges
of the wound asunder, divides the lateral ligaments, abducts the hand, isolates the
end of the ulna and protrudes it as far  as possible outwards, separates it from the
radius, passes a wooden spatula between them, and- saws through the bone above
the diseased part.
   The method laid down by Velpeau does not answer  the purpose;: it consists in
connecting the longitudinal cuts on the  side by a  transverse cut oij the back of the
hand,  and the flap being dissected back; in the soft parts being separated from- the
front of the bones, and1 in, a plate of wood or lead being pushed through, upon which
the radius and ulna are sawn through, and  the connexions of the joint divided  one
after the other>.
   [Butt (a) of Portsmouth, Virginia,  U. S., removed a large portion of necrosed
ulna, sawing it through about four inches below the olechranon, and. exartic'ulating
it at the wrist.  In three months the man was  able to return to hi? trade as a car-
penter, with flexion, extension, and rotation of the joint as uninterrupted; as ever.]
              IV.—OF EXCISION; OF THE  HIP-JOINT.

(Excisio Coxae, tat-; Ausrottung in Huftgelenke, Germ.; Resection Cexofemorale-,]?!.)
  2837. Excision of the head of the thigh-bone, which in the seven cases
(a) Philadelphia Journal, vol.. Lp. 117.  1825. 
736             OF EXCISION OF THE HIP-JOINT.
hitherto published has had but one successful result, has been variously
given in reference to the direction and nature of the cut.
  First. By a simple longitudinal cut which, beginning an inch or two
above the great trochanter descends three  inches below it  on the outer
side of the thigh.  After the division of all the tendons, the opening the
capsule and division of the round ligament, the head of the thigh-bone
is dislocated by turning the  knee inwards, and then sawn off' (White,
Vermandois, Seutin, Oppenheim, and others).  Roux holds  a  single
vertical cut insufficient to lay bare properly the head of the thigh-bone,
and suitable only in cases of destroyed  ligaments and gun-shot wounds.
Oppenheim, (a) considers a simple cut as the  best method, inasmuch as it
is the most simple, is least injurious and heals most readily.
  Second. By the formation  of a flap,, either as a* A |J shaped flap on
the outer side of the joint, according to the method of Percy and Roux;
or /3.  A triangular flap, according to Jaeger's plan, by a longitudinal cut
beginning from two to  two and a half inches above the great trochanter,
and descending three inches below it, so as to make in the whole  a cut,
from four and a half, to five and a half  inches long, from the upper end
of which a second cut of four inches is carried backwards and downwards.
The triangular flap thus formed is dissected up, the insertion of the mus-
cles at the upper and fore part  of the trochanter Cut through, the capsular
ligament, and every  spouting vessel tied, the head of the thigh-bone dis-
located by  turning the knee inwards, the round ligament cut through, a
spatula passed under the neck  of the thigh-bone, and that or the great
trochanter sawn through with a small bow- or knife-saw.   If the  upper
edge of the hip-socket be carious, it may be removed with Hey's saw,
and the socket itself touched with the actual cautery,   y. A semilunar
flap, according to Velpeau,  in which the  cut  is carried  from the front
upper spine of the ilium to the ischial tuberosity, and  a semilunar flap
with its convexity downwards, is dissected up, and the back of the joint
opened.   Hewson's method of making a  semilunar flap above  the tro-
chanter, and turning it downwards, is inefficient.  And like it is Jaeger's
semicircular  cut carried round the great  trochanter with  its convexity
upwards.
   Third.   By Textor's oval cut;  he makes a cut beginning two inches
above the great trochanter, carries it obliquely backwards and outwards,
and ends it about an inch before the little trochanter.   To this  first  cut
follows a second, which, beginning on the  front of the thigh opposite the
point where the former ended, is carried obliquely outwards and upwards,
and meets with it at a rather acute angle above the great trochanter.   This
second cut at first divides only the skin, but afterwards is continued down
to the  neck of the thigh-bone.    The soft parts are  then separated from
the great trochanter, the capsular ligament cut into with a strong scalpel
from within outwards,  following always the edge of the hip-socket, over
half its extent, down to the head of the thigh-bone, the knee being then
bent inwards, the round ligament is divided with the scalpel, the head of
the bone dislocated, fixed with the hand, and a knife  carried round the
part where the bone is to be divided, so that the track of the saw may be
made easy and then the bone  cut through with  the osteotome, or with a
small bow- or knife-saw.
(o) Hamburger Zeitschrift, vol. i. part ii. 
OF EXCISION OF THE  HIP-JOINT.
737
   When the operation has been finished, the vessels tied, and the wound
cleansed, some sutures are put in  at the upper part, and  supported with
straps of plaster, but the lower end is left open with a strip of linen in it,
to favour the escape of the discharge.   The wound is covered with  lint
and compresses, which are kept together with a cloth passed around.   The
feet may be tied together, or, if circumstances permit, Hagedorn's  appa-
ratus may be put on.
   Of the seven eases, published, of excision of the neck of the thigh-bone, but one
has terminated successfully.  It is incorrect to include with these, those cases in
which the head of the thigh-bone had been completely destroyed by caries, or  had
been removed  necrosed, (Schmalz,) as well  as the  mere  sawing through the neck
of the bone in anchylosis, (Barton, Rogers.)  A case of  Kluge's (a) and  one of
Ohle's (6) are doubtful.
   Anthony White (c), cut off the head of the thigh-bone in a boy of fourteen years,
on account of very severe hip  disease; four inches of the bone were  removed, it
formed a very useful artificial joint; the patient lived five years, and could use  the
bone perfectly well; it did not even appear much shortened.  Carmichael (d)  per-
formed the operation on a young woman for medullary sarcoma of the thigh, but she
died next day.  Oppenheim (e) performed it on account of a crushing of the head
and neck of the thigh-bone, and of the great trochanter, by a musket-ball; he sawed
off the lower end of  the fracture close to the  little trochanter, enlarged the wound
upwards, and after dividing the capsule and  round ligament, he removed the three
pieces of the  head  and  also the  bullet.  The patient died eighteen  days after.
Hewson (f) performed this operation for caries;  the bone was sawn off above  the
little trochanter.   The patient died three months after, in consequence of the burrow-
ing of a large quantity of pus, which passed by an opening in the hip-socket  into
the pelvis.   Seutin (g), in a gun-shot wound which had split the neck of the thigh-
bone to pieces, and injured the soft parts but little, made a  cut from the crest of the
hip-bone, to three inches above the great trochanter, adducted the limb, dipped into
the bottom of the wound, and removed fifteen loose pieces of bone of various  size
and form ; the lower  fragment of the bone was lifted out of the wound and sawn off
beneath the lowest split portion.  The getting out the head of the bone, which was
broken immediately in the cavity of the socket, was difficult; including the neck and
head, six inches of the bone were removed.   The contentive apparatus, and a half-
bent posture on a double inclined plane, were  employed.  The patient died on  the
ninth day, of gangrene.
  Textor (A)  has operated three times.  In the  first case, on a child seven and a
half years old, on account of fracture of the  neck of the thigh-bone, and  abscesses
following; the head of the bone, and two inehes from the great trochanter, above the
little trochanter, were removed.   In the second case, in a young man of eighteen,
for caries of the head  of the bone, the patient died on the fourth day.   In the third
case, in a man of fifty-four years, on account of caries of the great trochanter, and of
the neck of the thigh-bone, six  inches were removed, and the patient died on the
fifty-third day.
  The interesting results after removal of the head of the thigh-bone in brutes, in
reference to the regeneration of bone, are given in Heine's {i) experiments.
   [Charles White would seem to have been the proposer of estision of the head
of the thigh-bone, although he did not perform the operation, for he observes (j):—
" I have likewise in  a dead subject, made an incision  on  the external side  of  the
hip-joint, and continued it down below  the great trochanter, when cutting through
the bursal ligament, and bringing the knee inwards, the upper head of the osfemoris
  (a)WAGNER, Article Decapitatio; in Buscb,    (/) Oppenheim,  above cited.
von Graefe, Hufeland, and Rudolphi's En-    (g) Gazette Medicale  de Paris, vol.  i. p.
cyclopaedisches Wflrterbuch, vol. ix. p. 188.  135. 1833.
  (6) Schmidt's Jahrbuch, vol. ii. part. i. p.    (A) Lepold, F., Ueber die Resection des
116.   1834.                            Huftgelenkes.  Wurzburg,  1834.—Oppen-
  (c) London Medical  Gazette, vol. ix. p. 852.  heimer, S., Ueber die Resection des Hiift-
1832.                                  gelenkes.  Wurzburg, 1840.
  (d) Oppenheim's Zeitschrift, vol. i.          (i) Oppenheimer, above cited, p. 51.
  (e) Above cited.                          (j) Cases above cited. 
738
OF EXCISION  OF THE HIP-JOINT.
hath been forced out of its socket, and easily sawn off; and I have no doubt but
that this operation might be performed upon a living subject with every prospect of
success.   The Royal Academy of Surgery at Paris  proposed  for a prize question,
whether amputation of the thigh at its articulation with the os innominatum, was ever
advisable; but, was I under a necessity of performing this operation,  or that which
I have been describing, I should not hesitate a moment which to prefer."  (p. 66.)
  The first successful excision of the head of the thigh-bone was performed in West-
minster Hospital by Anthony White, in April 1822, to which Chelius refers above,
from the slight notice by Beale.  It has since been fully published by S. Cooper (a),
from notes furnished by White, who has also kindly given me the following more
consise account.—jr. f. s.
  Case.—" John West, when nine years old, slipped down stairs and  slightly hurt
his left hip.   After a few weeks, he was observed to limp in his gait, and complained
of stiffness and pain in his groin ; and subsequently he lost the power of locomotion,
had the usual symptoms of disease in the hip-joint, and  the head of the thigh-bone
became displaced and rested far back on the dorsumilii.   He suffered very acutely,
and underwent ihe usual treatment'of cupping, blistering, with every mode of local
and constitutional treatment for many months, but  without benefit, and after a time
suppuration in the joint took place, which was .evacuated from the front and upper
part  of  the  thigh.   Temporary relief  was thus obtained, but during two  years a
succession of similar abscesses  formed  around, and small portions of bone were fre-
quently protruded through the  sinuses  which remained, and more especially, from
those formed over the pubes.  At  the end of  the third year he was in the greatest
possible  state of emaciation, no longer suffering7 acute pain,  but  exhausted by the
previous suffering and by an overwhelming discharge from numerous apertures. The
integuments over the displaced  bone had become at various parts absorbed, and the
bone at these points was readily found  to be in a state of superficial  caries.  The
knee had been long imbedded and immovably fixed on the inner side of the opposite
thigh, and the right side on which he could alone  lie was cruelly galled with bed-
ridden ulcerations.  The formation of fresh abscesses had for some months ceased
and further diseased  processes were not apprehended.  In the month of Aprilit was
determined, on consultation with Travers, to remove the head of the bone ; the cir-
cumstances  of  his  health, with the  exception of  great  emaciation, not forbid-
ding it.
  Operation.—" An  incision was first  made through the integuments, beginning
about an inch  above the point where the head of the femur was deposited, and then
carried down the centre of the bone to a point as far as was considered necessary for
sawing through  it.   The integuments were then  separated on each  side,  making
their dissection as close to the  bone as possible.    The straight saw was then used
and the femur divided without difficulty about two  inches below the top of the great
trochanter and including the little trochanter.  So closely adherent was the upper por-
tion of the bone  to the ilium, that I was compelled to introduce a spatula between the
sawn ends and used it as a lever, by which he was enabled to detach the subjacent
parts, and to finish the operation.  A very small quantity of blood was lost, and the
boy suffered less than was anticipated.   The bone  had lost very little of its original
form ; the round ligament and the cartilage were gone, and the head of the bone was
 slightly affected  with superficial caries.   Several  patches were also  seen on  other
 parts where absorption of the surface had taken place.  Neither the finger nor probe
 could detect anyTOorbid condition of the ilium, but the original site of the acetabu-
 lum was not to be- found.
   " The knee was now gently  carried oHtwards, the removal of the fixed head of the
femur now no longer acting as  opposing that movement; and the divided end of the
 bone which had been exposed during the operation was thus brought deeply into the
 wound.   After the dressing and application  of bandages necessary to retain the parts
 in their new situation, and  also to secure the  limb  in the straight line with the body,
 he was put to bed  upon his back, and treated as  for compound fracture.  A slight
 attack of symptomatic fever ensued, which did not continue beyond a few days.
   " The wound  quickly healed; the various sinuses soon ceased to discharge, and
 the health of  the patient speedily improved.   Within twelve  months he enjoyed  a
 most useful compensation for the loss of the original joint; had perfect flexion and exten-
(a) Dictionary of Practical Surgery, p. 272.   Edition of 1838. 
OF EXCISION OF THE KNEE-JOINT.               739
sion of the thigh, and every other motion except that of turning the knee outwards.
The limb, of course, remained shorter, by as much as had been cut off from the top
of the thigh-bone."  He died five years after  the operation, of phthisis, and an op-
portunity was  thus obtained of ascertaining the condition of the parts.
  Examination.—The thigh-bone had been sawn off a little below the less trochanter;
the upper end  of its shaft was largely covered with fibrous tissue and very loosely
though firmly  connected on the inner side with a mass of this structure which filled
up the hind part of the hip-socket, so that the  top of the  shaft lay against but not at
all supporting the upper lip of the socket, the front of which seemed filled with bone.
It is probable that before the operation, as usual in cases  of advanced disease of the
hip-joint, the margin of the socket had become everted, and the whole socket shal-
lowed.  There was no appearance of synovial membrane, capsular ligament nor other
part of a true joint.  And the condition may be described as that of a soft anchylosis
with  the connecting medium  so long as  to admit of very free movement.  The pre-
paration is now in the Museum of  the Royal  College of Surgeons of England; and
from  careful examination of it, the account I have just given is drawn up.—j. f. s.
  The second successful case is Fergusson's (a,) who operated in March 1845, on
a boy of fourteen years, who  had been firstattacked with  hip disease thirteen months
previous.   "The head of the bone could be felt through the soft parts, lying on the
dorsum ilii, and  its identity  could be  more accurately  ascertained  by  passing the
finger into a large sinus, which opened on the surface, over and behind the trochanter
major.  The articular extremity was.so isolated that the finger could be passed round
it in all directions.  *  *  *  A longitudinal opening  about six inches long, was
made in the line of the femur, extending from over the head of the bone to a little be-
low the trochanter major, and the tissues were separated  from the shaft of the bone,
so as to permit a curved needle to be  used for the introduction of a chain-saw."
This, however, broke, and " I was compelled to adopt another mode of procedure.
With a sharp-pointed bistoury, I separated all the  soft parts from the neck of the
bone  and the trochanters, and then, by causing the knee to be  moved across the op-
posite thigh, and using the femur as  a lever, the head  and portion of the bone thus
isolated, was  so thrust  out of  the wound, that I could with  facility apply the  or-
dinary saw for.the requisite section.  Not being satisfied with the condition  of the
interior of the bone at the  surface exposed by the saw, I enlarged the opening, and
removed about three quarters of an  inch more, then  closed the  wound with a few
points of interrupted suture, and covered it loosely with a pledget of lint.  No ves-
sel of sufficient magnitude to require a  ligature was divided.   The cotyloid cavity
was  filled  by  a fibro-gelatinous mass, similar to the lining of the sinus.  When the
patient was put to bed, a long splint was applied, with a view to keeping up gentle
extension.  *   *  *  There was scarcely any shock succeeding to the operation,
and the chief  complaint was pain in the knee, which for some days  after, was more
severe than at any previous period.   *  *  *  The length of the bone removed was
four inches and a quarter, measured  through the curve of the neck and shaft, and the
limb  is now (after his recovery) two inches and a half shorter than its fellow.   The
cartilage was  almost entirely removed  from  the head of the bone, and the surface
 was in a state of ulceration.  The trochanter and rest of the shaft seemed in a healthy
 condition." (p. 572-76.)  The operation was performed  on the 1st of March, and on
 the 8th of May he was able  to get up and move about on crutches.  Some months
 after he was in good health, walked about on crutches, and had "free movement both
 at the knee and hip, and already at the latter part, has considerable power in elevating
 the thigh by the action of the psoas and  iliacus internus muscles." (p. 579.)
               V.—OF  EXCISION OF THE KNEE-JOINT.

 Excisin Genu, Lat.; Ausrottung im Kniegelenke, Germ ; Resection du Genou, Fr.)

   2838. In  excision of the knee-joint,  according  to  Moreau's method,
after placing the patient on his back, and  compressing the femoral artery

  (a) Excision of the upper end of the Femur, in an  example of Morbus Coxarius; in Med.
Chir. Trans., vol. xxviii. 1845. 
740
OF EXCISION  OF THE  KNEE-JOINT.
with a tourniquet, two longitudinal cuts are to be made, one on each side
of the knee, beginning from two inches above the condyles of the thigh-
bone, and running down till they reach the shin-bone, where  they are
connected by a  transverse  cut below the knee-cap.  This flap together
with the  knee-cap, is turned up, and  the latter, if diseased, removed.
The knee is then bent, so that the exposed condyles protrude on the sides,
the soft  parts very carefully separated  from the hind  part of the bone,
pressed backwards with the left  forefinger, and  the bone  sawn off.  If
the joint-ends  of the shin- and  splint-bones must also be removed, a
longitudinal cut is made upon the front edge of the shin-bone, and the
already-made outer cut lengthened  to the  head of  the splint-bone;  the
two flaps thus formed are now turned down, the head of the splint-bone
removed with a  small saw, and  afterwards the head of the shin-bone
cleared and sawn  off.  After the  bleeding  is stanched, and the wound
cleansed the soft parts are brought together and covered, with lint, com-
presses,  and Scultetus's bandage.   The whole limb is placed on a long
chaff pillow, and kept in this posture with two well-padded splints, so as
to prevent any movement of the limb, but without pressing on it.
  Park made a longitudinal cut, beginning two inches above the knee-cap and end-
ing two inches below it; then  a transverse cut above it down to  the thigh-bone,
nearly in  a half circle around the joint.  He then removed the knee-cap, divided all
the ligaments, and carried a narrow knife close above the condyles behind the thigh-
bone, thrust in a  spatula, sawed off the bone, and then protruded  the head of the
shin-bone forwards.
  Mulder (a) proceeded in like manner; only, after having cut through  the thigh-
bone, he bent the leg, by which the condyles were protruded, and then he sawed off
the upper part of the shin- and splint-bones, having passed a spatula behind them.
  Sanson and Begin (b) recommend, after half bending the leg, to make a  transverse
cut from one lateral ligament to  the other, and to  divide them and  the ligament of
the knee-cap at a stroke.  The joint surfaces of the thigh- and shin-bone are then
easily laid bare; and by continuing the cut, according to circumstances, along these
bones,  the joint-surface of one  or other bone may be  protruded and thus easily
sawn off.
  Jaeger proceeds in like manner, making upon a transverse cut nine inches long,
which  divides the ligament of the knee-cap and the lateral ligaments, two side cuts
an inch long, of which  each is distant about an inch from either end of the  transverse
cut -£—!-•
  According to Syme (c), two semicircular cuts should be made across the fore part
of the joint,  extending  from one lateral ligament to the other, meeting at their ex-
tremities, and including the knee-cap between them.  Very free room will thus be
afforded,  which may be easily enlarged, if required, by cutting longitudinally at the
point of union of the transverse incisions.
  The transverse cut, according to Jaeger's method has the advantage of at once
affording a close insight into the seat and extent of  the disease, and assists in the
necessary variations of the operation.  This proceeding is  safer than Moreau's as
the separation of the soft parts  from the back of the thigh  may be  effected without
the slightest danger, and the longitudinal cut may be rendered  either unnecessary,
or at least of but half the length formerly employed.
  According to  Moreau, the cure  does  not  take place by  the union of the ends of
the bones with callus, as Park, and  Moreau, the  father  supposed;  however, in
Mulder's case even in twelve days after the operation, good callus had been formed ;
and on cutting into it three months after, it was found  well formed ; only a partial
destruction seemed to have taken place in it by the suppuration.
  Jaeger is also of opinion that true bony union by callus  follows  very rarely, and
that even in  most of the successful cases, only a tough fibrous tissue, like the inter-

                          (a) Wachter, above cited.
        (b) Sabatier, above cited, p. 457.           (c)  Above cited, p. 133. 
OF EXCISION OF THE KNEE-JOINT.
741
 vertebral substance, or the ligamentous bands in many fractures of the neck of the
 thigh-bone, is formed, but which does not in the least oppose the movements of the
 joint, as there is a restricted artificial joint and a sort of motion.   He correctly seeks
 for the causes of the  non-union, in the very extensive removal of the ends of the
 bones, in  the  undoubted destruction of union by improper dressing, and the early
 movement of the joint.  The whole of the condyles, therefore, should not be removed,
 so that the thigh-bone may rest with a broad surface on the shin-bone; such an ap-
 paratus should be applied that the limb should very rarely be  lifted up to be used,
 and  the knee  should  be free.  For the first four weeks  the patient should observe
 the strictest quiet, the splints should only be removed after the complete closure of
 the fistulous passages; and the first attempt at rotating  the thigh should not be made
 before the tenth or twelfth week, and raising the leg only after sixteen weeks.
    Syme  (a)  believes that it is often very difficult  after the operation to bring the
 limb exactly straight, on account of the contracted state of the flexor muscles, which
 prevent it being straightened, notwithstanding the relaxation, which arises from the
 shortening of the limb ; that it is best to  place the limb on a double-inclined plane,
 and in as good a position as is possible, with suitably^strong pasteboard splints.  In
 some days the tension  ceases,  and the bone must again be put perfectly straight.
 During the cure no absolute rest of the limb is observed, for the purpose of prevent-
 ing actual anchylosis or bony union, as the very long bone that would be thus formed,
 besides being  very inconvenient, as the joint is stiff, would be also more exposed to
 the danger of  being fractured, as  it offers a long lever to any violence which may
 act upon  the extremity.   Great  mobility WOuld render the limb useless.   The prin-
 cipal difficulty in the cure consists in.preventing the tendency of the  limb to bend
 outwards; as well, also, as in preventing too free motion.
    [I cannot refrain from noticing here a case of  compound dislocation of the thigh-
 bone behind the leg which occurred to Anthony White some years since in West*
 minster Hospital, and  from the  following  slight sketch of which* from  memory, I
 am much  indebted to  him, as it is one of the most  remarkable amongst, the many
 instances of constitutional power, in young persons, with Which I am acquainted.
   Case.—Matthew Burgess, aged seven and  a half years, whilst  running behind a
 cabriolet on August 2d,  1839, had his left leg caught in  the wheel, which twisted
 and dislocated the condyles of the thigh-bone  through  a large transverse wound
 above the bend of the knee-joint, and  extending a little in front of either hamstring.
 The twist was so  violent, that the condyles were alsO forced through the leg of his
 duck trousers,  where they lay, on his admission into the hospital in the morning.
 The trousers having been cut off  and the parts  examined, neither popliteal nerve,
 vein, nor artery were found in the pit between the condyles, and  it was not certain
 that they had not been torn through.  Attempts were made to replace the bone, but
 without success.
   Looking at the child's age, White was very averse to amputate the limb, and on
 consideration was determined to make an effort to save  it.  The boy was, therefore,
 left some  hours  that he !might recover the immediate shock  of the accident, and
 towards evening having cheered  up, White passed a broad plaster spatula between
 the front of the condyles and the skin of the calf of the leg upon which  they lay,
 and without difficulty sawed them  off. The saWn shaft  immediately dropped into
 its place, and on passing the finger into the wound, Which could not previously be
 done, it was with much pleasure that the  popliteal  artery was  found  pulsating.
 The limb  was then placed on the side with the knee a little bent, the wound dressed,
 and some  splints applied to keep it steady.  Directions having been given to cut a
 hole through the bed, so  that his motions might be passed  without alteration of his
 position, this was  made  so large  that in the course of the night  he slipped right
 through, and was found on the floor.  He  was immediately replaced and  the appa-
 ratus re-adjusted.   I am not informed  how he went on, but at the end of a twelve-
 month, short of four days, he was considered well enough to leave the house, the
 wound being  healed;  but he could not  bear upon his leg. Some months after a
 large abscess formed in front above the head  of the shin-bone, and  after the lapse of
 twenty months from the  time of the accident, a large piece of bone about an inch
thick exfoliated and came away.   From this time his  amendment was permanent,
and about five  or six months after he became able to bear on his  leg, and at last to
Vol. iii.—63
(«) Above cited, p. 134. 
742            OF EXCISION OF THE ANKLE-JOINT.
walk, having a wooden pin, about four inches long, fixed on the sole of his shoe,
which was firmly fastened to the back of his leg by a light iron shield fitted to it.
  January 5, 1847.—I saw the boy, now fourteen years of age, a  stout lad.  The
thigh- and shin-bone are firmly anchylosed by  bone, in  a slightly bent posture.
The scar is very distinct, and to the extent already described.  The leg and foot are
inclined a little outwards, so that the inner joint-surface of the head of the shin-bone
juts forwards before the shaft of the thigh-bone, and is rounded.  The connexion of
the two bones seems to be complete right across.  The knee-cap is distinct, rather
small, quite free from anchylosis, and capable of being moved a very little from side
to side,  but  quite sufficiently to  show that its natural condition is unchanged.
Above the  knee-cap is the scar by which the exfoliated bone came away.  The calf-
muscles are larger than usual,  I think, for a boy of his age, which is rather remark-
able, as the m. gastrocnemius externus  must have  been completely deprived  of its
principal upper attachments.—j. f. s.]
             VI.—OF EXCISION OF  THE ANKLE-JOINT.
 (Excisio Tali, Lat.; Ausrottung im Kniegelenke, Germ.; Resection du Pied, Fr.)
  2839. Excision of the lower end of the  shin- and splint-bones was first
performed by Moreau (a) in the following manner:—The patient being
laid on his sound side, on a table covered with a mattress, the knee bent
and the leg resting on the whole length of its inner surface, one assistant
grasps it above, and another at the foot.   THe scalpel is  thrust in perpen-
dicularly upon the  hind  edge of the lower end of the splint-bone, the
skin and cellular tissue cut through from above downwards, and the wound
about three inches long, ends in a transverse cut, extending from beneath
the outer ankle to the m. peroneus tertius.   This flap is now separated from
the surface  of the  splint-bone, turned up, and held 'upon  the  front
of the leg.   The m. peroneus longus and  brevis are now  separated from
the part of the bone to be  removed, which being cut off at the proper
length with  a sharp  chisel, can  be easily  taken away.   Through the
same  wound the lower  end of the shin-bone  is to be separated from
all the soft parts attached to its outside.  The patient is  now to be turned
round, the leg laid  on its outer side, and a fresh flap made  by one cut,
three inches long, on the back and inner edge of the shin-bone,  and another
from ihe lower end of the former, running below the inner ankle to the
m. tibialis anticus, and the flap then turned up.   The fleshy parts attach-
ed to the back of the shin-bone  are then  separated to the height deter-
mined by the caries, so that the finger can be  passed between  them.
The leg is then turned on its front, and carried  so far from the other leg,
that the operator can kneel down between its inner side and  the edge of
the table.  A small narrow saw, with a blade six inches long, is now
passed from  within outwards, through the opening  between  the muscles
and the bone, to  the other side, then worked, and the handle sunk as  it
gets  deeper  in.   After  the sawing  is completed, the divided  piece of
bone  must  be freed  and removed  through  the inner wound; in  doing
which the tendons of the m. tibialis posticus and of the  m. flexor quartus
digitorum longus must be avoided.   The chiseled end of the splint-bone
must  be made to correspond to the shin-bone.   If the  disease  have at-
tacked the astragalus, all  that part of the bone  which is  affected  must
be carefully chiseled  away, so as not to leave  a cut surface, which will
prevent the  new  connexion between it and the  shin-bone.
                (a) Above cited, p. 91.—Roux, above cited, p. 53. 
OF EXCISION OF THE ANKLE-JOINT.              743
   After the wound has been cleansed and the bleeding stanched, each
 angle of the flaps is to be fastened with a suture, the knee half bent, the
 leg placed on its outer side, supported on a chaff pillow, and the wound
 covered with lint, compresses,  and a  Scultetus's bandage.
   Jaeger (a) has modified Moreau's method  in the following manner.  The lon-
 gitudinal cut of three inches  is sufficient, but  the transverse cut must be larger,
 about two inches and a half, as he now only meddles with the skin, and therefore
 passes over the tendon of the m. peroneus iertius without injuring it.   The L shaped
 flap is dissected upwards, the external malleolar sheath opened, and both tendons and
 muscles dissected from the back of the splint-bone.  The anterior, posterior and ex-
 ternal ligaments of the splint-bone  are then  cut away from that  bone, the  joint
 opened,  and next the ligaments between the splint-and shin-bones, cut through, and
 the splint-bone divided above the diseased part  with a chain saw, or  in want of this,
 nipped off with the  sharp bone-nippers; the outer ankle is then grasped with the
 fingers of the left hand or  with forceps, pulled up and completely separated from its
 hind connexions with the  shin-bone; and whatever splinters remain must be taken
 away also.   The joint-surfaces of the shin-bone and astragalus being now exposed,
 if they be found healthy the operation is concluded ; but if otherwise, the extirpa-
 tion of  the inner ankle must be proceeded with.  For this purpose the longitudinal
 cut of three inches must be carried  through the middle of the inner ankle, and the
 transverse one forward an inch and  a half, it may also be lengthened backwards so
 that a J. shaped cut may be formed.  The flap is now, together with the fascia, to
 be dissected off close to the bone, the internal  malleolar sheath opened, and all the
 parts on the back of the shin-bone, together with the nerves and vessels, carefully
 separated from the bone; and also on its front,  the deltoid ligament cut through and
 the whole joint opened, in doing which the foot is again turned and the wound en-
 tered from the outside.  After opening the joint, the  inner ankle must be dislocated
 and  brought out of the wound, by which  the foot is turned at a right angle and rests
 on its sole.   The shin-bone is then sawn off above the ankle with  a small bow-saw.
 If the upper part of the astragalus be diseased, a small knife-saw may be passed into
 the wound,  with which it  may be  sawn off, or what is better it may be removed
 with the file.
  Throughout the whole of this operation  no  tendon need  be wounded, and the
 front of the annular ligament not cut through,  as otherwise the antagonism  to the
 Achilles' tendon is taken away, and the operation is without satisfactory result (b).
   Mulder (c) removed the lower end of a carious splint-bone, in doing which he first
 took off the fungous growth from the bone,  then removed a portion of healthy bone
 together  with the diseased part, enlarged the wound  downwards with  the  scalpel
 below the ankle, separated it  from the interosseous ligament, and through the cap-
 sular ligament and removed the lower part of the splint-bone.  Kerst (d) also pro-
 ceeded in nearly the same manner.
   [Excision  of the Ankle-Joint is most commonly employed  in  English practice,
 for compound dislocation, in which the shin- and splint-bones, both usually, broken
 from  their malleolar processes, which still remain attached to the astragalus, are
 protruded through the skin wound, and either cannot be drawn back into their place,
 or if they can, are held to excite such irritation by the inflammation of their synovial
 coverinc, as to endanger the life of the patient,  or at best to render the cure very te-
 dious and exhausting.   Under such circumstances, Astley Cooper strongly advised
 the protruded ends of the  bones  should  be  sawn off, and afterwards the shaft re-
 placed.   If  the patient? be young, there is  generally little shortening of the  limb
 even after the removal of ha-lf an inch or an inch of hone; and in the cases  I have
 seen, anchylosis generally  has not followed.—j. f. s.]

   2840. After decapitation of the splint-bone the wound is to be lightly
 filled with oiled lint, the  flaps fastened with  some sticking plaster, the
 wound covered with lint, and the foot laid upon its outside with the knee

  (a)  Above  cited, p. 688.                 Beitrage zur Natur und Heilkunde, vol. ii.
  (b) Weber, B.,Zwei Resectionen im Fuss-  p. 142. 1827.
gelenke;  in Friedkrich und Hessklbach's    (c) Wachter, above cited.
  (d)  Heelkundige Mengelingen. Utrecht, 1835.—Hamburg.Zeitsch.,vol.ii. parti?.p. 169. 
744     OF EXCISION OF THE METACARPAL JOINTS,  ETC.

half-bent, upon a chaff pillow covered with lint and compresses, and the
usual dressings.
  After decapitation of both bones, their ends  must be brought near to
the heel, the longitudinal and transverse wounds brought together  with
sutures, the angle of the wound left open for the escape of the discharge,
the wound covered with lint, and a bandage applied in the usual way.
  According to Moreau and Boyer, during the treatment the foot should
be steadied!  by a foot-board attached to two side splints  on the leg, to
keep it immovable.   This Jaeger thinks onlybf consequence if the shin-
bone be left.  In his case  he dislocated both bones on the outside and
placed  them in Sharp's concave splints on Sauter's  swing till he ap-
plied the  common splints.
  During the cure the ends of the bones approach each other, and become  firmly
united; in consequence of which, in many cases, when the astragalus is left entire
motion is destroyed.  This firm connexion is only first produced  in the space of a
year, from  the use of a limb.
  After the healing of the wound Sharp's splints must be applied. So  long as the
foot is not firm, the patient must walk with a crutch, till at last he can be fitted with
a heel, corresponding with the length of the lost bone (Jaegbtr.)
  VIL-^lOF EXCISION OF THE JOINTS  OF THE METACARPUS AND
                           METATARSUS.

(Excisio Metacarpiet Metatarsi, Lat.; Ausrottung in den Gelenken der Miltelhand-und
  Mitteffuessknochen, Germ.; Resection des Mitacarpiens et des Metaiarsiens, Fr.)
  2841.  In the metacarpal and metatarsal bones, decapitation has the
great advantage of preserving the  joint.   The decapitation of the meta-
carpal and metatarsal bones is performed with a longitudinal cut carried
to the extent of the portion of bone to be removed, the sheath of the
tendon covering it opened, laid aside, the muscles" separated from the
sides of the bone,H and the joint opened from above.   The chain saw  is
then  introduced by means of  a small semicircular  needle,  or a narrow
finger-saw is passed  beneath the  bone which it divides, or it is cut off
with Liston's cutting forceps,  or with the osteotome, lifted up, and whilst
turned forwards or backwards, is completely separated from the soft parts.
  After the wound has been cleansed, a connecting bandage is put on and
cold applications made.   To keep  the bone in proper position, it is ne-
cessary to fasten a narrow pad, a  foot long,  on both sidesa  or upon the
dorsal and plantar surface of t\e foremost phalanx with sticking plaster,
and by drawing back equally the ends of the long pad the bones are kept
together,  and the ends of  the pad  are fastened upon the wrist or  ankle-
joint with plaster.  On the foot, with a foot-board, a pad of lint and some
straps of plaster are commonly used, passed over the end of the phalanx,
and the ends brought over and fastened on the foot.
  In old dislocations of  the  metacarpal bone of the thumb, decapitation is often indi-
cated, and  frequently performed.  Textor removed the end of the middle metacar-
pal  bone and the os magnum in a case of caries., Textor, Kramer, and Roux  have
also decapitated metatarsal bones;  and Fricke  has obtained most successful results
therefrom (a).
       (a) Gernet, Ueher Resectionen;  in Hamburg. Zeitsch,, vol, iii. part iv. 
L   745   ]
             VIIL—OF  EXCISION OF  THE LOWER JAW.

(Excisio Maxillae Inferioris,.Lat.; Ausrottung des Unterkiefers, Germ.; Resection de-la
                          Machoire Infirieure, Fr.)

  2842.  Excision, Decapitation, and even the total  Extirpation  of the
Lower Jaw, may beindicated by various kinds of disease (1).   First, On
account of cancerous degeneration, which has extended from the  lips to
the bone, or when the-cancer has arisen in the bone  itself.   Second, On
account of osteosteatoma', osteosarcoma,  spina ventosa, or fungojd degene-
ration of the jaw.   Third, On  account of deep-seated caries.  Fourth,
On account of exostoses, which cannot  be  removed at their  base.   And,
Fifth, on account of want of union of fractures of the lower  jaw.  Ac-
cording to  the difference of the seat and' extent of the disease, excision
of the middle  part, the-chin, or  of the sides^ with or without the removal
of the processes at the same  time, or  even the extirpation of. the whole
lower jaw-bone, may be required'.
   That this operation should have a favourable result, the skin must  be
sound to such extent that it can properly cover the place of the removed
part, and swelling of the- neighbouring1 glands^ or the signs of general can-
cerous  dyscrasy must not in general forbid every operation.  The hope
of a favourable issue-is greatest in sarcomatous degeneration  of The jaw,
but  it is  doubtful in all cancerous affections.
  Only, under the above-stated'conditions of the skin  and glands can cancerous dege-
neration be considered as  indicating this operation;  but they are very rare ; and so
far is Jaeger's (a)  opinion correct, who although the cases of Dupuytren, von
Graefe, Fricke, and others favour undertaking this operation for eancer, considers
that in general it is contraindicated.   Necrosis of the lower-jaw, if unaccompanied
with caries, must not be held to indicate the operation ; for with proper treatment the
dead  piece>of bone will be thrown off (2) or may be removed j for I'have in several
instances taken away- more than half and in one case nearly the whole lower-jaw.
  [(1) As will be presently seen, Deadrick was the first who, in 1810, cut  away
the side of the lower jaw ; in 1812, Dupuytren sawed' off a large  portion of the
front of the jaw ;■ in 1816, Anthony White- removed half a necrosed jaw from the
socket; in 1818, Astley Cooper sawed off the projecting part of the chin; in 1821,
Graefe removed the front of the jaw, and in the same year, one-half of the lower
jaw,  which he exarticulated, and-the patient  lived : Mott's first operation, in which
half the  jaw was removed, by-sawing through the chin and  across  the ascending
branch, was performed in  March, 1822; his  second, in which he exarticulated one-
half, in  May, 1822; died on the evening of the fourth day.  Cusack  removed the
left half of the jaw in 1825, first sawing through the horizontal and afterwards the
ascending branch, an<hthen exarticulating the condyle*  These several cases will be
referred  to presently.
  I have thought it well to give this brief historical aceount of the  amputations of
the lower jaw,, the authorities for which the readerrcanrefer to ; because the French
claim excision of the jaw for Dupuytren, and the Americans, exarticulation of the
jaw for Mott ; but neither of these justly-celebrated surgeons have title to the ori-
gination, or to the first performance of either  operation, and their reputation willfose
nothing  by the  just meed of merit, being awarded to others, of whom, probably,
their too ardent admirers had no cognizance.
  (2) I  regret I have no  particulars, nor am able to obtain any particulars, but I
have a perfect  recollection of a case of my late colleague, Tyrrell's, about ten- or
fifteen years since, in  which a man, who had been very severely  salivated, had
necrosis of the whole lower-jaw ; the right branch and the chin  had come away before
his admission into our  hospital, aud the left  came away whilst he remained in the
house.  The jaw separated on both  sides from the  joint.  He was not much dis-
                (a) Rust's handbuch der Chirurgie, vol. vi. p. 503.
                                   63* 
746
OF  EXCISION  OF THE LOWER JAW.
figured by the exfoliation, but had the appearance of a person the horizontal branches
©f whose jaw were very short and the chin very receding, his mouth was much pursed
up, the skin of the chin  puckered, and the upper lip much, overhanging the lower.
His speech was not very materially affectedi-r-J. f. s-]
   2843.  Excision of the middle  of the lower-jaw is. performed in the fol-
lowing manner.  The patient being seated in a chair and his head fixed
by an assistant, a cut must be made in  the healthy skin, beginning from
the middle  of the lower lip and carried over the chin down to the tongue-
bone ;  or if the skin be diseased, two cuts must be made from the edge
of the lip to the tongue-bone, where they meet at an angle enclosing the
diseased skin.   The  soft parts are now  to be separated on each side from
the affected bone to the places where it is to be sawn through,, at which
the periosteum and one or more teeth  must be removed to prevent any
hindrance to  the sawing.   At this, place a pointed bistoury must be thrust
through the soft parts, forming the bottom of the mouth, on the inner side
of the jaw,  a narrow compress thrust through this opening, and the  bone
s.awn through  with a small  bow-saw, or with  Hey's  or Heine's  saw.
The other side of the jaw is next  treated in like manner, and then with
a button-ended; bistoury the soft parts attached to the inside of the sawn-
off piece  of bone, to wit, the insertions of the m. mylo- andtgenio-hyoideus,
divided ; in doing this, the bone must be held tightly with the fingers of
the left hand, the knife kept  close  to the bone, and: the tongue pressed
aside by an  assistant.   The  bleeding  from the spouting vessels of the
soft parts must be stopped by ligature, and that from the bone by pres-
sure with, wax or German tinder, or if need be,  with the actual cautery;
and the wound must be brought together at its upper part with the twisted^
and at the  lower  part with the interrupted  suture and'supported  with
straps of plaster.
  If the tunjour be of large  size, it may be convenient to make a second transverse
cut through the. former, on the middle of the chin, so as to be able to turn back four
flaps.
  The division of the soft parts from the insides of  the jaw, after having sawn it
through as ahove mentioned, is more convenient and  easy than first separating the
soft parts and then sawing.  A narrow compress introduced and< properly held by an
assistant is a better guard than a spatula, strap of leather, horn, or leaden plate, and
the like.  Sawing the bone obliquely from before  backwards as recommended  by
many, unless something  more of the  healthy bone can be thereby preserved, as also
bringing the ends, of the bone together, is objectionable. The same also applies to
Delpech's advice, that the ends of the bone should corresponds on both sides, even
if for that purpose it be requisite to  remove-, more healthy bone on the sound side.
Delpech, in a  case,, where, by bringing the ends of  the bone together, danger of
suffocation was caused-: by the pressure of the tongue-bone, kept them  together at
proper distance with,a piece of gold wire, and united the wound.  The distance be-
tween the, ends of the  bone gradually diminished and they became  firmly con-
nected.
  Only after removal of a small portion of the chin  are the ends of the bone united
by a ca//us-like tough tissue;  generally and after  the large loss of bone, a hard
fibrous or cartilaginous intersubstance only is formed, which, however, has sufficient
toughness.for chewing..
  At the moment when the s.oft par4s on the inside  of the bone are cut through, the
tongue often retracts suddenly, and there  is danger of choking.  It is unnecessary to
draw the tongue forward and  fix it; its retraction depends on the contraction of the
m. sterno-hyoideus after the separation of the m,> mylo-hyoideus and genio-hyoideus if
the head,be drawn backhand therefore, if the head be bowed towards the chest, the
tongue resumes, its proper place and the choking ceases, as I noticed: in a case in
which I removed the; fore part of the jaw., in front «f the m>.masseteres, on both 
OF  EXCISION  OF THE LOWER JAW.             747
sides (a).  Lallemand, in one  case, opened the windpipe, and Delpech fixed the
tongue with a hook.
  If a large piece  of the jaw-bone  be removed, it may be convenient to introduce
some lint between the ends of the bone, to prevent the soft parts dropping in.
  [Dupuytren  (b) according to his own statement, performed this operation, on
30th of November, 1812, in a case of cancerous tumour, extending from  the right
cuspid tooth to the left branch of the jaw-bone; the  part thus described was three
times its natural size*. The jaw  was  removed by sawing it through an inch in front
of each of its angles.  The patient suffered little after the operation ; on the twenty-
seventh day he was  able to drive one of his cabriolets;  on  the thirtieth  some small
portions of bone came away; and fifteen days after, his cure was completed.
  Graefe  (c) removed, in the  early part of 1821, from a woman aged forty, the
front of the lower jaw, which had" become involved in cancerous disease, sawing
through it on each side ; and the patient recovered completely in the course  of five
weeks.
  The case in which Astley Cooper (d) operated, was a fungous medullary exos-
tosis on the chin.  He eut down through the skin on each side of the tumour, and then
sawed  through the healthy part of the jaw, cutting off the prominence of  the ehin,
but without meddling with the  alveolar processes so that  the arch of  the jaw re-
mained perfect.   The operation  was  performed, I believe, in 181S, but certainly .not
later than in the beginning of  the year  following, and  the woman did well.  Al-
though the operation was not of such importance as those just mentioned; yet as it was,
so far as. I am aware, the first upon the jaw performed in London, I have thought it
right to notice it.  The preparation is. in. St. Thomas's Museum.—*j. f. s.] .

   2844.  In removing  a portion  of the side of the lower jaw without the
condyle the cut for laying bare the bone must be made in different  ways,
according to the sise  and  seat of the  bony tumour, sometimes from the
corner of the mouth to below  the edge of the jaw ;  still better is an ob-
lique cut from  the  corner  of the mouth  to the place where the  bone  is
to be  cut through,  or  from the corner of  the mouth in form of a _J cut;
in very large swellings a J cut;  when  the skin is  much diseased,  two
elliptical cuts from, the corner  of the mouth ; or if the entire side with the
angle  or part of the ascending branch is to be  removed, then a |   I. cut
or the like.  The flaps are  now to be separated close to the bone, held
back by the  assistants, and the soft parts  on the inside of the bone care-
fully detached, the knife being carried close to  the bone where  it is to be
sawn through.  After  the compress has been introduced, the bone is to
be sawn through, first  in front, and then the piece,  grasped with the left
hand, must be pressed downwards and outwards^and with the  knife car-
ried close to. the bone  all the remaining soft parts carefully separated to
the extent of  the tumour  behind;  the compress is  then introduced, the
bone  held in  this position  by an  assistant and eui  off.   The  sawn-out
bone is now drawn outwards and  completely separated from the  soft
parts forming the bottom, of the mouth, the bistoury being kept with the
greatest care close to the bone.   After stanching the bleeedin^,the wound
must be brought  together  at the lip  with  the  twisted, and on  the cheek
with the interrupted suture and; supported  with sticking  plaster.

  Sawing through the bone first in front is-most convenient, because, the operator can
then draw it to him, and turn it down. If the soft parts be  divided from the  whole
inside of the bone before it is sawn through, at the back part, the sawing is accom-

  (a) Chelius, Ueber Resection  des. Unter-    (c)  Jahresbericht des chirurgisch-augen-
kiefers; in Heidelberg. Medic. Annalen, vol.  arztlichen Institute zu,Berlin.—Graefe und
i. part. i.                              von Walther's Journal, vol. iii. p. 256. 1822.
 ' (6) Clinical Lecture translated; in Lancet,    (d) Cooper and Travers's Surgical Essays
1833-34 ; vol. i. p. 56.                    part i. p. 179.   1818. 
748
OF INCISION OF THE LOWER JAW.
panied with greater difficulty than if the soft parts be divided afterwards, especially
if the tumour be of large size.
  Since Deadrick and Dupuytren first performed resection  of the lower jaw, the
operation has been very frequently performed and with'much success.
  [Deadrick (a) of Rogersville, Tennessee, is justly entitled to the merit of having
first, in 1810, amputated a portion  of the jaw of a child of fourteen, who had a tu-
mour occupying the left side of the lower jaw.   " An incision was commenced under
the zygomatic process; and continued on the tumour, in the direction of the bone, to
nearly an inch beyondUhe centre of theehin.   A second" incision was begun about
midway, at right angles with the  first, and extending a short distance down the
neck.  The integuments were now separated from their connexion with the tumour,
and the bone was sawed off immediately at the angle and centre of the chin.  The
wound was united in the usual manner, and the boy had a speedy and' happy re-
covery."
  Mott's first operation  was in 1821 (b),  in which after having sawn through the
chin, and after the maxilla inferior had been laid bare-just below its division into
two  processes, and it appeared sound, he " with a fine saw, made for the purpose,
smaller and, more convex than Hey's,  began  to saw through the bone obliquely,
downwards and backward's and finished  with one* less  convex."   This was for
osteosarcoma.
  It is claimed' for Wardrop (c), that he first, in England, in March, 1827, ampu-
tated the lower jaw, in a case of exostosis; the  jaw was cut through first behind the
last molar tooth, and then between the middle two incisive teeth*
  The following are accounts of some of these operations:.—
  Klein; in Neue Chiron von Textor, vol. i. part. ii. p. 345.
  M'Clellan, in Medical Review, and  Anal. Journal.  Philadelphia, 1824.
  Delpech; in Revue Medicale, vol.  iv. p. S.   1824.
  Lallemand; in Journal Universel des Sciences Medicates, voh xxviii. p. 340.
  Dybeck ; in Froriep's Notizen, vol. viii. p. 95.
  Schuster; in same, p. 304.
  Behre, G., Bemerkungen iiber die theilweise Excision und Exarticulation des
Unterkiefers, nebst den zer  Geschichte  dieser Operation gehorigen Fallen; in
Rust's Magazin, voh xxiii. part iii. p. 387.
  Meyer, J. C, Dissert de Exstirpatione partiumidegeneratarum Maxillae Inferioris.
Berol., 1624.  4to.
  Koecker, An Essay on the Diseases  of the Jaws  and their Treatment; with Ob-
servations on the Amputation  of a part or the whole of the Inferior Maxilla.  Lon-
don, 1828.
  Delbech^ Memorial des Hopitaux du  Midi  et de la  Clinique- de Montpellier.
1829; p. 123.
  Jaeger; in Rust's Handbuch der Chirurgie, vol. vi.p. 496.
  Boyer, Memoire sur l'Amputation de l'Os Maxillaire Inferieur; in Journal Com-
plement, du Diet, des Sciences Medicates, cah. 174.
  Dupuytren, Logons 0rales de la*Clinique ohrrurgicale, vol. iv. p.  625".
  [Report  of a Committee upon  the subject of Osteosarcoma of the
Lower Jaw, to the Medical Society of N. York.  1830;]

  2845. Excision of the lower jawr^together with the  removal of its con-
dyle  (Exarticulatio  Maxilla Inferioris)   requires  a  different  mode of
making, the cut,, according to the  different condition of the tumour and of
the skin over it.  The cut may be  made  from, the  corner of the mouth
over the swelling, to the front  of the  ear, and the condyle of  the jaw
(Mott, Schindler) ;  or to the hinder ed£e of the branch of the jaw, a
second, cut from the beginning, to the  end of, the first cut,  circumscribing
the diseased skin,  and  thence in  an oblique direction  to the  condyle

  (a)  Amer. Med:  Recorder^  vol.  vi.  p. Recorder, Jan., 1822. This case is given at
516.   1826.                           • length in Gibson's Institutes and Practice.of
  (6) New  York  Medical and  Physical Surgery, vol. ii. p. 28.  Philadelphia, 1827.
Journal, vol.  i. p. 386.—American Medical    (e) Lancet, voL xii. p. 27.  1626-27. 
OF EXCISION OF THE LOWER JAW.
749
(von Graefe); or in very large swellings, and great disease of the skin,
two elliptical cuts, of which the one passes in the  direction of the base
and branch of the jaw to the condyle, and  the other upwards, by which
the  coronoid process is laid  bare, the  m. temporalis  divided, and the
joint opened at its fore part (Syme) ; or  in shape of an  oblong, four-cor-
nered flap, from the corner of the mouth to the neighbourhood of the ex-
ternal maxillary artery, from thence at a distance of a quarter of an inch
from the edge of  the bone to the angle  of the lower jaw, and then  up-
wards to  the front of the  joint an inch distant from the ear (Jaeger).
The flaps are now separated from the  bone, and in doing this,  injury of
the Stenonian duct and parotid gland, must be avoided.  The  m. mas-
seter is cut through at the base of the lower jaw, the m. buccinator sepa-
rated from  the outer surface, and both together with the parotid  gland
raised up  till the  joint is laid  bare.   The soft parts are now separated
from the inside of the bone, and the bone sawn through at its fore part,
as already described, and  the  division  of the soft parts from its inside
completed.    The  bone is then  depressed as much as possible, for the
purpose of  disengaging the  coronoid process from the zygomatic arch,
and rendering  the m. temporalis  tense.   The condyle is  thus thrown
completely on the articular tubercle, so that there is perfect dislocation.
The knife is now carried above the coronoid process and the tendon of
the temporal muscle  cut off, then, over the semilunar notch  between the
two processes,  and whilst the point of the knife is kept as close as possi-
ble to the condyle,  the internal pterygoid muscle is divided.   The jaw
can now be further  dislocated, which is so much the better, as thereby
the condyle is still further separated from the vessels.    Continuing close
to the neck of the condyles, the stretched capsular ligament is cut into in
front.   The assistant pressing  the jaw still more downwards, and moving
it backwards, the condyle next becomes visible, and the knife being car-
ried  over  it  to the hinder ligament, cuts through it, whilst the edge of
the knife is kept close to the bone, and the point  not carried  forward.
After the bleeding vessels have been tied, the wound is brought together
and managed as in resection of the jaw.
  von Graefe (a), Mott (b), Langenbeck (c), and Jaeger (e?) operate in this way
which is generally to be considered as  the most safe  and convenient.  Cusack (e)
considers it better, when in large tumours it is not thought right to lay hold  of the
bone sawn through  in  front, to grasp it between the angle and the condyle with
strong forceps, and to press the condyle against the front  of the capsular ligament,
penetrate the joint, enlarge the opening with  the button-ended bistoury, thrust the
condyle out, and separate its- other connexions with the capsule as well as with the
external pterygoid muscle.
  Jaeger speaks very decidedly against this  sawing through  the bone  above its
angle, and the after removal of the processes; in one case where the bone was com-
pletely separated from its branch, it was impossible to pull forward  the remainder
of the bone so as to separate the tendon of the temporal muscle from the coronoid
process. The joint must be opened in  front,  and by pulling forwards the head of
the  bone with a strong hook, it must be gradually separated from its hinder connexions.
Cutting through the tendon of the temporal muscle is then effected so easily that he
advises the  condyle  should always be first set free. Holding the stump  of the
bone is especially difficult; and according to his experiments on the dead body, he
  (a) Journal, vol. iii. part ii. p. 257.       seclione. Gotting®, 1829.
  (b) Above cited.                        (d) Above cited, p.  605.
  (c) Tiensch, Dissert, de Osteosarcomate   (e) Dublin  Hospital  Reports, vol. iv.
partiali Maxillae inferioris, deque hujus Re- p. 37.
I 
750
OF EXCISION OF THE LOWER JAW.
considers sawing through the branch is difficult, and the exarticulation not rendered
easier by doing so.                                             ....
  On the other hand, Schindler (a) justly observes that the exarticulation may be
effected with complete certainty without sawing through  the jaw at its  hinder end,
when the tumour  of the bone  is not  of  great size; but that every large tumour
renders its removal indispensable, else the exarticulation  may become unnecessarily
difficult, and only be completed  with some danger.  In  his case the swelling was
so large, that even after removing its upper part, it was almost impossible to pene-
trate the joint,  and effect the disarticulation with safety.  He  found no difficulty in
the  division of the diseased bone, and could grasp conveniently the remaining piece,
although only  an inch and a quarter long, with the fingers of his left hand, draw it
well towards him, and easily dislocate the condyle.  The patient recovered.
  Mott, von Graefe, and Dzondi have held the previous tying the common caro-
tid artery necessary, but experience has shown that this is superfluous, is dangerous,
and no safeguard against bleeding (Jaeger, Schindler.)
  If the removal of the entire jaw be necessary, the bone must be sawn through in the
middle, and the extirpation performed  on either  side, as already directed (Dupuy-
tren), (b).
  [Samuel Cooper (c), after mentioning that Wepfer quotes a case of amputation
of the lower jaw,  which had occurred in his time, says, " Mr. Anthony White,
Surgeon to the Westminster Hospital, removed at Cambridge a considerable portion
of the bone for an  osteosarcoma many years ago.  Unfortunately the case was not
published,  so that the revival and execution of the operation are generally referred to
Dupuytren, who in 1812 performed his earliest excision of the lower jaw-bone."
(p.  275.)
  In consequence of Samuel Cooper's statement, I was induced to inquire of my
friend White, for information  in regard to his  operation on the lower jaw, and I
have much pleasure in  communicating to  the profession the following particulars,
with which he has kindly furnished me, from which it appears, that he  actually dis-
articulated  the lower jaw-bone from its socket five years before  Graefe, and six
years previous to Mott.
  The following is White's
  Case.—" In  the summer of 1816 I was requested to see a man, named Litchfield,
residing in the town of  Cambridge, who for  upwards of three years had  been
miserably affected with a disease of the lower jaw, occupying the entire left cheek,
and wholly incapacitating him from opening his mouth.  He states, that in attempt-
ing to bridle his master's  horse, the animal, by an unexpected jerk of the head, struck
him a violent  blow on the under jaw";  that the part for a few weeks remained pain-
ful  and swollen, and although after a lapse of time, the enlargement occasioned by
the injury had considerably diminished, yet a slight preternatural fulness and occa-
sional pain remained.   Some months after a rigidity in the motions of the jaw at its
joints succeeded, accompanied with a slowly accumulating and hard enlargement ex-
tending from the ear nearly to the chin..  By degrees, the jaw wholly lost its powers
of motion, and finally the teeth became firmly fixed on those of the upper jaw, which
was followed  by the formation  of small abscesses externally and internally.  Thin
fluidiS, as milk and broths, have been for the last two years his  only nourishment;
and during this time he has been  compelled  to  sleep in an almost erect posture, on
account of a perpetual internal discharge which, whilst he was in the horizontal pos-
ture, poured down his  throat,  producing, when  he was  about to sleep,  a constant
alarm  of suffocation.  The whole cheek, from the ear to the orbit, ranging down the
side of the nose to the angle of the mouth, and thence to the under part of the chin,
and again upwards to behind the lobe of the  ear, presented one large irregular mass
of scirrhus-feeYwg growth, studded with many sinuses, the windings of which were
difficult to trace.  The eye was so considerably projected from the socket, that the
eyelids could  cover but a very small  portion of the globe, and such was the rigid
thickening of the  cheek, that much difficulty was experienced in introducing the
finger within it for the  purpose of examining the disease internally.  I discovered,
however, a point of the jaw-bone bare  within the cheek, and by pressure, perceiving
an obscure motion of its whole side, I was  induced to  believe that the bone was

  (a) von Graefk und von Walther's Journal vol. xvii. p. 568.   1831.
  (b) Above cited.               (c) Dictionary of Practical Surgery.  Edition of 1838. 
OF EXCISION OF THE LOWER JAW.               751
        either carious or dead throughout its whole extent, although there had not been at any
        time the least exfoliation through either of the many sinuses.  By repeated exami-
        nations, 1 was fully convinced of this impression being correct; and I afterwards by
        firmly grasping the chin and cheek, and then attempting to produce a lateral motion,
        distinctly perceived a grating sensation of the condyloid process on the skull.  I now
        contemplated, if there was  a possibility of removing the entire side of the  bone,
        the cause and continuance of the extensive mischief, that the opposite joint  When
        disentangled of its still adhering dead neighbour, might be restored to its important
        duties.  I also considered that from the long-existing thickened and altered state of
        the left cheek and surrounding parts, little was to be feared from haemorrhage, as the
        vessels were likely to have  become obliterated, and if my conjecture was well found-
        ed, as to the death of the bone, the large artery which runs along the maxillary canal
        must also have perished.
          " A few weeks  elapsed before I was again able to visit Cambridge, and the pa-
        tient being then in the same condition, and the operation having been proposed and
        explained to him being very desirous it should  be done, I proceeded to its perform-
        ance with the assistance of the present  Professor  of Comparative Anatomy in the
        University, Dr.  Clarke and Mr. Headlev, a practitioner in the town, to whose
        assistance I am much indebted.
          Operation.—" The patient's head having been firmly  fixed on the side upon a
        pillow, and my first object being to expose the bone, I began an incision, as near as
        I could guess, from the root of the zygomatic process of the temporal bone, and car-
        ried it  obliquely  downwards and forwards considerably beyond  the angle of the
        jaw towards the chin.  Inconsequence of the thickened   state of the integuments,
        the depth of the wound was very great before I could reach the bone; but having
        made sufficient room  for the introduction of my finger, I was gratified in  finding the
        bone without its periosteum; and with a curved bistoury, the  incision was speedily
        finished upwards  to the zygomatic arch, and downwards beyond  the edge of the
        lower jaw opposite the third molar tooth.  With the handle of a scalpel and the
        blade of a pair of  forceps, sufficient separation was made  to allow the point of the
        fore-finger to range freely and to separate the surrounding diseased  structure from
        the enclosed bone.  By thus doing, I was enabled to slide the fore-finger within the
        ascending branch  of the jaw-bone into the mouth, and  the thumb  under  its angle.
        On endeavouring to ascertain the degree of fixture  whieh the bone  might have, I
        discovered a complete fissure of separation in an oblique direction from where the
        finger entered the  mouth towards the chin< through the entire jaw, but the bone was
        immovable at the  temporo-maxillary articulation.   After repeated  unsuccessful at-
        tempts at dislodging the condyle, I determined to saw vertically through the ascend-
        ing  branch of the  bone, between the condyloid  and coronoid processes, calculating
        that the separation would be more easily effected by bringing it away in two or more
        pieces.  I therefore applied  a small straight and narrow saw upon this part with ex-
        cellent effect, as its end  passed  with facility, in the required movements, under the
        zygomatic arch; and  Hey's saw was very useful in cutting through the thicker part
        towards the angle.  I now with  a pair of strong forceps, grasped  the lower edge of
        the divided bone,  and easily dislodged the coronoid  process, and  I removed  it to-
        gether with the lower part of this portion.  Having thus gained considerable  room,
        the separation of the condyle and remaining portion of the ascending branch became
        quite easy.  The  bone, although dead, retained its  form unaltered.  The glenoid
i»       cavity of the temporal bone  was by the finger discovered  to be denuded  and rough.
        The carotid artery was now felt  distinctly pulsating, the finger being enabled to rest
        upon it.  One great object having been thus attained, we  were anxious to ascertain
        the state of the other articulation, and were highly gratified in finding that a  slight
        degree  of motion  existed which gradually became increased.  Some few months
        after, I had  the satisfaction  of finding the wound and sinuses healed; the swelling
        and  its warty character subsided ; the globe of the eye retired into its socket, and the
        motions of the jaw restored.  The patient lived several years after."
          Graefe (a), in  1821, exarticulated one side of the lower jaw of a young woman,
        having previously tied the carotid artery, for hydrostosis  carcinomatodes,  which had
        destroyed more than half the jaw, and  on the left side  reached up to the condyle.
        The swelling extended far back, and pressed on the important vessels and nerves of
(a) Above cited, p. 257. 
752              OF EXCISION OF THE LOWER JAW.
    the neck.   Internally it thrust the tongue against the right cheek, and so completely
    filled the mouth, that latterly the patient was able to swallow even fluids with the
    greatest effort, could only utter words indistinctly, and breathe with extreme difficulty.
    As death by hunger or choking was all but certain, it was determined to run the risk
    of operating, in hope of saving her.   The left common carotid artery, which was
    very large and pulsated strongly, was carefully tied, and immediately the pulsation
    in the temporal and facial arteries ceased.   A cut was then made from  the angle of
    the mouth to the hinder edge of the jaw; a second, which included the diseased mass,
    was carried from the front point  of the first cut to its hind end ;  and a third, begin-
    ning at this latter point, was carried upwards in the direction  of the condyloid pro-
    cess, above the joint and nearly to the ear.   The  outer surface first, and then the
    inner surface of the diseased half of the bone, were freed from the soft parts con-
    tinuing the separation to the chin, and then, a piece of leather having been introduced,
    thejaw  was cut through at the chin, and afterwards exarticulated.  When the bleed-
    ing had  been stanched, and the corner of the mouth carefully fixed, a simple dress-
    ing was applied.  Up to the eighth  day she was  perfectly well, could  speak loud
    and distinctly, ate, drank, and could  press the remaining half of the lower firmly
    against the upper jaw; but on this day, after a violent thunder-storm in the previous
    night, she was suddenly and  severely attacked with apoplexy, which gradually sub-
    sided into  fatuity and speechlessness,  accompanied  with  hemiplegia.   By degrees
    the mental  powers returned ; the lameness of the right foot ceased entirely after some
    time ; the wound healed completely under  very simple treatment; the paralytic state
    of the right arm and tongue began to lessen  more and more;  she eats any food, is
    well nourished, is quite capable of walking to some distance,  and is delighted with
    her condition, as she improves from month to month.
      Mott (a) exarticulated, on \bth May, 1822, the right side of the jaw of a young
    man of eighteen, affected with osteosarcoma, which had existed  eight years, had com-
    menced  at the molar teeth, filled the whole mouth and spread as far as  the first bi-
    cuspid tooth on the opposite side.  He first made a semilunar cut through the integu-
    ments from the lobe of the ear to the chin; sawed through the jaw at the second bi-
    cuspid tooth on the left side, and then exarticulated thejaw on the right side.  The
    swelling weighed  twenty-two ounces, and  was as large as  the head of a  full-grown
   foetus.  The patient went on well, and on the morning of the fourth day two-thirds of
    the wound  had healed ;  but on the evening of that day he died.  On examination, the
    lungs were found violently inflamed ; the anterior mediastinum contained a quantity
    of yellow lymph, nearly of the consistence of pus;  the pericardium held  a  pint of
    yellow serum, and the pleura was enormously thickened.  The inference drawn
    was—"Hence it appears clear, that the patient died of disease of the lungs which
    had no connexion  with  the operation."   To which the editor in Graefe's journal
    appends 1  with which most readers will probably agree.
      Cusack (b) in his excellent  Report  of  the Amputation of portions of the Lower
•   Jaw, shows, that tying the carotid artery, as had been  done by  Graefe and Mott
    to guard against bleeding from wounding the external carotid  or internal maxillary
    artery in exarticulation of the lower jaw, is unnecessary.  " Neither of  these ar-
    teries," he  observes, "is in immediate contact with the jaw.  The  internal maxil-
    lary, which would appear more exposed to danger, inclines backwards in  its passage
    behind the  neck of the condyle being distant about  a quarter of an inch from  the
    bone;—the natural structure of the joint allows this distance between the artery and
    articulation to be still further increased ;  so that by sawing the bone through at any
    point and separating the attachment of  the temporal muscle, the capsular ligament
    may be opened anteriorly, the condyle dislocated, and the jaw disengaged, without
    endangering any vessel  of consequence." (pp. 13, 14.)  Cusack is the first surgeon
   who, in this country, exarticulated the jaw, which  operation he performed thrice in
    1825 and once in 1826.   After having separated the soft parts, and drawn as many
    teeth as were necessary, he cut through the jaw at the chin, and after having sawed
    across the ascending branch, " the cut extremity was seized in a strong pair of for-
    ceps, and the attachment of the temporal muscle having been divided, this fragment
      (a) New York Med. and Phys. Journal,  been able  to see either of  the American
    vol. ii. p. 401.—American Medical Recorder,  Journals quoted, nor to  find  it in any other
    vol. v. 1822.—Graefe und von  Walther's  Journal of the time, American  or English.
    Journal, vol. iv. p. 547.  I have been com.  —j. f. s.
    pelled to  use Graefe's  report  not having    (6; Dublin Hospital Reports, vol. iv.  1827. 
OF RESECTION OF THE UPPER JAW.             753
of bone, was nsed as a lever to press the condyle against the anterior and external
part of the capsular ligament, which was thus put on  the stretch.  An opening
having been made into the capsule at this part, the disengagement of the condyle
was effected by a blunt-pointed bistoury, carried cautiously round the joint, and di-
viding the attachment of the external pterygoid muscle.  This second section of the
bone may  appear, at first view, unnecessary, when the jaw is to be removed from
the articulation; but the body of the bone is, in general, so much disorganized, or
so deeply  involved  in the tumour, that it  could not be used as a lever to press the
condyle against the capsule;  a  case might occur,  however, in  which the second
division of the bone would be unnecessary." (p. 37.)  As has  been  already no-
ticed by Chelius, Jaeger  objects to sawing through the  ascending branch of the
jaw, whilst, on the other  hand, Schindler supports it.  This operation has been
repeatedly performed in England and Scotland without either previously tying the
carotid artery or sawing across the ascending branch of the jaw.
   Liston  (a) recommends partially sawing through the bone at the chin  and then
by placing the cutting forceps in the notch to clip it through.  He observes also, in
regard to stanching the  bleeding, that " much  time and trotble will often  be saved
by at once looking  for and securing the common trunk of the temporal and internal
maxillary  arteries as they emerge from under the border of the  posterior belly of
the dtgastric muscle." (p. 318.)
   Upon this subject the following writers may also be consulted :—
   Gierl.  Einige Bemerkungen fiber die Resection  und Exarticulation  des Unter-
kiefers; in Textor's Neuer Chiron, vol.  ii. part ii. p. 345.
   Lambert, Dissert, sistens casum  Exsectionis dimidiae Maxillae Inferioris ex ar-
ticulo, praevia subligatiene carotidis.  Aal., 1826.
   Jaeger; in Rust's Handbuch der Chirurgie, vols. v. and vi.; and in Handwor-
terbuch der Chirurgie, Article Reseclio Orsium, which treats very fully of the deca-
pitation and resection of the several bones.
   [Perry (b) had a case  of necrosis of the whole lower jaw, the front of which he
removed by making an incision from the  front of one masseter muscle to the other,
dividing the bone on each  side with the saw and nippers.  On the next day the right
ascending branch which had dropped a little,  was removed without difficulty; and
three weeks after, the left, which adhered rather more firmly.]
Sixth Section.—OF RESECTION OR EXCISION  IN THE CONTINUITY
                               OF BONES.

  (Reseclio Ossium in continuitaie, Lat.; Resection in der Continuitdt der Knochen,
                           Germ.; Resection, Fr.)

                    I.—Of Resection of the Upper Jaw.

  2846.  Resection of the Upper Jaw, performed at an  early period  for
various diseases in the Highmorian  cavity, with chisel and  hammer, or
with the sickle-shaped knife (Desault), has been in modern times spe-
cially brought  into notice by Dupuytren in  1819, and since then per-
formed by many surgeons.   It is indicated jn caries, fungous degenera-
tion of the alveolar process and of the upper jaw, in osteosteatoma  and
osteosarcoma,  in  medullary fungus, and polypus  degeneration  of  the
maxillary cavity.   The  performance  of this  operation is difficult,  the
shock very great; violent bleeding, and  spreading of the inflammation
to the brain may occur;  and in  malignant  degeneration, the permanent
benefit of the operation is  very  doubtful on account of the frequent re-
currence  of the disease.

    (a) Practical Surgery>         (b) Med.-Chir. Trans., vol. xxi. p. 290.  1838.
  Vol. hi.—64 
754                          OF RESECTION
  [Gensoul (a) shows that Dupuytren did not remove the whole jaw in 1819, but
only followed Jourdain and Desault's method of scooping out the contents of the
antrum; and in regard to  Sanson and Pinel Grandchamp, who were stated to have
witnessed this operation,  he says:—" I saw these two practitioners for the purpose
of knowing what method had  really been adopted.   Sanson  informed  me that he
had no knowledge of the  fact of an entire removal of the superior maxillary bone;
that he knew only of  the operation performed in 1820, which was similar  to De-
sault's, and of one other in the year 1824;  and that in the latter case, a large
piece of  the  edge of the alveolar process had been removed with  a  small saw.
Pinel Grandchamp said  he had witnessed the two operations mentioned by San-
son, but he had never heard say that Dupuytren had even thought of removing the
whole superior maxillary bone." (p. 10.)
  But neither Dupuytren nor  Desault, nor  Garengeot, nor Jourdain,  were the
 original performers even  of this scooping operation, for Akoluthus (b)  a physician
at Breslau, being consulted in 1693, by a woman who had a tumour on the jaw,
which followed the extraction  of a tooth, enlarged the mouth  with  a cut, removed
part of the swelling, togather with four teeth, but not being able at once  to get com-
pletely round it, he attacked it several times, at intervals of a few days, sometimes
with cutting instruments, and  sometimes with the actual cautery, and at last suc-
 ceeded in curing  his patient.                                              •
   The nearest approach to a total removal of the whole superior  maxillary bone, if
 indeed the entire bone were not removed, is detailed in the following interesting
 and important case, which was operated on  by Dr. Thomas  White, the father of
 Charles White, to whom reference has been recently made.   He relates it among
 his own Cases in Surgery, and I am not aware of any other case in which such ex-
 tensive mischief had  been done by disease of the antrum, and  yet the  patient had
 recovered.
   The patient was a woman " afflicted with a tumour betwixt the  zygomatic pro-
cess and'thenose, arising from the  lower part of the orbit of the left eye.   It pressed
 the nostrils to one side, so as to stop the passage of the air through them, and thrust
 the eye out of its orbit, so that it lay on the left  temple, yet, though thus distorted,
 it still performed its office.  The tumour occupied the greatest part of  the left side
 of the face, extending from the lower part of the upper jaw, to the top of the forehead,
 and from the farthest part of the left temple to the external canlhus of  the eye.  It
 had an unusual and unequal bony hardness.   It was of a dusky livid  colour, with
 varicose veins on the surface, and there was a soft tubercle projecting near the nose,
 where nature had endeavoured in vain to relieve herself."  For the removal of this
 disease, he continues, "  I began with  a  semicircular incision below the  dislocated
 eye, in order to preserve that organ, and as much as possible of the orbicular mus-
 cle ; then carrying  the incision round the external part of the tumour, I brought it to
 the bottom of it, and then ascended to the place where I began, taking care not to
 injure the left wing of the nose.   After taking away the external part of the tumour,
 which was separated in the middle  by an imperfect suppuration, there appeared a large
 quantity of matter, like  rotten cheese, in part covered by a bony substance, which,
 however, was so carious, as to  be easily broken through.   I scooped  away abun-
 dance of this matter, with a great  many fragments of rotten bones.  Upon cleansing
 the wound from blood and filth, with a sponge, I found the left bone  of the nose, and
 the zygomatic process carious, and easily removed  them with an elevator.   There
 were no remains of the  bones composing the orbit of the  eye, which were plainly
 destroyed by the same  disease.   The optic nerve was  denuded as  far as the dura
 mater; and the dura mater and pulsation of the vessels of the  brain were apparent to
  the eye and touch.   The left superior maxillary hone, in  the  sinus of which this
  disease had its origin, and remained a long time concealed, was  surprisingly dis-
  tended, and in some places became carious; it had  exfoliated from the lower part to
  the sockets of the  teeth, which  part was in  like manner  removed. I applied the
  actual cautery to the rest of the bones and putrified parts, taking care  not to injure
  the eye and neighbouring parts, which were  sound.  The patient drew  her breath
  through the wound, and was so incommoded  by the foetid matter flowing into her
  throat, that she was obliged for several weeks to lie on her face to  prevent suffoca-
    te) Ltttre Chirurgicale sur quelques Mala-    (b) Ephemerid. Medico-physicarum, etc.
  dies graves du Sinus Maxillare et  de l'Os  Decad.  iii. Ann. iv. Obs. 57.  De horrenda.
  MaxUlare Inferieure.   Paris, 1833.  8vo.    Epulide. 
OF THE UPPER JAW.
755
tion.  *  *   *   The patient recovered.  The eye returned to its place, and she
enjoyed the perfect sight of it.   The only inconvenience that remained was a con-
stant discharge of mucus from the greater canthus of the eye, which I could never
thoroughly cicatrize." (p.  135-38.)
  As regards the actual  proposer of .the entire removal of thejaw, there can be no
doubt, as will be presently shown, that in 1826 Lizars  proposed it, recommending
also that the carotid artery should be first tied.  But Gensoul, seemingly without
any knowledge of Lizar's proposition, performed the operation in the spring of 1827,
and without previously tying the carotid or any other artery.—j. f. s.j
   2847.  The  operation  consists  in the  following acts:—flrst, cutting
through the skin and muscles ; second, cutting out the diseased part of the
jaw, and, third, bringing the wound  together.   The different mode of
conducting, these acts depends especially upon the extent of disease in
the bone.
   2848.  The  patient is seated on a  chair not very high, with his  head
resting on  the breast of an assistant, who  stands behind him.  A cut is
made from the corner of the mouth in a semicircular direction to the
zygomatic arch ; or a _J or "f shaped cut through the cheek; or a  cut from
the inner corner of the  eye, through the  upper lip, above the cuspid tooth,
from the middle of which, or perhaps a little above the base of the nose,
a second cut is made to within four lines of the lobe of the ear, and then
a third,  which,  beginning five or six lines to the outer side of the  outer
angle of the orbit,  ends at the extremity of the second cut.   (Gensoul.)
For the purpose of  avoiding palsy of  that half of the  face, by cutting
through the facial nerve, as well also as to prevent a salivary fistula, by-
wounding  the Stenonian duct, the cut  should be carried, according  to
Diffenbach, in the middle line of the face, instead of through the cheek.
The flaps,  formed in one of these  ways, are  separated from  the  bone  to
sufficient extent, any spouting vessels, especially the transverse facial and
the facial  arteries tied, and the flaps held aside by an assistant,  with his
fingers, or with a blunt hook.
   [There can be no doubt that Lizars is justly entitled to the credit of having, in
1826, proposed the entire removal of the superior maxillary.  Speaking of "polypi or
sarcomatous tumours  which grow in the antrum," he says (a) —" All the  cases that
have come within my knowledge, (with the exception of one,) wherein these sarco-
matous tumours have been removed by laying open the antrum, have either returned
or terminated fatally.  I am therefore decidedly of opinion, that  unless we  remove
the whole diseased surface,  which can only be done by taking away the entire supe-
rior maxillary bone, we merely tamper with the disease, put our patient to excrucia-
ting suffering, and ultimately to  death.  The inferior  maxillary bone has  now been
nearly entirely removed for  osteosarcoma with success, and I see no difficulty in ac-
complishing the same with  one of the  superior maxillary.  We secure the common
carotid artery for other  tumours of the face, and for aneurism by anastomosis, and
why not do  it for so loathsomeand fatal a disease as this 1  The steps or plan of the
operation I would suggest for so fatal a disease, are, first, to secure the trunk of the
common carotid artery of the affected side;  next to  make an incision through the
cheek, from the angle of the mouth backwards or inwards to the masseter muscle, care-
fully avoiding the parotid duct, then to divide the lining membrane of the mouth,
and to separate  the soft parts from the bone upwards to the floor of the orbit; thirdly,
to detach the half of the velum palali from the palate bone.  Having thus divested
the bone to  be removed of its soft coverings, the mesial incisive tooth of the affected
side is to be removed;  then the one superior maxillary bone to be  separated from the
other, at the mystachial and longitudinal  palatine sutures, and  also the  one palate
bone from the other,  at the same palatine suture, as the latter bone also will require
   (a) A system of Anatomical Plates, &c, part ix. The Organs of Sense, &c, Edinburgh
 1826.  8vo. 
756
OF RESECTION
to be removed either  by the  forceps  of  Mr. Liston, or  a saw ; thirdly, the nasal
process of the superior maxillary bone should be cut across with the forceps; fourthly,
its malar process, where it joins the cheek-bone ; fifthly, the eye with its muscles
and cellular cushion being carefully held up by a spatula, the floor of the orbit is to
be cleared of its soft connexions, and the superior maxillary bone separated from the
lachrymal and ethmoid bones, with a strong scalpel.   The only objects now holding
the diseased mass, are the pterygoid processes of the sphenoid bone with the ptery-
goid muscles.  These bony processes will readily yield  by  depressing  or shaking
the anterior part of the bone, or they may be divided  by the forceps, and the muscles
cut with the knife.  The bone or bones are frequently so soft  in this disease, as to
be easily cut with a knife or scissors.   After the bone with its diseased  tumour has
been removed, the flap is to be carefully replaced, and the wound in the  cheek  held
together by one or two stitches, adhesive  plaster and  bandage.   In  no other way do
I see  that this formidable disease can be eradicated." (p. 58.)
   The operation which Lizars proposed,  he endeavoured to  perform in  December,
1827, but without success, and  he  thus mentions it (a) :—" I  attempted to remove
this bone for a medullary sarcomatous tumour of the antrum, from a  miner or collier,
after securing the common carotid artery of the affected side, but I was prevented by
the haemorrhagic disposition of the  gum and  palate, my patient  having lost, in a few
seconds, upwards of two  pounds of blood, which welled out at every incision, as if
there  had been an aneurism by anastomosis.  The man survived this attempt seven-
teen months." (p. 54.)
   On August 1, 1829, Lizars performed his second  operation  (b) ;  he first tied the
trunk of the temporal  and internal maxillary arteries, and also  the  external jugular
vein which had been divided on the first incision.  He cut through the alveolar pro-
cess and bony palate on the left side of the palatine suture, and completely separated
the upper jaw, with the saw, Liston's forceps and strong scissors; but  the orbitar
plate  was separated from  the  eyeball by  the handle  of a knife.  The tumour was
medullary sarcomatous, and a portion of it, attached  to the pterygoid process of the
sphenoid bone, could not be detached; but part of the malar bone involved in  the
disease was  removed.   On the sixteenth day the wound had healed, and she left the
house on that day.  Three days after she  expired suddenly, but no examination was
permitted.
   Lizars' third operation (c) was performed on  10th January, 1830, on a woman,
after  having  first tied the external carotid  artery.   After slitting up  the nostril
making a flap of the cheek, and divesting the borie of its coverings  where it was to
be sawn through, he applied the saw on " the front  of the superior maxillary bone
between the nostril and the mouth, or at the side of the mystaehial suture ; the pala-
tine plate backwards from this,  parallel with  the longitudinal  palatine suture, to near
where the transverse palatine suture exists; across the same  palatine plate towards
the bulbous process ;  upwards between the bulbous process and  the  pterygoid pro-
cesses of the sphenoid bone, across where it joins the cheek-bone ; and, lastly, at its
nasal  process, parallel with the  inferior margins of the lachrymal and nasal bones.
I then-with strong seissors cut- the connexions of the orbitary plate with the os planum
of the ethmoid bone, and orbitary process of the palate-bone, deep into the orbit, to
the spheno-maxillary fissure, and was,  lastly, able, by notching with  the bone forceps
at every point where the saw had been applied, to  remove the entire bone which had
its cavity filled with a firm sarcomatous tumour.  The patient was able to walk about
her room on the eighth day, and went out  to take an airing on the thirtieth day; and
she left the Hospital on 5th March  following." (p. 55.)
   I have, for the sake of convenience,  put these three cases together; but although
Lizars first proposed  the operation in this country,  it was first performed by Gen-
soul,  of Lyons, on 26th May, 1827, who states that he was  not aware what method
Lizars had  employed (d), on  a lad of seventeen, for a fibro-cattilaginous. tumour
of the upper jaw-bone, " occupying the whole left side of the face, and  pushing to
one side the orifice of the mouth ; it extended from above downwards, from the  floor
of the orbit to two  lines above the chin; from before backwards,  from the  nose,
which was thrust to the right, to the top of the" angle  of the inferior maxillary bone."
(p. 17.)   He did not first tie the carotid ariery, but  " made a vertical cut from the
  (a) Lancet.  1829-30 ; vol. ii,        (b) London Medical Gazette,, vol. v. p. 92.
  (c) Lancet, above citei             (d) Above cited. 
OF THE UPPER JAW.                    757
inner corner of the eye vertically down through the upper lip,.opposite the left cus-
pid tooth.  From the middle of this cut, or rather nearly on a level with the floor of
the nose, he made a second  up to four lines from the front of the lobe of the ear,
and a  third cut beginning five or six lines to  the outside of the  orbit down to  the
end of the second, and then turned the flap up to the forehead. But for the purpose
of completely exposing the tumour, he was obliged to continue, from the junction
of the second  and  third cuts, another along  the inner edge of  the  m. masseter to
within an inch  of the base of the lower  jaw; and this lower flap he turned down.
He then commenced  with a  chisel and malletcutting through the outer margin of
the orbit near the suture  connecting  the  malar and frontal bones, into the spheno-
maxillary fissure : and next cut through the zygomatic process of the malar bone.
The maxillary  bone being thus  freed externally, he placed a  very broad chisel
below the  inner angle of the eye, and carried it through the lachrymal bone and
the orbitar plate of the ethmoid ; and  in  the same way detached  the  corresponding
part of the nasal bone.  Cutting away with a bistoury all the  soft parts connecting
the wing of the nose to the upper jaw, he proceeded to separate the two superior
maxillary bones, which  he effected easily and  quickly,  having drawn the first  left
incisive  tooth, by introducing a chisel not directly from before backwards,  but by
wriggling it through the mouth.  Lastly to detach the maxillary bone from  the
pterygoid processes of the sphenoid, and to  destroy any connexions  with the back
of the ethmoid still  remaining, he thrust the  chisel  into the tumour,  passing it  ob-
liquely in the orbit, so as to cut through the superior maxillary nerve, which  he was
anxious not to drag, and to push it sufficiently deep to form a lever, so as  that he
could  turn the tumour down into the mouth.  This answered very well, and  he had
then only*to divide with  curved scissors and bistoury the attachments  of the bone to
the soft palate, so as to leave the latter unharmed.  The operation was scarcely con-
cluded,  when the patient fainted, but revived  on being laid  upon his bed. The
flaps  of the  wound yielded  but a few. drops  of blood and the bottom oozed  but
slightly.  About  an hour after, no ligatures  being needed, the edges were brought
together with pins and* twisted suture.   On the eighth day the sutures were  re-
moved, and the wound was healed, except a very small  portion of the middle cut."
(p. 18-23.)]

   2849. Cutting away the diseased jaw  is now effected by means of  Hey's
saw,  or the osteotome, in  the different  ways, according  to the extent of
the disease.   If only  a: portion of the upper jaw,  with its broad base  to-
wards the alveolar process, have to be removed, two A shaped cuts united
together, are to be made with the saw, including all the diseased part.  If
the swelling be broader above, a vertical  cut must be made on each side,
connected at  the  upper part with a  transverse  cut  with the saw, or with
the chisel and hammer.  If the extent of the diseased bone be still greater,
so that the whole jaw must be removed, the outer wall of the orbit must
be divided with the chisel and  hammer, near the suture connecting the
cheek-bone with  the outer orbitar process of the frontal bone, so that the
chisel should penetrate into the spheno-maxillary fissure, and afterwards
the zygomatic process of the cheek-bone is to  be  divided in like manner.
The upper jaw-bone having  been  thus separated on the outside, a very
broad chisel is  placed below the inner corner of the eye,  and held in such
direction that when struck with the hammer, it passes through the lower
part  of the  os unguis and the orbitar  plate of the ethmoid  bone.   The
ascending nasal process of the jaw-bone corresponding to the nose-bone,
is to  be separated in the same manner; and all the soft parts connecting
the wing of the nose to the upper jaw are now to. be cut through.   The
incisive teeth of  the  affected side are now to  be  inclined outwards, and
whilst the chisel is  entered between the two upper maxillary bones, not
directly from before backwards,  but obliquely from the mouth, their  se-
paration is very quickly and easily effected.   Lastly to separate the jaw- 
755
OF RESECTION
bone from the  pterygoid  process, and any still remaining connexions
with the ethmoid bone behind, the chisel  must be passed from the orbit
obliquely downwards to loosen every thing which has firm adhesion, and
by lever-like movements, to push down the separated bone into the mouth.
Nothing more remains but to  cut through the attachment of the  palate-
bone to the soft palate^ either  with the curved  scissors  or  with the bis-
toury, in  such way that the  latter may still remain  connected with the
pterygoid process, and with  its other side.   When the upper jaw-bone
has been removed, there  is a  large cavity bounded on the inside by the
mucous membrane of the septum narium, above and  before by the lower
straight muscle.of the eye, by  fat  and'  cellular  tissue, the outside by the
cellular tissue beneath the  m. buccinator, and behind by that part of the
throat above  the  soft palate.
  In five cases in which, I have performed resection of the upper jaw with perma-
nent success, I", have operated  in two cases according to the first;  in one according
to the second;  and  in two cases according to the third method; only that besides
the chisel, I  used Hey's saw for the division of the bones.  In other two cases the
disease returned.
  Heyfelder (a) performed resection of both jaws in the following way :—He made
two cuts from, the outer angles of the eyes into the corners of the mouth,  then sepa-
rated all the  soft parts from the swelling to the inner corners of the eyes and to the
nose-bones.  He then raised this four-cornered flap upon the forehead, carried Jef-
fray's chain-saw through the upper fissure of the left orbit, and divided the connex-
ion of the left upper jaw-bone, and cheek-bone.  In like manner he proceeded with
the division of this bone from its  Connexion with the frontal, laehrymal, ethmoid,
and nasal bones. In the same way, the right upper jaw-bone  was separated from
its connexions, and afterwards -the vomer and the still remaining connexions were cut
through  with strong scissors.   A lever-like pressure was made on the upper part of
the tumour to complete the operation.  Torsion and compression stanched the bleed-
ing, and twenty-six sutures united the wound.
  [Syme's, (b) directions for performing excision of the upper jaw-bone are the most
simple, and will not be  found  less  convenient than any other.  He says " two inci-
sions should be made through  the cheek, one extending from, the inner angle of the
eye directly downwards to the lip,  the  other beginning over the junction of the max-
illary, and malar bones and terminating at the angle- of the mouth.  The triangular
flap thus formed is to be dissectedtfrom the tumour, and? the margin of the orbit ex-
posed." (p. 487.)
  Liston (c) performs this operation in the following manner:—" The extent of the
disease is to be accurately ascertained, and the points at; which the bones require to
be separated decided upon.  If the os  malae he involved,  and  it is necessary to re-
move it as well as. the superior maxilla,, a  pair of straight tooth-forceps, a  full-
sized  bistoury, copper spatulre,  powerful  scissors,  artery  forceps and  needles
for interrupted and twisted suture will  be sufficient.   If the superior maxilla only,
with, perhaps, some of the smaller bones, is to be removed, then the addition to the
apparatus of a small saw will be  necessary for the purpose of more readily effecting
the separation oftthe os malae from  its anterior attachment.   The proceeding is not
to be dreaded  on account of  its extent; indeed, removal of the superior maxilla
alone is  the more troublesome.  Supposing that the more extensive extirpation is
required, incisions must be made so as to expose freely the tumour and bones where
it is proposed to cut them*. First of all, one Of the central incisors must-be extracted,
either the one on the affected  side or the other, according  to the extent  of the tu-
mour.  I have been obliged to remove a considerable portion of the jaw opposite to
that principally affected; and in that case one of the molares was  removed, in order
to admit ofthe division of the  bones.  The point of the bistoury is entered over the
external angular process of the frontal  bone, is carried  down through the cheek to
the comerjof the mouth, and is guided hy the fore and middle fingers of the one  or

  (a) Chiruxjfische und Augenkrankea-KU-    (6) Principles  of Surgery..  Third  fidi-
nikum  der- Universitat, Edsmgen, p. 81.  tion..
1844.                                   (c) Practical Sargery.. 
OF THE UPPER JAW.                      759
other hand, as may be placed in the cavity.   A second  incision made along and
down to the zygoma falls into the other.  Then the knife is pushed through the in-
tegument  to the nasal process  of the maxilla, the cartilage of the alas is detached
from the bone, and the lip is cut through in the mesial line.  The flap thus formed
is quickly dissected  up, and held by an assistant; the attachment of the soft parts to
the floor of the orbit, the inferior oblique muscle, the infra-orbital nerve, &c, are cut,
and the contents of the cavity supported and protected by a narrow bent copper spa-
tula."  (pp. 311, 12.)  Or, the  flap  may be formed in the following way with less
extensive  cuts.  " The  incisions  were commenced  at the inner canthus of  the eye,
carried  by the side of and close to the ala of the nose, along the margin of the nostril,
and then through, the upper lip exactly in the middle line.  Another incision was
made from the commencement of the first, in a curved form, along the lower margin
of the orbit, and., of course, in the directions of the fibres of the orbicularis palpebra-
rum.  The flap thus formed was, by dissection, turned outwards and held by an as-
sistant until the processes were cut."  (p. 314.)
  Fergusson's (a) directions for making the skin-flap are, " that an incision should
be made from the margin of the upper lip towards the nostril, and then from the ala,
as high as within half an inch of  the inner canthus  of the eye-lids; next the cheek
should be laid open from, the angle of the mouth (or near it) as far as the zygomatic
process of the malar bone, and, if necessary, an incision  at right angles with this
one should extend from the external angular process of the  frontal bone, towards the
neck of the lower jaw; now the flap between the nose and the wound in the cheek should
be dissected from off the tumour, and turned upwards on the brow ; then that portion
of the cheek below  and behind the wound should  be turned downwards, and the
mucous membrane divided,  so as  to expose freely the  interior  of  the  mouth."
(p. 548.)
  Cases may certainly occur in which the use of chisel and hammer may be neces-
sary, but they cause  great jarring and  should not be used by choice, more especially
as in general the detachment of the jaw can be most quickly and conveniently made,
cutting  pliers, or nippers, and strong scissors, as recommended by Syme and  Liston.
The former directs, that  " one blade of a large pair  of cutting pliers be introduced
into the nose, and  the other into the orbit, so as to divide the nasal  process of the
maxillary  bone.   The connexion with the malar bone is next separated in the same
way, and  then the palate, previous to which one of the incisor teeth roust be extracted,
if necessary.   The surgeon having now deprived the bone of  all its principal attach-
ments, wrenches it out either with his hands or strong forceps." (p. 487.)   Liston's
proceeding is nearly  the same.  " With  the cutting forceps the zygomatic arch, the
junction of the os make and frontal bone by the transverse fecial suture, and the nasal
process of the superior maxilla are cut in succession; then, a notch having been cut
out of the alveolar process, the palatine arch is clipped  through by strong scissors
placed along it, one blade in the nostril of the affected side, the other in the mouth.
Then it is that an assistant will be prepared to place his fingers  on the trunk of one
or both carotids.   The tumour is now shaken from its bed, and, as it is turned down,
the remaining attachments are divided by the knife ; the velumpalali is carefully pre-
served, and also, if possible, the palatine plate of the palate bone." (p. 312.)
  O'Shaugnessy (b) has given in his short but clever book, the following  account
of the removal of  the upper jaw of  a Hindu, of twenty*-one years  of age, which he
performed in November, i837.  " An enormous growth completely occupied the left
side of  the face, rising to a level with the floor of the  orbit, and extending a long way
below the inferior maxilla, but unattached to it; occupying the whole of the  anterior
and  left side of the mouth, and protruding between the lips, pressing down the lower
jaw, so as almost to  make the chin touch the throat, and flattening  the nose,  so as to
leave but  little trace  of the prominence of that organ.  Still  there was no difficulty
of swallowing, and the patient seemed to breathe without inconvenience, through the
right nares.   That portion of the tumour which protruded through the mouth was
of a bright red colour, and covered with mucous membrane, having at its upper part
the canine, and two incisors of its own side, with the central incisor of the opposite
maxilla sticking out  of it.  The dimensions of, this mass were as follows :—From
  (a) Practical Surgery.
  (Jo) On Diseases of the Jaws, with a brief
Outline  of their Surgical Anatomy, and a
description of ihe Operations for their Ex-
tirpation and Amputation, &c.  Calcutta,
1844.  8vo. 
760
OF RESECTION
the part near the ear to the most prominent part which protruded from the mouth, ex-
actly twelve inches, and from that part which bulged below the inferior maxilla to
the edge of the orbit, about ten  inches.  It looked, as near as may be,  equal in
size to the patient's  head.   *   *   *  The  principal source of pain to the patient
seemed to be, from distention and pressure on the surrounding parts." (pp. 70, 71.)
Notwithstanding its  large  size, the tumour  seems to have  been removed without
much difficulty, the zygoma having been first Cut through, and afterwards the malar
bone info the spheno-maxillary fissure, with Liston's bone-nippers.   The orbitar
process of the superior maxillary bone and the nerve were next cut through with a
strong knife, and afterwards the  nasal  process of the bone.  The second incisive
tooth on the opposite side having been drawn, the extent of the disease requiring it,
the alveolar process and  hard palate, as far back as the palatal process of the palate-
bone, were then cut through with  the bone-nippers," and now all the strong attach-
ments  of the tumour being completely severed, he had no difficulty in removing that
mass, carefully separating with the knife the palatal process of the superior maxilla
from the palatal process  of the palate-bone, so as  to preserve the soft palate from in-
jury.   The tumour weighed four pounds, it was  nearly globular in form, having at
its inferior surface a deep groove into which the lower jaw sunk, and the teeth be-
fore mentioned projecting from its  anterior upper part." (pp. 73, 74.)   The patient
did not lose more than eight or nine ounces of blood, no ligatures were required,and
a few minutes after the tumour was removed, all bleeding ceased.   "The mouth
remained as wide apart after the operation as before the tumour that distended it was
removed; he appeared to have lost the power over the muscles that raise the lower-
jaw." (p. 78.)  This, however, was  gradually recovered, and on the eleventh day
" the mouth was nearly  as small as it ever could have been." (p. 79.)   The patient
completely recovered.
  Hetling (a) of Bristol, relates  a  case of  Osteosarcoma; or rather, as he says, it
should be more properly called, from its true character, medullary sarcoma of both
jaws, in a woman of twenty-three, upon whom  he operated, removing part of the
upper jaw, and part of the lower jaw, which latter he exarticulated.  "The tumour
extended from the upper to the lower jaw, to  the latter of which it adhered so firmly,
as to  render it completely immovable, so that the patient could not masticate, and
could scarcely articulate, being only enabled to  answer questions put to her, by in-
distinctly mumbling 'yes,'  or 'no.'   In  this state she was compelled to live upon
fluids, and even these were with difficulty swallowed, deglutition being much im-
peded  by the pressure of the tumour upon the internal part of the mouth." (p. 279.)
The operation consisted  in making a  crucial  cut  through the cheek from the mouth
to the lobe of the ear, and from the infraorbitar edge to the angle of the jaw, turning
Up  the flaps and exposing the diseased mass, "the base of the tumour was  found to
occupy the palatine  and maxillary portion of the upper jaw, and in its extensive
growth, its head had been forced down and attached to the ridge of  the lower jaw,
nearly as far as the symphysis, extending along the whole of the alveolar border,
nearly in a horizontal line from  the  mental foramen to the condyloid  process, the
whole of which portion was discovered to be either absorbed or m a state of caries,
from the long-continued pressure of the tumour.  In fact the tumour had so worked
its  way across the lower jaw, both inwards and  outwards, that it was found buried
in its substance, and, consequently, absorption of its body had been going on for
some time on both sides of'the bone.  The substance of the tumour was next sepa-
rated by the knife and fingers, from its base and adhesions.  When this was effected,
an  extensive irregular surface  of  bone was found in a state  of'cartes, extending in
the upper jaw  from the pharynx across the palate to  the  malar bone.  Not the least
vestige of the thin walls of the antrum remained.  Fortunately, the floor of the orbit
was left uninjured.  With the assistance of Liston's bone-cutter, small saws, &c,
every  portion of diseased bone was taken away that could be safely removed, and the
general surface  scraped as  carefully as possible with the knife, it being intended,
finally, to  apply the  actual cautery  over  the whole plane  of the  diseased  bone.
Having accomplished this tedious and difficult part of the operation, ample room was
found  for amputating the lower jaw at the articulation ; caries having extended as be-
fore stated, from near the symphysis along the whole of the upper margin to  the joint.

   (a) Transactions of the Provincial and Medical and Surgical Association, vol. i.  London,
1833.  8vo. 
OF THE UPPER JAW.                    761
 This extensive line of bone was then sawed off, except the condyloid process, which
 was afterwards easily disarticulated and removed with Liston's bone-outter, having
 first divided the fore  part of its capsule, and also the temporal muscle from the coro-
 noid  process." (pp. 284, 85.)  There was no bleeding of consequence, and the ac-
 tual cautery was not  applied.  The flaps were brought together with sutures ; on the
 fourth day the external wound had united, and in course of a fortnight, she walked
 about the ward.  She left seven weeks after the operation, restored to a healthy ap-
 pearance.  This operation did  not ultimately succeed, for Heltling states, " that the
 disease returned some time after the patient left the Infirmary, that she languished
 for about a twelvemonth, and died." (p. 336.)
   This result is what usually happens in these cases of fungoid tumours of the jaw,
 if the whole of the bones affected, cannot be, or are not, removed  by the  operation.
 And  Liston has justly observed :—" If any thing is to be done, it ought to be  under-
 taken with a thorough determination to go beyond the limits of the morbid growth,
 to remove the cavity  which holds it, and thus get quit, if possible,  of all the tissues
 implicated, or which may have become disposed to assume a similar action. I know
 from  experience, that  this step, if adopted in time, may prove successful; and though
 at least a doubtful and very severe proceeding, not  by any means unattended with
 danger, it is the only remedy.  Let it  be borne  in  mind, that it is only in the very
 earliest stage that any benefit can accrue even from the thorough extirpation; very
 generally the case is  not presented until much too late, to  one who understands the
 nature of the  malady, who is capable  of undertaking its treatment, and who has
 courage to propose and perform what is necessary.  After the parietes have given
 way, and the growth  has appeared in the nostril or cheek, the case is hopeless; and
 the patient, as, of old, were those who ventured on the ocean, may be numbered with
 the dead." (p. 307.)]
   2850. After  the wound has been properly cleansed, every spouting
 vessel must be  tied or  twisted, the parenchymatous bleeding stanched
 with cgld water, or with the actual cautery, the application of which may
 be necessary to destroy any remaining  diseased part, the edges of the
 wound brought together and closed with the interrupted or with the twisted
 suture, and  the  interspace with strips of sticking plaster.   Filling up the
 cavity with  lint is injurious, but laying in some pieces of German tinder
 convenient, as  when  suppuration  comes  on, it  easily and  completely
 separates.
   2851. The after-treatment must be conducted according to the general
 rule.
   The dangers to be dreaded are violent inflammation, which may extend
 down the throat and  to the  brain ; nervous symptoms; ill-conditioned
 copious suppuration, to  contend with which frequent washing the mouth
 with  warm water or  any slightly aromatic  infusion  are most proper, at
 the same time  supporting  the strength; after-bleeding, for which  com-
 pression with  German tinder  must be made, which I employed in two
 cases with success; necrosis of the cut surfaces, which require purifying
 washes for the mouth, and  the ultimate  removal of the separated pieces
 of bone ; fungous  granulations, which may be touched with  caustic or
 with  the actual  cautery.
  If the disease recur, it depends  upon the previous extent of the resec-
 tion and the other conditions of the patient whether any repetition of the
 operation should be undertaken.   Palsy of the face diminishes and gene-
 rally  after a time ceases.
  Upon this subject may be consulted also,
  Chelius; in Heidelb. klinisch. Annalen.
  Guthrie; in London Medical Gazette, vol. xvii. p. 315.  1835.
  Blandin; in Gazette Medicale de Paris, vol. ii. p. 344.   1834.
  Adelmann,  Untersuchungen iiber  krankhafte  Zustande  der  Oberkieferhohle.
Dorpat, 1844. 
[   762   ]
                  II.—Of Resection of the Blade-bone.

  von Walther; in his Journal fur Chirurgie und Augenheilkunde, vol. v. p. 271...
  Haymann; in the same, p. 569.
  2852i The practicability of this operation von Walther rested on his
experiments upon the  dead  body.   The  blade-bone is laid bare by a
crucial cut through the skin, forming flaps by turning it back, but leaving
the muscles  on the hinder surface of the bone; the insertions of the  mus-
cles are cut  off close to  the outer and inner edge of  the bone, which is
then sawn through transversely immediately below the spine, so that the
upper angle and all the  parts above the  spine remain; lastly,  the subsca-
pular muscle is separated and the muscles generally  on the front of the
bone, which can be  done with the handle of the knife.  The trunk of the
subscapular artery is not in this way injured.
   2853.  Haymann performed this operation successfully on account of a
tumour attached to the blade-bone.   He laid it bare with two large semi-
lunar  cuts through the  skin  and  tendinous expansion, and   cut  it  away
with some quick strokes of the knife; the bone was then sawn obliquely
through the spine, so that only  the  glenoid cavity and the  parts above
the spine remained.   After the cure  the  upper arm  could be moved in
most  directions, its  elevation alone was interfered with.
   Liston (1), Janson  (2), Luke (3), Syme  (4), Wutzer, and Textor have per-
formed this operation (5).
   [(1) Liston (a) removed in 1819 about three-fourths of the scapula, leaving only
the glenoid cavity, processes, and half of its  spine.   It had been at first intended to
 remove " a very large, hard, inelastic tumour, firmly attached  to the  bone, and ex-
 tending from its spine over all the lower surface of the bone;" but on attempting to
 detach it from the spine, " the knife and fingers  suddenly slipped into its substance.
 This was attended with a profuse gush of florid blood, with coagula."   Liston then
 considered it necessary to remove the portion  of bone above mentioned.  The disease
 seemed to have been medullary sarcoma.   The disease, however, recurred, and the
 patient died.
  -  (2) Janson (b) removed a large portion of the blade-bone  which was involved in
 a tumour, but left the  glenoid cavity.
    (3) Luke's (c)  operation in  October, 1828, was  for  a medullary sarcomatous
 tumour, occupying the whole of the infraspinate pit of the blade-bone, and protruding
 from the subscapular-pit deeply into the arm-pit.  The patient was a girl of fourteen,
 and had only noticed the swelling about six weeks.   He " made an incision through
 the skin, beginning at the axilla, and expending it along the axillary margin of the
 tumour and anterior costa,  and then with a sweep around the inferior angle to within
 a short distance of the spine of the scapula.  He extended a second incision from the
 commencement to the termination of the first, along the lower margin of the spine;
 also through the skin, which being drawn upwards, exposed the spine and adjoining
 muscles.  The muscles lying over the supra and infra spinal/ossa were next divided
 in the direction which he  proposed to saw through the bone. *  * * By grasping
 the tumour and inferior angle in his left  hand, the  scapula was steadied whilst he
  sawed it  through in a direction from  a little behind the glenoid cavity to a little above
  the superior angle, which  latter was therefore removed, the spine being sawn through
  near to the  root of the a.cromion.,,  (p. 237.)   The  soft parts were  then carefully
  separated from the tumour, which, was detached with about three-fourths of the
  scapula.   The bleeding was free, particularly in the neighbourhood of the armpit,
  where the axillary vessels and nerves were exposed. Twenty or thirty arteries were
  tied, and about a pint or a pint and a half of blood was  lost; but the girl  did not
  faint. The edges of the wound were brought together with straps of sticking plaster,
    (a) Edinburgh Medical and SurgicalJour-    (b) Malgaigne, Medecine Operatoire, p.
  nal, vol. xvi. p. 66 and p. 215.—Elements of 246.  .
  Surgery, p. 190.  Second Edition.            (c) London Medical Gazette, vol. V. 1830. 
RESECTION OF THE  COLLAR-BONE.              763
the arm secured with a bandage to the side  and the  fore-arm put in a sling.  In
about two months  the wound had healed completely.  Eleven months after the
operation, " the motions of the arm forward and backward were perfect, and in fact
more than ordinary, the limb  moving with more  than  usual pliancy, but yet there
was considerable power.  She can also perform the actions of rotation outwards and
inwards.  The elevation of the arm from the side cannot be easily accomplished, and
requires the aid of the opposite hand to raise it to  a horizontal level.  She possesses
considerable power, and can lift with ease moderately heavy substances."  (p. 239.)
   (4) The operation of Syme's (a) here alluded to, like Liston's, sprung out of
another, which was amputation at the shoulder-joint for a fibro-cartilaginous tumour
of the upper  part  of the humerus, having exposed which, he "easily cut through
the acromion process and clavicle, and then depressing the arm, separated its remain-
ing attachments.  It now appeared that a fibrous anchylosis had existed between the
glenoid cavity and  the tumour, which  had a cup-like  form, and embraced it on all
sides.  He therefore sawed through the neck  of  the scapula, and removed a portion
of the bone, including the coracoid process."
   (5) Travers in  July, 1838, removed all the  blade-bone  immediately below its
spine, for a large medullary sarcomatous tumour occupying the whole infraspinate
pit.   He first cut through the skin from the upper to the lower angle, and  next from
the root of the acromion, along the inferior costa to the beginning of the first cut. He
then turned up the flap of skin to rather above the spine of the  bone;  detached the
rhomboid muscles  from its base and the m. teretes  and latissimus  dorsi from the in-
ferior costa and  angle, and next made  a cut immediately beneath  the whole length
of the spine down to the bone, in doing which  a large gush of bloody fluid, as in
 Liston's case,  followed.  The base of the bone  first, and afterwards the inferior
costa, were sawnthrough with a narrow saw ; and it was then attempted to cut across
 the bone with cutting nippers, but this  failing it was sawn through  without difficulty,
close to the spine.   The bleeding was  severe, and he was much exhausted, but only
 seven vessels were tied.  The flap was laid down and fixed with two sutures and
 straps of sticking plaster.   The wound healed  kindly in about three weeks ; but three
months after  the operation, a small tumour of the same kind appeared in the  scar,
 and soon after another on the side  of the chest.  These  gradually increased, burst,
 and threw out bleeding fungous growths ; but he lingered a  long while, and died
just twelve months after the operation.
                 III.—Of Resection of the Collar-bone.

   2854.  Resection of the collar-bone,  which may be indicated in commi-
nuted fracture, if the sharp ends of the fracture thrust outwards or injury
to the vessels or nerves be feared, in caries and necrosis, and bony tumours,
requires, according to the different states  of the soft parts, a transverse
cut along the bone, from the two ends of which a small vertical cut must
be made, or two elliptical cuts, including the diseased part; or for a very
large swelling  a crucial cut.   The bone is then carefully separated from
the soft parts, the knife being  always  kept close  to it;  a spatula or a
leather strap is thrust beneath the  bone, which is then  cut through with
Hey's saw or with the  osteotome.   The edges of the wound are brought
together  with sticking plaster, lint and compresses  put  over it, and  the
arm supported with Desault's  or Boyer's fractured clavicle apparatus.
   In the total removal of the collar-bone, which Cuming (b) performed after ampu-
tation at the  shoulder-joint, and removal of the blade-bone in consequence of a crush
by a gunshot-wound, Meyer (c) and Roux (d), on account of caries, Warren (e)
   (a) Edinburgh Medical and Surgical Jour-   nal, vol. xix. p. 17.
nal, vol. xlvi.  p. 249.  1836.                 (d) Bulletin general  de Therap., vol. vi.
   (6) London Medical Gazette, vol. v. p. 273.   livr. 8.
1830.                                   (e) American Journal of Medical Science,
   (c) von Graefe und von Walther's Jour-   vol. xiii. p.  17.  1833. 
 764    RESECTION OF THE BLADE-BONE AND COLLAR-BONE.

 and Mott (a) for osteosarcoma, a cut was made along the collar-bone, and  brought
 down a little below each end, at which  a vertical cut about two  inches long was
 made, the flaps turned back and the bone laid bare.  The acromial end was then dis-
 jointed, the bone raised up and separated by disjointing its sternal end.
   [Travers (b) operated on a  boy of  ten years old, who, in consequence of a fall
 which probably broke the  collar-bone without rupturing  the periosteum, had large
 effusions of blood within it, which formed  a tumour that by degrees involved and
 destroyed nearly the whole bone, except at  its sternal end.   He made " a crucial
 incision through the integument and platysma myoides, one limb of which was nearly
 in the line of the clavicle, and the other  at  right  angles;  and the flaps and fascial
 coverings successively dissected down to the external  basis of the tumour.  The
pectoralis and  deltoid muscles were  then carefully detached  from  their clavicular
 origin, avoiding the cephalic vein, and the fibres of the trapezius and cleido-mastoid
 muscles divided on  a director.  One considerable vessel, in the situation  of the
 transversalis humeri, required a* prompt ligature.  The circumference of  the  tumour
 was now well defined, though it was found  to  be  firmly imbedded and adherent on
 its posterior aspect. . Disarticulation of the scapular extremity of the bone was next
 effected without difficulty, and the mobility thus communicated to  the mass facili-
 tated the completion of the operation.   A director was now worked beneath the bone,
 as near to the sternal articulation as was practicable, and with a pair of strong bone-
 nippers thus introduced, it was completely and  clearly divided.  The subclavius
 muscle and  a part of the rhomboid ligament were  now detached from the tumour,
 and the mass being well raised by an assistant, while the edges of ihe wound were
 kept wide apart by metallic retractors, the cervical  prolongations of the tumour were
 separated from their remaining connexions by a few touches of the scalpel  without
 injury to the subclavian vessels,  (pp.  137, 38.)  A twelvemonth after, the boy had
 the full and  free use of the  arm." (p.  147.)]
  Mott gives the following account of his removal of the collar-bone :—" The inci-
sion extended from the articulation at the sternum to the  top of the  shoulder, in a
semicircular direction; below, the dissection, to get under the tumour, was on a line
with the fourth  rib; above, in a direction to the top of the shoulder, an inch below
 the thyroid cartilage and base of the jaw, and terminated at the same point with the
first.  The tumour of  a bony character, was in contact with the coracoid process,
insomuch that I was obliged to saw it through  near the acromion scapulas.   Below,
the vein was imbedded  in  the  tumour, from  the  coracoid process  to the scalenus
anticus.  Then  my attention was directed to separating the tumour from the deep-
seated fascia of the neck, to protect  the deep-seated  jugular and thoracic dfcct, the
operation being on the left shoulder."   " This operation far surpassed in tediousness,
difficulty, and danger, any thing which  I have  ever witnessed or performed.  It  is
impossible for any description which we are capable of giving, to convey an accurate
idea of its formidable nature.  The attachment of the morbid mass to the important
structures of the neck and shoulder of the left side,is sufficient to indicate its magni-
tude and difficulty."   So arduous was the task of separating  the diseased clavicle
from the vessels and thoracic duct, that he was at one time, he said, almost inclined
to doubt the possibility of accomplishing his purpose (c).   The operation lasted four
hours, and thirty vessels were tied.  The tumour,  when separated, was the size of
two fists.
  Chaumet (d) of Bordeaux removed  four-fifths  of  the clavicle, on account of a
tumour originating from  it.]
         [IV.—Resection of Blade-bone and Collar-bone together.
   This formidable operation was successfully undertaken by Mussiey, of
Cincinnati, who has published  an interesting account of it (e).  In 1818
a patient consulted him about  a  tumour  connected with  the thumb, for
which the first metacarpal bone was removed.   Several years later, pain
  (fl)  American Journal  of the Medical  ences, vol. ii.  p. 482.  1828.
Sciences, vol. iii. p. 100.  1828.               (d) Gaz. Med. de Paris, vol. i. p.209. 1846.
  (6) Med-Chir. Trans., vol. xxi.  1838.       (e) American Journal of the Medical Sci-
  (c) American Journal of the Medical Sci.  ences, vol. xxi. p. 390,  1837. 
       RESECTION OF THE BLADE-BONE AND COLLAR-BONE.    765


attacked the humerus, which became greatly enlarged, and in 1831 the
arm was amputated at the  shoulder-joint.  In  1836  the same disease
appeared in the shoulder, and  accordingly Mussey undertook the com-
plete removal of the  scapula and  clavicle in September, 1837.   " The
tumour was round and prominent, measuring horizontally over the sum-
mit, from the  anterior to the posterior margin of its base, 14 inches, and
vertically, from the upper to the lower margin  of its  base, 10 inches."
The integuments were dissected away from the clavicle, that bone dis-
jointed fronvthe sternum, its sternal extremity elevated and detached from
the subclavius muscle, so as to admit of the finger of  an assistant being
passed under  it to secure the subclavian artery.  The  subsequent steps
of the operation consisted in " plain, coarse, and sometimes rapid dissec-
tion."  Having tied'the subclavian artery, Mussey divided  the accom-
panying vein, when a bubble of air passed into the latter, which caused
the patient instantly to swoon,  and  he  was roused with much difficulty
from this state of collapse.   "The immense wound, with flaps of seven
or eight inches in extent, united by adhesion, and became  consolidated
and sound, literally without the formation  of a teaspbonful of pus.   In
less than three weeks  the patient was dismissed, and he rode home  in a
stage-coach between thirty and  forty miles, and remained sound arid well
in November.
  In 1841-, Rigaud (a) of Strasburg, amputated a man's arm  at the shoulder-joint,
for disease of the humerus.  The man recovered, and remained well for eight months.
A tumour was  then  found  growing from the scapula, and  Rigaud removed the
whole of this bone, together with the outer extremity of the clavicle, in 1842.  In
two months the parts were healed, and  the man remained well  in July, 1844.
  M'Clellan, of Philadelphia, removed the scapula and clavicle from a boy.   The
patient recovered after the operation, but died from a return of the malignant disease
in another part.
  Dr. Blackman, of New York, informs me, that Gilbert, of Philadelphia, has re-
cently removed the scapula and clavicle, but I have not been  able to ascertain the
particulars of the operation.
  I am specially obliged  to my friend Fergusson for the following short account of
the removal of the whole scapula and part of the clavicle, which he has this day (Fe-
bruary 6, 1847) performed on a man aged thirty-three, who had his right arm am-
putated about three years ago for caries  of the shoulder-joint.   The humerus was ex-
tensively diseased, which is presumed to have been  the reason  for amputating; and
the glenoid cavity being also affected, was removed at the same time, but either not
sufficiently, or else there had been subsequent  extension of  the disease.  Ten or
twelve fistulous openings communicated from  the surface with the carious bone,
which seemed to be so extensively diseased that  Fergusson considered it best to re-
move the whole bone.  An incision Was made, beginning an  inch and a half  from
the sternal end of the clavicle, along that bone to the acromion; room wa^s thus made
to apply a saw to the middle of the bone. An incision Was next made in the course
of the spine of the scapula, nearly to the base.   The first cut was then extended
down into the axilla.  The posterior flaps were now partially dissected off the thick-
ened mass covering the scapula; the anterior next raised, then them, pectoralis minor,
next the m. trapezius were  cut through, and the bone, being forcibly pulled out-
wards, was soon severed  by the division of the other muscles and tissues.  The an-
terior attachment of the  trapezius had  been in  part divided when making way for
the saw on the clavicle.  The axillary vessel was not obliterated, but spirted freely
when the finger was taken off the subclavian on the  first rib, where it had been com-
pressed ; during the operation not more  than four ounces of blood were lost.   There
was no shock and no  pain, for the patient Was under the iuflnence of ether during

  (a) American Journal of the Medical Sciences. 1844^; p. 512. I have not been able to
consult the original import.
  Vol hi.—65 
766
RESECTION OF THE  RIBS.
the whole time.  He was not aware that the operation was actually done, though
he fancied it was going on.                            ,,   ,  ,  3,         ■,
  Gaetani Bey (d), in the case of a boy fourteen years old, who had been severely
wounded  in the shoulder by the discharge of an old piece of artillery, which ex-
ploded whilst re-melting, amputated at the shoulder joint, removed the whole blade-
bone, which had been broken into  several pieces, and cutoff the acromial end of the
collar-bone.  In about two months the wounds were healed.
  It may not be amiss  to notice  here  five cases, in which the arm and the entire
scapula'were torn from the body by machinery.  In the  first case, related by Bel-
chier (b), no arteries were 4ied, and the man was well in two months.  James (c)
records a similar accident to a boy eleven-years old, and here again no ligatures ap-
pears to  have been  required, and the cure was complete in nine  weeks.  Scar-
nell (d), removed the outer third  of the clavicle which projected from the wound,
and tied the subclavian artery.  In a patient of Lizars's (e),  the outer half of the
clavicle was torn away, as well as the arm and  scapula; a ligature was placed on
the subclavian  artery, which had  bled but -little, and the patient rapidly recovered.
A similar case did equally well under the care of Cartwright (/).
                       V.—Of Resection of the Ribs.

   2855.  Resection of the ribs, which has often  been  performed for in-
curable disease restricted to the bone, as in caries and bony tumours,
(Percy,  Cittadini,  Richerand, Milton, (g) Antony, {g)MorT, Clot-
Bey, Jaeger, Textor,) requires  the rib to  be  laid  bare by a longitu-
dinal or transverse cut; the intercostal muscles are then divided by a cut,
first at their upper and afterwards at  their low«r edge  close to the bone,
and the intercostal artery tied if it bleed.   The pleura is then separated
with a blunt needle and the rib cut off with  an osteotome, which, in con-
sequence of its sheath, best ensures the pleura from wound.   The wound
is to be lightly filled with lint or German tinder, and treated in the usual
way.
  In compound comminuted fractures of the ribs, the removal of the ends of the bone
with the saw may be necessary; though here the greatest caution is always requisite
to avoid injuring the pleura, which is closely connected with the rib, whilst in caries
the pleura is generally thickened, and in part also  separated from the rib.
   In a case where about an inch-and-a-half of theninth rib had been removed, Tex-
tor found a mass of new bone at the .place where the removal had been made, al-
though caries had extended backwards to  a  considerable extent, the whole of the
diseased part not having been completely removed.
   [Warren (h) removed, in January, 1836, a large, hard, immovable tumour, with
a fistulous opening, and situated on the junction of the sixth and seventh ribs with
their cartilages, which had existed about four years.  He made an oblique cut over
the swelling, and at each erid of it another at right angles, so as to form two quad-
rilateral flaps, which being turned back, a firm cartilaginous substance was exposed,
that had destroyed the natural appearance of the parts.  This was removed, partly
hy shaving off' with the scalpel, partly by bits with the cutting forceps, and both
ribs were  then found carious.   These were  carefully detached by a probe from die
pleura, which was much  thickened, and  from the diaphragm, and  three inches of
   (a) Annali Universali  di Medicina, vol.    (/) Fergusson, p.  235.
xcviii. p. 5.  1841.—^London Medical Ga-    (g) [These names evidently refer to the
zette, vol. xxxi  p 286.  1842.              same operation, viz. that of rest ction of parts
   (6) Philosophical  Transactions,  vol.  xl.  of the fifth and sixth ribs by Milton Antony,
1741.                                  M.D. of Georgia.  See Philadelphia Journal
   (c) London Medical Gazette, vol. v. p. 497.  of the  Med. and Phys.  Sciences vol. vL
1830.                                  1823,-g. w. n.]
   (d) Lancet.  1832 ; p. 114.                (h) Boston Medical and Surgical Journal.
  '■■&) Fergusson's Practical Surgery, p. 235.  1837.—Lancet. 1837-38; vol. ii. p. 606. 
RESECTION OF THE FIBULA
767
the seventh rib with its cartilages, with two inches of the sixth, were removed by
the chain saw and cutting forceps.  There  was little bleeding, the intercostal arte-
ries having been obliterated  in the course of the disease.  He recovered.  War-
ben also removed in March, 1837, an osteosarcomatous tumour; circular, above six
inches in diameter and three in height, covering parts of the seventh, eighth, ninth,
and tenth ribs, attached to all, but most firmly to the ninth.  It had been growing.
six years.  A "J" cut was made through the skin, and the flaps having been turned
back, the insertions of the external oblique muscle were exposed and dissected off,
as was also the m. latissimus dorsi, which latter was divided with  some difficulty,
and excessive pain.   The tumour then found originating from the ninth, but firmly
connected with the seventh,  eighth, and tenth ribs, was then cut off from the former
about an  inch distant from  its junction with  its cartilage.  The intercostals were
then cut through, the diaphragm carefully separated from the rib and pleura, a- di-
rector passed under the points where the rib was to be divided; and this done with
cutting forceps, removing about two inches of  the bone, and a part of its cartilage ;
upon  which the  diaphragm  immediately rose up like-a hernia. There was little
bleeding, and no vessel required  tying.  This case did well.
  Dixon  (a) removed the cartilage of the tenth-rib of the left side, which had been
broken off two years previously,  and from a few weeks after had caused severe neu-
ralgia at first in the part and then over the region of the stomach, and had become al-
most unbearable.   A careful dissection exposed tha cartilage  unattached ; it  was
easily removed; the pain immediately ceased,  and the patient completely recovered
in the course of a week.
  In a case of necrosis of the fifth rib, of which Roux (b) removed with the chain
naw, four inches, a collection of matter was found between it  and the pleura, not,
however, communicating with the cavity of the chest.   Within  a few days, respira-
tion became oppressed.   He was attacked with symptoms of pleuritis on the right
side, and died.  On examination, the right cavity of the chest was  found  to con-
tain a considerable quantity of purulent serum, with albuminous flakes of recent
formation.  The lungs were  filled with softened tubercles, as  might be expected;
the patient having been much emaciated, and coughed much with copious expecto-
ration, previous to the operation.]
                       V.—Resection of the Fibula.

   [2855.* Resection, or Extraction  of the  Fibula, was proposed by De-
sault, but has  been, however,  only recently performed by  Setjtin (c).
He detached the  muscles  from the bone, then  applied the  crown of a
trephine below its head, slipped a  narrow riband between the bone and
the muscles on its inner side, down to the outer malleolus, and cut it off
with a curved saw.   Malgaigne removed the upper third of the^z&i^^
and exarticulated it; but care was necessary  to avoid injuring the ante*
rior tibial nerve as it passed round the neck of the  bone.]
   2856'.  From this account of the several resections in the contiguity and
continuity of the bones, it may be easily determined which mode of prac-
tice shall be  pursued in the  partial resection of  some bones, to wit, the
radius, ulna, tibia,fibula, metacarpus and metatarsus, and so on;  as also
in the entire  extirpation of  single bones.

  For a careful collection of the cases hereto belonging,  see
  Jaeger, Handworterbuch der Chirurgie, Article Resectio ossium, vol. v.
        (a) New York Quarterly Journal, No. I.—Lancet.  1839-40 ; p. 137.
  (b) Journal Hebdomadaire, vol. vii. p. 299.     (c) Malgaigne, Medecine Operatoir*  p
—Lancet.  1829-30; vol. ii. p. 619.        249. Fourth Edition.   1843. 
768
POSTSCRIPT.
  Kreitmair, Darstellungdes Ergebnisses der im konigl. Julius Spitale zu Wurz-
burg seit 1821 angestellten Resectionen.  Wurzb., 1839.
  Schirlinger, Beitrag zur Casuistik der Resectionen.  Wiirzb., 1841.
   [Resection  of the Os  Coccygis, for  the cure of  Neuralgia, has  been
done by Dr. Nott of Mobile.   See  New Orleans  Medical  Journal  for
May, 1844.—g. w. n.]
                                 Postscript.

  [The year 1846 seems in a fair way to be known as the Annus Mirabilis of Surgery.
The profession and the public in both hemispheres are in a complete ferment, con-
sequent on the discovery by Morton, an American dentist, of a  mode of producing
insensibility, during which an operation may be  borne without pain, nay, even ren-
dered so  agreeable as to induce a desire for its repetition.   This safeguard against
pain, consists  in inhaling  the vapour of ether, till the person is brought by it into
the  condition vulgarly known as  "dead drunk," in which state the operation is  to
be performed.
  From the accOunt given by Bigelow {a), it appears that this proceeding was'first
largely,employed to render toothfdrawing easy, and in consequence of the success.
which attended it, Warren of Boston, thought it might be useful in more serious
surgical operations.   He, therefore, on the 16th  October,  1546, having put  a patient
under the ethereal influence, made "an incision near the lower,jaw of some inches
in extent.  During the operation the patient muttered, as  in  semi-conscious state,
and afterwards stated that the pain was considerable, though mitigated; in his own
words, as though the skin had  been scratched with a hoe.  There was, probably,
in this instance,  some defect in  the process of inhalation, for on  the following day
the vapour  was administered to another patient with complete success. A fatty tu-
mour of,  considerable  size, was removed by Dr.  Hayward, from the arm of a wo-
man, near the  deltoid  muscle.   The operation lasted  four or five minutes, during
which time the  patient betrayed occasional marks  of uneasiness, but upon subse-
quently regaining her  consciousness, professed not only  to have been insensible to
surrounding objects, to have known nothing of the operation, being only uneasy about
a child left at home."  (p. 271.)  Two other cases are ajso mentioned by Bigelow,
one of amputation above the knea, the other of  removal of a portion of the lower
jaw, during both which operations tire patients were insensible to pain. An account
of this wonderful discovery reached this country on the 17th December, 1846, and on
the 19lh, a young female,  having been intoxicated by inhaling ether for  a minute
and a half, had a molar toOlh extracted from the lower jaw by Rorinson (b).  On
the same day, Liston (c) amputated the leg of one patient, and twisted off the great
toe-nail of another, whilst  they  were under  the influence of ethereal [inhalation,
and " neitheriof the patients knew, when they recovered from their stupor, that the
operation had been performed." (p. 251.)
  Since this time, the public and medical journals have  been teeming with "pain-
less operations " of all kinds, performed in all parts of the country.
  That insensibility to pain, consequent on complete intoxication by breathing the
fumes of ether, may be produced in  many cases,  is  beyond all doubt; but that this
condition will be induced in all instances  is certainly untrue.  Its failure does not
depend, as is  asserted, on the inhalation not being properly performed, for all per-
sons are not  alike affected by it, however carefully and perseveringly  the ether
may be administered.   In  proof of this, I may select, from among many instances,
a case which occurred during the present month, (February, 1847,) at St. Thomas's
Hospital.  A man, whose toe-nail was to be twisted off, inhaled ether most assidu-
ously for more than half an hour, without the slightest degree of insensibility being
induced ; but it could not be objected that he was not fully subjected to the influence
of the medicine, since  after twenty-four  hours his breath was still so impregnated

  (a)  Insensibility during Surgical Opera-  Medical and Surgical Journal; cited in Me-
tions produced by Inhalation ; from Boston  dical Times, vol^xv.  1847.
              (6) Medical Times, vpl. xv, p. 273.               (C)  Ibid. 
POSTSCRIPT.
769
with the  ether, that it was  strongly smelt by persons standing at the foot of his
bed.
   The avidity with which ethereal inhalation has been generally ad opted; and appa-
rently without consideration of the possibility of its indiscriminate  employment
being ever attended with, danger, is one of the most remarkable circumstances con-
nected with it.  But, that it is not unfrequently accompanied with inconvenientand
even dangerous results there can be no doubt.  Bigelow, in his  paper before the
Boston Society, mentions the more or less  severe cough, which was immediately
induced in several of the cases he ■ relates.  In another instance, I have  known
hasmoptysis and  bronchitis induced,' in  a  patient who had previously- suffered  from
haemoptysis.  Morris (a) states  of'a. woman,  that "she did not appear at all timid,
andbegan to inhale the vapour with' the greatest confidence; after five or six inspi-
rations she suddenly  became  deadly pale, and stated  that  she; was  suffocating,
and refused to continue breathing the ether; she had scarcely done speaking before
she coughed violently  three or four times,, the  flbwyof. blood  to. the head was instan-
taneous :  she became quite purple in the face, the  temporal veins were much dis-
tended; and the arteries throbbed violently; she was  perfectly sensible, and  com-
plained of a sense of suffocation, and that she should die.  She remained in this state
for five minutes  at least, when the face began to assume its natural colour.  She
was a long time before she was able to leave  the house ; and after she had been at
home-two hours had  a fit; in which she was stiff and insensible for ten minutes.
Although upwards of  a fortnight has  elapsed since she inhaled the vapour, she is
far from recovered, complaining of a great deal of pain and confusion about the head,
and oppression at the chest."  He mentions also, of one boy, that " after having in-
haled for a short time, instead of depressing him-, he became furious, called out
loudly, and we had great difficulty in pacifying  him ;" and of another, that the in-
halation "brought on a  most distressing cough, which continued  so long as he
breathed the vapour; after a time it produced precisely the same effect as  nitrous
oxide;,he laughed most  heartily, and) looked  quite  idiotic.   After  waiting an
hour he again  tried  the vapour,  but with  the same  results." (p. 352.)   Cotton
also states, that in OnWof his cases " boisterous,, hysterical-like spasms followed,
as-observed by Professor Barker, requiring all trio force of the bystanders to hold
the patient.  Further inhalation, however, served to effect the required degree of un-
consciousness." (p. 35*3.)
   It has also happened,: that the patient has not recovered so speedily after the re-
moval of  the inhaler, as is commonly  stated ; indeed, it was almost feared he was
dead, and he only  revived by pouring quantities of wine down his throat.  In this
case, .the surgeon  who operated-noticed, that all  vital resistance of  the tissues had
ceased* and that the sensation igiven by his  knife was as if he were cutting into  a
dead body.
   I have thought it right to mention these facts,  to put practitioners on their guard
in the employment of  ethereal inhalation, for  I feel assured, that unless more cau-
tiously employed  than hitherto,  it will not be long before  many disastrous conse-
quences will result.  A medical friend of high  standing, with whom I had some con-
versation, insisted on  the propriety of subjecting the patient to some preliminary
trials of the effect of the inhalation before employing it at  the time of operating.
With this opinion I fully concur, and I should certainly adopt it, if I made up my
mind to try inhalation  at all;  but upon that  point I arn not  decided, for I have con-
siderable doubt of the  propriety of putting a patient into so unnatural a condition as
results from inhaling ether, which seems scarcely different from severe intoxication,
a state in which no surgeon would be desirous of having a  patient who was about
to be submitted to a serious operation.
   It was Suggested, with much appearance of  probability, that a far more important
benefit than even the prevention of pain would arise from the use of ether; that it
must lessen the shock  to the nervous system generally, and  that the after-treatment
would be greatly facilitated by the absence of constitutional  irritation   But expe-
rience has  not confirmed  these hopes.  A patient who recently underwent an im-
portant operation, which was performed with rapidity and skill while he was quite
unconscious, gradually sank, and died in three weeks, although little blood had  been
lost, and there  was no organic disease found after death  to account for the un-

                        (a) Medical Times, vol. xv. p. 273.
                                     65* 
77f>
POSTSCRIPT.
favourable termination of the case ; there were two fresh effusions-of blood beneath
the arachnoid membrane.  Another case, still more recent, .terminated fatally within
three days ;  the patient never rallied from the sedative effects of the ether, while, at
the same time, the  spasms  in the  stump of the amputated limb were  unusually
severe.
  In conclusion I may^observe, that there are no operations in whieh the use of ether
seems to be  so decidedly contra-indicated, as in those for the  cure of Cataract; for,
when.skilfully performed, they cause hardly any pain, so that stupefying the patient
is at least superfluous.  But voluntarily to  induce congestion in an organ, where
inflammation, once set up, is so difficult to control, and  where if unchecked, it pro-
duces such deplorable effects, appears to be the  height of imprudence.   Yet all this
risk has been run, and the npn-professional public have been astonished to hear how
quickly a Cataract may be got out: the  final results.of the operations, have not been
so eagerly proclaimed.—j. v. s.]
  [Warren,.I, Mason  On the Inhalation,of Ether.   Boston,1847. 8vo.
G. W. N.]
% 
ANALYTICAL INDEX-
Abdomen, Wounds of, i. 501 ; varieties of
  wounds of the abdomen, i. 501; super-
  ficial wounds, i. 501; bruises—symptoms,
  treatment, and consequences,  i. 501;
  treatment  of wounds  of the epigastric,
  internal mammary,  or  abdominal  ar-
  tery, i.  502;  Travers on the effects of
  injury of the  abdomen, i. 502; general
  treatment of wounds of the abdomen, i.
  502; penetrating wounds, i. 502; symp-
  toms, i.  502;  Hennen on the escape of
  the intestines from injury, in penetrating
  wounds of the  abdomen, i. 502; Green's
  case .of fatal penetrating, wound of  the
  abdomen,  i. 502; treatment of simple
  wounds of the  abdomen, i. 503; Travers
  on wounds of the abdomen, i. 503 ; use of
  sutures in wounds of the abdominal parie-
  tes,  i. 503; occasional symptoms caused
  by the  use of  sutures, i.  503; mode of
  applying the sutures, i. 503; Graefe on
  the application of sutures, and including
  the  peritoneum in the suture,  i. 504;
  treatment of penetrating wounds, i. 504 ;
  Hennen on the treatment  of penetrating
  wounds  of the  abdomen, i. 505;  protru-
  sion  of the omentum  or  intestines, i.
  505; return of the  protruded  part, i.
  505; enlargement  of the  wound some-
  times necessary to  effect the return, i.
  505; condition of the protruded intes-
  tine a guide to its  return, i. 506; if  the
  omentum  be  inflamed,  bruised,  and
  partly disorganized,  or gangrenous, it
  must not be returned, i.506; Dupuytren
  objects  to  the  return  of  the protruded
  omentum into  the abdomen, i.  507;
  Tfrounds of the Intestines, i.  507; symp-
  toms, i. 507;  Travers", Green, Tyrrell,
  and South's cases of wounded intestines,
  i. 507; Travers on wounds of the intestines
  communicating directly with the surface,
  i. 508;  varieties of wounds of the intes-
  tines,!. 508;. Travers on the varieties of
  wounds of the intestines, i. 508; difference
  of opinion as to the treatment of wounded'
  and protruded intestine, i.  509; different
  kinds of stitches employed, i. 509; Scarpa
  and  Larrey's practice, i. 509; Denans,
  Beclard, Jobert, Lembert, and Reybard's .
 practice in  wounded  intestine, i.  509,
 510;  Shipton's  and  Travers' experi-
 ment,  i.  511;  Else,  Benjamin  Bell,
 John  Bell, and  Hennen, on the use of
 the suture in wounded intestine, i. 511,
 512 ;  objections to the use of stitches in
 wounded  intestine,  i. 513;  reasons  in
 favour of  their use, i. 513; Travers on
 the objections to returning a wounded in-
 testine, without suture, into the abdomen,
 i. 514 ; Travers and Benjamin Bell, on
 the withdrawal of the suture, after union
 has taken  place, i. 514; Travers' direc-
 tions for stitching a wounded intestine,
 i.  514; approval  of Lembert's plan, L
 515; Astley Cooper's practice in small
 wounds of the intestines, i. 515 ; Dupuy* -
 tren's modification of Lembert's plan, i.
 515;  Travers  on the  reparation by arr
 tificial connexion of the divided parts of
 a wounded intestine, i. 516; treatment of
 a perfectly divided intestine, oneend only
 being found, i. 516 ^treatment of wounded
 intestine, i. 516 ; treatment of wounded
 intestine when the faeces-escape by the
 wound, i.  516; Travers and South on
 the treatment of wounded intestine with-
 out fascular discharge or prolapse, i. 517;
 Travers on  spontaneous - reparation in
 wounded intestine, i. 517;  contraction of
 the intestine sometimes the  result of a
 wound, i. 517; effusion of. faecal matter,
 blood,  or other  fluid constitutes  the
 most  dangerous  complication of pene-
 trating wounds of the abdomen, i. 517;
 Travers and Hennen  on  effusions, into
 the cavity of the abdomen under such
 circumstances,  i. 518; extravasation  of
 the intestinal contents, i. 518;  Travers
 on the impediments  to effusion of the
 intestinal contents, i. 518;  symptoms of
 effusion, i. 518; effusion of blood into the
 cavity of the abdomen, i.  519; the ef-
 fused blood is  either collected in a cir-
 cumscribed space, or  diffused over the
 abdomen, i. 519; treatment of extravasa-
 tion, i. 520;  Hennen's  case of musket-
 shot  wound  of the abdomen, the ball
 passing afterwards per anum, i. 520.
.bernethy,  on  severe  phlebitis,  i. 93; 
772                        ANALYTICAL INDEX.
on poultices, i. 101; on  opening a cold
abscess with  a  lancet puneturey orf a
trocar, i. 105; onincisions in carbuncle, i.
157;  on permanent chordee, from  the
extension  of  the inflammation  to  the
corpus spongiosum, i. 178 ; on gonorrhoea
virulenta, i. 183;  objection toany attempt
to check gonorrhoea, i. 191; recommends
a soothing practice, i.  191; on lumbar
abscess generally connected with carious
vertebrae,  i. 209; experiments to  cause
the absorption of the pus, i. 211; treat-
ment of lumbar abscess; i; 212; supported
by Astley Cooper and Lawrence, i. 213;
on the symptoms  of the  inflammation
which sometimes supervenes after the arb-
scess has been opened, i. 214; paronychia
ungualis, i. 215 ;  paronychia tendinosa, i.
216; paronychia osseosa, i. 217; on epiny-
chia, or ulceration, with great thickening
at the ends of the fingers, i. 217 ; on the
cure of epinychia, i. 221; case of wounded
meningeal artery, i; 333; on a costive state
of the system preceding tetanus^ i. 416;
on the treatment of simple fracture of the
skull  with depression, without  the tre-
phine, i. 432; on puncturing the dura
mater, to evacuate the effused blood i. 448;
only employs the  trepan in injuries of the
head, when secondary symptoms of irrita-
tion and pressure  require it, i. 454; on the
use of a broad-chest bandage in emphy-
sema,!. 497; mode of treatment of wound-
ed joints, i. 538; commended by South, i.
538; on the qtiestion  of immediate am-
putation in compound fractures, i. 568 ;
on  symptomatic   fever;  i.  571;   the
bracket splint, i. 574 ; denies  the possi-
bility  of simple dislocation of the spine,
i. 586; on the operation of trepanning the
spine, i. 593;  on  pseudo-syphilis, ii. 81;
on the means  of  distinguishing between
true and'false syphylis, ii. 8L; on the oc-
casional spontaneous healing of chancre,
ii. 85;  on  the effects-produced by  the
ligature on the arterial coats,f i. 293;  on
the application of two ligatures, and  the
division of the artery between them, ii.
407;  case of ligature  of the  internal
carotid, on  account of a wound, ii. 508 ;
case of ligature of the  external iliac  in
the groin, ii. 535  ; on the ligature of the
external iliac, ii. 538 ; on compression in
the treatment of  teleangiectasy* ii. 561;
on passing the bougie in stricture of the
urethra, iii. -71; on the use  of metallic
bougies, iii. 71; on hemorrhage from  the
urethra after passing the bougie, iii. 77;
on puncturing spina bifida iii.  189; on the
division of tumours, iii. 381 ;  on fungus
haematodes, iii. 460; on the treatment of
traumatic phlebitis, iii. 611; on the com-
  plete section of  the nervous  twig in
  cases, of wound  of a  nerve-branch  in
  bleeding, iii. 611; case, of division of a
  nerve wounded in blood-detting; iii. 635;
  case of  excision of part  of the digital
  nerve, iii. 636; mode of amputating at the
  hip-joint, by  the circular cut, iii. 689.
Abscesb, i. 47,' 48 ; formation of the walls
  of, and the circumscription of the pus, i.
  48 ; the walls are secreting and absorbing
  surfaces, i. 48; metastatic abscesses, i. 48;
  Travers  on  the  lining membrane of  an
  abscess, i. 49 ; Hunter and Trarvers on the
  circumstances which determine an abscess
  to the surface, i. 49; cold or lymph  ab-
  scess i. 57; abscess of congestion, i. 57;
  symptoms  of cold abscess, i.  57 ; Mr.
  South's case  of cold abscess, i. 61 ; Dr.
  Rigby  on puerperal abscess, following
  contagious or adynamic puerperal fever,
  i. 60; when  an  abscess is ripe, it either
  opens of-itself, or it must be opened, i. 102;
  small abscesses j ust beneath the skin, and
  those in glandular structures should alone
  be allowed toburst, i. 102; circumstances
  under which.the early opening of ab-
  scesses is required, i. 103"; circumstances
  under which abscesses are.opened Jate, i.
  103; South recommends the early opening
  of abscesses just beneath the skin, and in
  glandular structures, i. 103; opening of ab-
  scesses (oncotomia) effected by the knife,
  escharotics, and the seton, i. 103; deep ab-
  scesses with  thick coverings should  be
  opened with the bistoury, i. 103 ; South's
  condemnation of pressure and squeezing
  an abscess^ i. 104; mode in which  es-
  charotics are employed, i. 104;  passing
  a-seton through an abscess, i. 104; open-
  ing an  abscess  with a  cutting instru-
  ment generally preferable,!. 104; South
  on  opening an abscess, i.  105;  treat-
  ment of cold abscess, i. 105; various plans
  for opening a cold abscess recommended
  by Abernethy, Beinl, Walther, Schaack,
  Rust, Nasse, Zang, and Callisen, i. 105 ;
  in selecting his  plan of  operating, the
  surgeon must be guided by the difference
  of constitution, by the more or less weak
  state of the cellular walls, and by the size
  of the swelling, i. 105; constitutional treat-
  ment also required, i. 105; Kluge's plan
  of treating lymph abscesses, i. 106; fur-
  ther treatment after opening the abscess, i.
  107 ; if there be deficiency of power in the
  part, stimulants may be used, but moist
  warm poultices are more effectual, i. 107;
  tonics may be given internally, i. 107; if
  the opening close too soon, the edges may
  be drawn asunder, or separated with a
  probe, i.  107  ; proud flesh repressed with
  caustic, i. 107; formation of fistulouspas- 
ANALYTICAL INDEX.                       773
sages, i. 107; membrane of the fistula, first
pointed out by Hunter, since described by
Villerme, Laennec and Breschet, i.  108;
Hunter's description of it, i. 108 ;  treat-
ment of the fistulous passage, i. 108; plans
of treatment' recommended by Langen-
beck, H. Dewar, Cramer, Walther, and
others, i. 108; Langenbeck's recommen-
dation of the ligature, i. 109;  attention
to the general  health requisite during
suppuration, i. 109; abscess of the tonsil,
i. 159 ; opening an abscess of the tonsils
with a guarded bistoury or the pharyngo-
tome, i. 160; treatment after the pus has.
been evacuated, i. 160; in rare  cases the
abscess becomes external under the jaw,
i. 161; Allan Burns on the spontaneous
bursting  of the  abscess, i. 160; it is at-
tended with much danger, i. 161; details
of a case in which the trachea was deluged
with purulent matter, and death by suffo-
cation ensued, i. 161;  Burns'  advice  in
such cases to tap the abscess with trocar
and  canula, l 161;  in most cases of ton-
sillar abscess the action of emetics will
cause the rupture of the abscess; if not*
it must be  opened,  i.  161;  Burns' and"
South's directions for opening a tonsillar
abscess, i. 161; cases of fatal haemorrhage
consecutive to opening  a tonsillar abscess
mentioned by Portal, Allan Burns,Tyrrell,
and  Brodie, i. 162;  Lawrence's case  of
alarming haemorrhage from puncturing an
immature tonsillarabscess,i. 162vabsoess
of the parotid gland sometimes of con-
siderable magnitude, i.  168; Evanson and
Maunsell on the suppuration of mumps, i.
169; treatment of mumps after an abscess
has  formed, i. 169; abscess of the breast,
i. 170; opening the abscess only advis-
able, when it is very deep, has proceeded
slowly, the pain is g?eat, and  the  fever
high, i.  170;  South's recommendation
that abscess of the breast be opened freely
and  early, i. 171; advantages of the pro-.
ceeding, i. 172; deep-seated abscesses in
the  mammary gland, or between it and
the pectoral muscles, i. 173; to be opened
early, i. 173; fistulous passages  to be laid
open throughout their whole  length, i.
173; Astley Cooper on  chronic abscess of
the breast, i. 173"; South's case of chronic
abscess of the breast, operated on by mis-
take for scirrhus, i. 173; abscesses in the
labia or  nymphae,  i.  180;  Hunter and
Ricord on abscesses complicating gonor-
rhoea in the female, i. 180; suppuration
of the testicle to be feared, when the in-
flammation  is severe, and the pain throb-
bine, i. 201; suppuration of the testicle
rare3, when the  swelling is sympathetic,
i. 202; Astley  Cooper on suppuration of
the testicle, 202;  bursting of the abscess
sometimes followed by a fungous growth,
i. 202; treatment of suppuration and ab-
scess of the testicle, i.  203; South  on the
treatment of fungus of the testicle, conse-
cutive to  abscess, i. 203; seat  of  the in-
flammation in lumbar abscess, i. 207;
symptoms,i.207; formation of the abscess,
i. 207 ; general symptoms  of suppuration
not present if the  abscess be not large, i.
208; Astley Cooper on the symptoms of
psoas abscess, i. 208;  Pearson  on the
symptoms  preceding,  and  accompanying
the formation of the abscess, i. 208; causes,
i. 208; English  surgeons  generally con-
sider disease of the vertebrae  to  be the
cause, i. 208; Pott on  the diseased condi-
tion of the spine in this complaint,  i. 208;
Astley Cooper on the origin of psoas or
lumbar abscess in inflammation  of the
spine and intervertebral substance, i. 209;
Abernethy, Lawrence, and Dupuytren on
lumbar abscess, generally connected with
carious vertebrae, i. 209;  South  on the
origin of the  disease from external vio-
lence, its origin then being in the spine, i.
209; South on the distinctive characters
of psoas  abscess  from femoral hernia, i.
209; John Pearson on the situation of the
external abscess, i. 210; Samuel Cooper's
notice of  Ramsden's case  of lumbar ab-
scess, i. 210; South on the insidious pro-
gress of the disease, i.  210; abortive treat-
ment of lumbar abscess, i. 210; opening
the abscess, i. 211;  Dupuytren  on the
changes that sometimes take place in the
abscess, i. 211; Astley  Cooper  remarks,
that  the abscess must  be allowed  to take
its course, i. 211; this  opinion controvert-
ed by South, i. 211; Cline and Aberne-
thy's experiments to cause absorption of
the pus,  i. 211;  South on issues  in the
treatment of lumbar or psoas abscess, i.
211; difference of opinion as to the pro-
priety of waiting the self-evacuation of the
abscess, or of puncturing: and emptying it,
either entirely or  partially, i. 212 ; Deck-
ers, Benjamin Bell, and Crowther on tap-
ping the abscess with a  trocar, i. 212;
Latta recommends the use of  a seton in
addition, i. 212;  this  latter practice con-
demned  by South, who prefers opening
the abscess with  a lancet, i. 212; Aber-
nethy's plan oftreatment,  i. 212;  Astley
Cooper  and  Lawrence   support  Aber-
nethy's views, i. 213 ; Kirkland  advises
to let the abscess break of itself,  i. 213 ;
John Pearson  prefers making a small
aperture, and  treating the ulcer  in  a
gentle manner, i. 213; Dupuytren leaves
the abscess to nature, i. 213; South's plan
of treatment, i.  213;  treatment to  be 
774'                       ANALYTICAL  INDEXT.
  pursued after the abscess is opened, i.
  213; Pearson and Astley Cooper on the
  treatment of the sinuous cavities  result-
  ing from the abscess, by injections, i.
  214; Dupuytren recommends cauteriza-
  tion, or weak  injections  of nitrate  of
  silver,  or nitric acid, i. 214; treatment
  of the  abscess, if inflammation  super-
  vene after it has been  opened, i. 214;
  Abernethy on the symptoms of the super-
  vening inflammation, i. 214;  Pearson
  mentions that the larger arteries some-
  times ulcerate into the  abscess, i. 214;
  M'Dowell  mentions  a  case in  which
  ulceration took place in a portion of the
  ileum adhering to the cyst of the abscess,
  i. 214; whitlow and its varieties, i. 214;
  South's cases of abscesses external to the
  joint, i. 235; Astley Cooper and Coulson
  on the bursting  of abscesses of the hip-
  joint, i. 282; Mackenzie and Scott's cases
  of abscesses of the hip-joint, i. 282;  the
  abscesses  to be freely  opened, i. 298;
  Ford, Wend, van der  Haar, Rust, Brodie,
  and  Jaeger, on the  treatment  of  these
  abscesses, i. 298; Sabatier and Ficher
  advise  their being opened with caustic,
  i. 298; Larrey, with the red-hot  trocar,
  i. 298; Rust, with the actual cautery, i.
  298; Rust advisespassing-a seton through
  the joint, i.  298;  Brodie and Jaeger re-
  commend free incisions in opening these
  abscesses, i. 299; Brodie  and South on
  the  management of  abscesses at  the
  hip, i.  299; subsequent treatment, i.
  299; connexion of Pott's disease with
  lumbar and psoas  abscess, i. 308; Brodie
  on the disappearance of psoas abscess, and
  its appearance elsewhere, i. 309; Brodie
  on abscess connected with vertebral caries
  in the neck, i. 315; treatment of abscess
  resulting from, a  bruise, i. 369; abscess
  of the brain, i. 439 ;—see wounds of the
  Head; abscesses  of the  liver consequent
  on injuries of the head, i. 469; Morere
  and Duparcque on abscess of the womb,
  i» 532; abscesses about the anus, ii.  162;
  treatment of abscesses in the  neighbour-
  hood of the rectum,  ii.  164; Brodie on
  the treatment of large abscesses high up
  by the side of the rectum, ii. 165:; Key
  on abscess in the hernial sac  after the
  operation for strangulated hernia, ii. 302,
  309; abscesses by the  side of the rec-
  tum, from the irritation of foreign bodies,
  iii. 108; abscess of the prostate, iii. 136;
  abscesses aboijt the neck of the bladder,
  after the operation of lithotomy, iii. 343.
Acarus-scabiei, ii. 66.
Acephalocysts, iii. 441.
Achillis' Tendon, Division  of, i. 539;
  tearing of the tendon, i»539>;  causes and
  symptoms, i. 539; laceration of the sheath
  of the tendon, i. 539; John Hunter  on
  rupture of the  tendo Achillis, i. 540;
  mode of union of the ruptured tendon, i.
  540;  treatment, i. 540; John Hunter on
  the treatment  of the ruptured tendon, i.
  540;  various  bandages for the cure of
  the rupture, i. 541;  the bandages pro-
  posed  by  Gooch,  Petit,  Schneider, De-
  sault; and Wardenburg, i. 541;  Edmon-
  ston's  plan of  treatment,  i.  542;  the
  slippers of Petit,  Ravaton, Monro, and
  Graefe, i.  542; objections to bandaging,
  i. 542 ; after-treatment, i. 542.
Acromion, Fracture of, i. 600.
Adams,  Dr., on the acarus scabiei, ii. 67.
Adams',  Mr., case  of longitudinal  dis-
  location of the  radius, ii.  232; case of
  hydrocephalocele treated by puncture, ii.
  368.
Adams,  Mr. William, post mortem appear-
  ances in a case of hip-disease, i. 290.
Addison's, Mr.,  artificial leg, iii. 593.
Aetius  on aneurism, ii. 468.
Akolcthus' case of extirpation of the up-
  per jaw, the first on record, iii.  754.
Alanson's, Mr.,  mode of amputation by the
  circular incision, iii. 640; on amputation
  just above the ankle, iii. 674; mode of
  amputating at  the shoulder-joint with the
  circular cut, iii.  715.
Alban's, M.-, apparatus for fracture of the
  neck of the femur, i. 623.
Alcock, Mr., on  the removal of the edges of
  the cleft  in staphyloraphy, ii. 32];  mode
  of operating in staphyloraphy, ii. 32.
Alcock, Mr. Rutherford, on the differ-
  ence of the shock  to the-constitution in
  severe injuries of  the extremities, when
  occurring in civil life and on the field of
  battle, iii. 725.
Alibert's,  M., division of boils  into four
  kinds, i. 151; dispute with Lugol respect-
  ing the acarus  scabiei,  ii. 67; on  the
  varieties  of cancer, iii. 502.
Alison, Dr., on the symptoms of inflam-
  mation, i. 35.
Allan,  Mt., on  the.effects of the scorpion
  sting, i. 387; on compression in the treat-
  ment of aneurism, ii. 487;  on the seat of
  stricture  in the rectum,  iii. 46; case of
  retention of the urine in the ureter, iii. 127.
Alliot, M., on urethroplasty, ii. 179.  .
Alouette's, M. L\, mode of amputating
  at the hip-joint, by the flap cut with a
  single flap, iii. 691.
Amesbury's, Mr., fracture-apparatus, i. 562;
  apparatus  for  fractured clavicle, i. 603;
  apparatus for fracture of the olecranon, i.
  603;  fracture-bed, i, 625*; on  the  for-
  mation of a  false joint, with  a. fibro-
  ligamentous oapsule, and a lining mem- 
A-NALYTICAL  INDEX.
■77'5
• brane, ii. 14; on the causes of the non-
  union of fractional bones, ii. 14.
Ammon, M. von, on the causes of congeni-
  tal dislocation, ii. 208.
Amputation; the  circumstances in  gun-
  shot wounds requiring amputation on the
  spot, i.  378; Hennen  on the nature of
  the  injuries  in gun-shot wounds  re-
  quiring  amputation, i.  379 ; amputation
  under  the  -circumstances   mentioned
  should be performed early, i. 380; Wise-
  man, Le Dran, and Ranby on  immediate
  amputation, i. 380; Faure on the pro-
  priety of delaying the operation,  i. 381;
  Bilguer's objections to amputation alto-
  gether, i. 381; Hunter's objections to pri-
  mary amputation, i. -381; Hennen, Pit-
  cairn, Gunning,  and  -Guthrie   on im-
  mediate amputation, i.  381 ; Guthrie's
  reasons for an early performance of  the
  operation, i. 382; symptoms which may
  require  the performance of amputation
  at a time more or  less posterior to  the
  date  of  the injury, i. 383;  conditions
  under which amputation  may be neces-
  sary  in fractures, i.  567; Astley Cooper
  and Abernethy on  the question  of im-
  mediate  amputation, i. 568; Sonth on
   the principal points to be considered in
   determining on the  necessity for imme-
   diate  amputation,  i.  -568;  amputation
   must not be performed during the con-
   tinuance of symptomatic fever,  i.  572;
   Hunter  on the removal  of  the  injured
   limb during  the continuance of hectic,
   i.  572;  South on the  objects and occa-
   sional results of immediate amputation,
   i. 573 ;  cases in which amputation is in-
   dicated  in necrosis,  ii.  131; the question
   as to  the necessity of  amputation  in
   dislocations accompanied  with  tearing
   of the soft parts covering the joint, and
   thrusting out  of the head of the  bone,
   ii. 207; in  compound dislocations of the
   knee, ii. 248 ; of the ankle-joint, ii. 251;
   of the toes, ii. 256; amputation requisite
   when mortification ensues after the liga-
   ture  of  the principal  artery,  ii.  500; is
   rarely successful, ii. 500; the question of
   amputation in aneurism of bones, ii. 559;
   amputation requisite in exostosis, when its
   size does not permit its removal, iii. 412;
   inosteosteatoma,andin osteosarcoma, am-
   putation should, if possible, be performed
   above the next joint, iii. 414;  amputation
   requisite in some cases of spina ventosa,
   iii. 54;  amputation of  the  breast, iii.
   542; of the penis, iii.  544; amputations
   of the limbs, iii. 638; amputations divided
   into  those  which are  performed in  the
   continuity  of limbs and  those at joints,
   iii. 638; points to be considered in per-
forming amputations, iii. 638; precautions
against haemorrhage, iii. 638;  inconve-
niences of the application of the tour-
niquet, iii. 638; compression of the prin-
cipal artery by a capable assistant prefer-
able, iii. 638; Briinninghausen's  recom-
mendation to swathe the limb in flannel,
to diminish the loss of blood, iii. 638;
South  on  the  relative value  of  the
tourniquet, "and  of compression  of the
principal artery by  a capable  assistant
in amputation, iuV638; formation of such
wound that the bone can be properly
covered by soft parts, iii. 639; by the cir-
cular incision, iii. 639;  the Celsian ope-
ration, iii. 639 ; objections to this opera-
tion, ih. 639 ; Petit, Mynors, Briinning-
hausen, Louis,  Alanson, Gooch, Bell,
Desault, Richter, Boyer, Graefe, Dupuy-
tren,  Wilhelm, Valentin, and Portal's
modes of operating, iii. 640; flap amputa-
tions, iii. 641; Pott, Siebold, and Schrein-
er's operations, iii. 641; Langenbeck and
ScOutetten's  operations for disarticula-
tions, iii. 642 ; the oblique cut of Sedillot
and Baudens, iii. 642 ; the sloping cut of
Blasius, iii. 642; retraction of the divided
museles and sawing of the bone, iii. 642;
scraping off the periosteum superfluous,
iii. 642; Walther and Briinninghausen's
management of the periosteum, iii. 642;
South  on the retraction of the divided
muscles by the hand, iii. 642; South  and
Liston on  the use  of the  saw, iii. '643;
South  on  the~duties of the assistant,
when the  bone  is  being sawn through,
iii. 643 ; ligature of the divided vessels,
iii. 643; historical sketch of the treat-
ment of haemorrhage after amputation,
iii. 644; South  on venous haemorrhage,
and the ligature of  the veins after amputa-
tion, iii. 644; subsequentdressing of the
wound, iii. 644; leaving the wound  open
for some  hours after the operation, to
guard  against after-bleeding, iii. 644;
Dupuytren's practice, iii. 644;  South on
the exposure of the stump, iii. 645; mode
of dressing to promote quick union, iii.
645 ; South on the bringing the edges of
the  wound together in  the  horizontal
direction, iii. 645; South on the applica-
tion of the plaster straps after amputation,
iii. 646; use of cradles after amputation,
iii 646; South on the use of cradles, and
of a substitute for them, after amputation,
iii. 646; dressing after flap-amputations,
iii. 647; South on  the use of sutures after
flap-amputations, iii. 647 ; dressing of the
stump, when intended to  heal by sup-
puration and granulation, iii. 647; South's
objections to the practice, iii. 648;  acci-
dents which may ensue after amputation, 
776
ANALYTICAL  INDEX.
 iii. 648; renewal of the dressing under
 ordinary circumstances, iii. 648 ; mode
 of changing the dressings, iii, 648; with-
 drawal of the ligature, iii. 648 ;  general
 treatment after amputation, iii.  648;  Be-
 nedict's stimulant treatment of stumps,
 iii. 648; South on the treatment of liga-
 tures after amputation,  iii. 648; after-
 bleeding, and its  treatment,  LK.  648;
 ligature  of the  principal. arterial trunk
 for consecutive   haemorrhage,  iii. 648;
 causes and treatment of parenchymatous
 bleeding, iii. 648 ; treatment of consecu-
 tive haemorrhage,  from ossification or
 cartilaginous thickening of the arteries,
 iii. 649; South on the treatment of after-
 bleeding, iii. 649; South  on the  impro-
 priety  of tying the  main  arterial trunk
 for consecutive haemorrhage after ampu-
 tation, iii. 649; South on  the use of the
 actual cautery in  after^bleeding, iii. 649;
 violent inflammation of the stump, and its
 treatment, iii. 649 ; erythefic-Condition of
 the stump, iii. 649 ;  inflammation of the
 arteries or veins, a not infrequent cause of
 death after amputation, iii. 650; symptoms
 and treatment, iii.  650; insufficient degree
 of inflammation, or torpid condition of the
 stump, iii. 650;  treatment of sloughing,
 iii. 650 ; of too copious  suppuration, iii-.
 650; causes and treatment  of protrusion
 of the bone, iii. 650 ; South on the causes
 and treatment of  protrusion of the-bone,
 iii. 651;  necrosis of the bone, iii. 651 ;
 South on the exfoliation of bone after am-
 putation, iii. 651; ulceration of the bone
 or soft parts, iii.  651; South on the fun-
,>gous growth  from the medullary cavity,
 iii.  651; the relative value of the several
 modes of proceeding  in amputation of the
 limbs in their continuity, iii. 652; objec-
 tions to the'flap-operation, iii. 652; cases
 in which the flap-operation is suitable, iii.
 653; Liston's preference of the- flap-ope-
 ration, and objections to the circular ope-
 ration, iii. 653 ; South and Fergusson on
 the relative value  of the flap arid circular
 operation, iii. 653; Fergusson on  ampu-
 tation through the calf of the leg and at
 the shoulder-joint, iii. 653 ;  South's  ob-
 jections to flap-operations on the leg, iii.
 654;  the propriety  of quick  union  of
 stumps, or of the cure by suppuration and
 granulation, iii. 654 ; Dupuytren's mode
 of dressing stumps, iii. 654; South on the
 union of an amputation-wound, iii. 655;
 results of amputation, iii. 655;  Phillips,
 Lawrie, Potter, and South on the results
 of amputation, iii. 656.  Amputation in
 the continuity of the  several limbs .•—am-
 putation through the thigh, iii. 656; pre-
 paratory steps of the operation, iii. 657;
 compression of the artery, iii. 657 ; South
 on the position  of the  limb,  iii.  657 ;
 South on the position and duties of the
 assistants, iii. 657; the circular operation,
 iii.  657; division and retraction of the
 skin and cellular tissue, iii. 657;  South
 on the  circular 'Cut and vertical division
 of the skin laterally, iii.  658 ; section of
 the muscles, iii.  658; of the periosteum,
 iii. 658; sawing the bone, iii. 658; cutting
 through the muscles on the outside of the
 thigh, iii. 658;  South on the mode of
 using the knife in amputating, iii. 658;
 South on the retraction of the soft parts
 with the hand, while sawing through the
 bone, iii. 658; bandaging and dressing the
 wound, iii. 658;  South on bandaging and
 dressing the wound, iii. 659; amputation
 through the thigh, with twoflaps, iii. 659;
 mode of operating, iii. 659; Langenbeck's
 mode of amputating, iii.  659 ;  Liston's
 mode of amputating the thigh, by the flap-
 operation, iii. 660; preferred by Syme and
 Fergusson,iii.668; Fergusson and South's
 reasons  why the hind  flap  should  be
 longer than the front, iii. 660; amputation
 through the thigh, with a  single flap, iii.
 660 ; Benedict, Textor, and Jaeger's plan
 of amputating, with.a flap from the outer
 side, iii. 660; Zan and Textor's plan, with
 a flap from the inner side, iii. 660; Hey's
 mode, with the flap from behind, iii. 660;
 B. Bell, Le  Gras, and Foulliay's plan,
 with  a flap from before, iii.  660; mode of
 operating,  iii. 660; Dr. Little's  case of
 amputation, with a flap from behind, iii.
 660; Fergusson's recommendation to ex-
 cise a considerable portion of the sciatic
 nerve, in that operation, iii.  660; Syme's
 objections to amputation through the shaft
 of the thigh-bone,  and recommendation
 to amputate through the condyles or tro-
chanters,  iii.  660;  commented  on by
 South,  iii.  661 ;  Liston's account  of
eighteen amputations through the thigh,
iii. 661;  report of twenty-eight  amputa-
tions  through  the thigh,  iii. 662; Syme
and South on  the  formation of conical
stumps,  iii.  667; Syme  on amputation
through the epiphyses, iii. 668; amputa-
tion through the leg, iii. 668; directions
for the operation, iii. 669; application of
the tourniquet, iii.  669; South on the
application of  the  tourniquet, iii. 669;
modes of operating in amputation with
the circular  cut, iii. 669; amputation
 through the leg in its lower third, iii. 670;
Salemi, Lenoir, and Baudens' modes of
operating, iii. 670;  disjointing the head
of the fibula, iii. 670; Larrey's amputation
through  the head of the  tibia, iii. 670;
South on the seat of amputation through 
ANALYTICAL  INDEX.
777
 the leg, iii. 670; ligature of the vessels,
 iii. 671; after-dressing, iii, 671; South
 on the  ligature of the retracted anterior
 tibial   artery,  in  amputation  high up
 through the leg, iii. 671; South  on the
 treatment of haemorrhage from the nutri-
 tious artery of the tibia, iii. 671; South on
 the bringing the edges of the wound to-
 gether  horizontally,  iii. 671; South on
 the causes of subsequent sloughing of the
 integuments, iii. 672; amputation through
 the leg with a single flap, iii. 672; mode
 of operating, iii. 672; South's objections
 to flap operations on the leg, iii. 672; am-
 putation through the  leg with  two flaps,
 iii. 672; mode of operating, iii. 673;  Lis-
 ton and Fergusson's mode  of operating,
 iii. 673; amputation just above the ankle,
 iii. 674; Solengen, Dionis, White, Brom-
 field, Wright, Alanson, and Hey on this
 operation, iii. 674; Lawrenceand South's
 cases, iii. 675; Liston's statistics of ampu-
 tation through the leg, iii. 675;  Lawrie's
 objection to amputation below the knee,
 iii. 675$ South's tabular report of ampu-
 tations  through the leg, iii. 676;  ampu-
 tation through the upper arm, iii. 679;
 steps preliminary to the operation, iii. 679;
 Liston's statistics of the  operation, iii.
 679;  South on the  propriety of having a
 long stump  if possible, iii.  679; South's
 tabular  report of  amputations through
 the upper  arm,  iii. 680; amputation
 through the fore-arm, iii. 681; directions
 for the  operation, iii. 681; amputation
 with a single flap, iii. 681; with twoflaps,
 iii. 681; South on flap amputations through
 the fore-arm, iii.  682; South's tabular
 report of amputations through  the fore-
 arm, iii. 682; Liston's cases, iii. 682; am-
 putation through the metatarsal and me-
 tacarpal bones, iii. 682; application of the
 tourniquet,  iii. 683; amputation through
 the metatarsal bone of the great toe, iii.
 683, mode of  operating when the flap is
 formed  from the sole, iii. 683; when the
 flap is made from  the  inner side of  the
 metatarsal bone, iii. 683 ; the bone  best
 sawn through obliquely from within  out-
 wards, iii. 684; mode of operating when
 the flap  is made  from the dorsal surface
 of the metatarsal bone, iii. 684; South on
 the consequences of amputation through
 the metatarsal bone of the  great toe, iii.
 684;  amputation through  the  interme-
 diate metatarsal bones, iii. 685; mode of
 operating, iii.  685; amputation through
the metacarpal bones, iii. 6S5;  amputa-
tion through the metacarpal  bone  of the
thumb,  iii.  686; South and Liston on
amputation through the metacarpal bones,
iii. 686; amputation  through the fingers
   Vol. iii.—66
 and toes, iii. 686; amputation through
 the phalanges of the fingers, iii.  686;
 mode of operating, iii. 686;  cutting off
 the finger with a chisel, iii. 686 ; Mayor
 on the amputation of the phalanges with
 the tachytome, iii. 686; exarticulation or
 amputation through the  joints, iii. 686;
 cases in which exarticulation is required,
 iii. 687; Scoutetten's mode of operating,
 iii, 687; general directions, iii. 687; con-
 dition of the  parts around the joint, iii.
 687 ;  exarticulation of the thigh  at  the
 hip, iii.  688; danger and statistics of  the
 operation,  iii.  688;  Jaeger, Krimer,
 and South  on the  operation, iii.  688;
 cases requiring  the operation, iii. 688;
 La  Croix d'Orleans,  Perrault, and  H.
 Thomson's cases, iii.  689; the modes of
 operating, iii. 689; by the circular cut, iii.
 689;  Abernethy, Veitch,  Cole, Jaeger,
 Kerr, and Graefe's modes of operating,
 iii. 689;  by the flap-cut with a single flap,
 iii.  691  ; Puthod,  Hunczorsky,  Bryce,
 L'Alouette, Langenbeck,  Delpech, Le-
 noir,  Plantade, and Manec's mode  of
 operating, iii. 691; with two flaps, iii. 691;
 Blandin, Larrey, Mott, Dupuytren, Lis-
 franc, von Walther,  Vohler, Bell, Be-
 clard, Liston, Begin,and Sanson's modes
 of  operating,  iii. 692; the oval cut,  iii.
 696; Sanson, Guthrie,  Scoutetten, and
 Corneau's modes of operating, iii. 698;
 the preference given to Larrey's  opera-
 tion, iii. 698; after dressing, iii. 698; exar-
 ticulation of the leg  at the knee, iii. 699 ;
 opinions respecting the propriety of  the
 operation, iii. 699; Jaeger's statistics of
 the operation, iii. 699; modes of operating,
 iii. 699; amputation with the flap-cut, iii.
 699;  Blandin,  Rossi, Maingault,  and
 Kern's operations, iii. 699; the circular
 cut, iii. 700; Velpeau, Cornuau, and Bau-
 dens'  operations, iii. 700; the operation
 when  the knee-cap is diseased, iii. 700;
 exarticulation of the ankle-joint an infe-
 rior operation to amputation through  the
 leg, iii. 700; exarticulation of the foot at
 the ankle,  iii. 700; Velpea-u, Baudens,
 Syme, and  Handyside's modes of opera-
 ting, Hi. 702;  Syme on the advantages of
 this operation, iii. 702; exarticulation of
 the tarsal bones, iii. 703; the operation re-
 stricted to the removal of the astragalus
 and navicular bones, iii. 703; Hammond's
 case of exarticulation of the astragal us, iii.
703; Green's case,  iii. 703;  general di-
 rections  for the operation, iii. 703; am-
putation  of the foot between the astragalus
 and navicular bones, and  the heel and
<cuboidboms, iii. 703; Chopart's operation,
 iii. 703; cases requiring the operation, iii.
 704; mod*  of operating, iii. 704 ;  when 
778
ANALYTICAL INDEX.
an  under flap only is formed,  iii. 704;
when an under and upper flap are formed,
iii. 704; Maingault's operation,  iii. 705;
Langenbeck, Klein, and  Richerand's ob-
jections to the upper flap, iii. 705; Wal-
ther's operation preferred, iii. 705; Scou-
tetten's oval cut, iii. 705;  Blasius' oblique
cut, iii. 705; exarticulation of the metatar-
sal bones, iii. 706; advantages and dis-
advantages of the operation, iii. 706; Hey,
Scoutetten, Lisfranc, and  Miinzenthaler's
modes of operating, iii-. 706,707; exariicu-
lilion of single metatarsal bones,  iii. 708;
preservation of the great toe Important, iii.
708; mode of operating,  iii. 708; exarti-
culation of the metatarsal  bone of the great
toe, iii. 709; mode of operating, iii. 709;
Langenbeck and Scoutetten's operations,
iii.  709; exarticulation of the  metatarsal
bone of the little toe, iii. 709; of the middle
metatarsal bones, iii. 710; consentaneous
removal of the diseased tarsal bones, iii.
710;  Key, Dieffenbach, and  Ruyer's
cases, iii. 710 ; exarticulation of  the toes,
iii.  710; mode of operating with an under
flap, iii. 710; with a flap on the dorsal
surface, iii. 710;  with an outer  or inner
flap, iii. 710; exarticulation of the second
from the first phalanx, iii. 710; of all the
toes at once, iii. 711; Scoutetten's opera-
tion, iii. 711; exarticulation of the arm at
the  shoulder, iii. 711; various modes  of
operating, iii. 712;  compression of the
subclavian artery by an assistant  safer
than with an instrument, iii. 712; Wal-
ther's operation by an upper and an under
flap, iii.  712; dressing the wound, iii,
712 ;  Le  Dran,  Garengeot, Dupuytren,
Onsenoort, Lisfranc,  and Champesme's
modes of operating; iii. 712,713; the ope-
ration on the left arm, iii. 713; Astley
Cooper's amputation at the shoulder-joint
with a single flap, iii. 713 ;  Hesselbach,
Desault, Larrey,  Langenbeck, and Du-
puytren's modes  of operating, iii. 714 ;
exarticulation with the circular cut, iii.
715; Morand, Sharp,  Nannoni, Bertrandi,
Alanson,  Graefe,  Cornuau,  Sanson, and
B. Bell's operations, iii. 71S; Scoutetten's
operation  with the oval cut, iii. 715; Du-
puytren, Beclard, Bonfils, and  Blasius'
operations, iii. 716; circumstances which
guide  the choice of either of  these
methods,  iii. 716;  removal of the injured
acromion  or glenoid cavity, iii. 717, prac-
tised  by Brown, iii. 717; recommended
by  Robinson and  Fraser, iii. 717; Lis-
franc's modification of the operation when
performed prior to the age of fifteen, iii.
717; gun-shot wounds of the head of the
humerus, iii.7I7; excision of the head  of
thebone,  orremoval of the broken pieces
 requisite, iii. 717; Lanrey's operation for
 the excision of the head of the humerus
 in such cases,  iii. 717; Guthrie  on gun-
 shot wounds causing fracture of the hu-
 merus beneath and exterior to the cap-
 sular ligament, iii. 718;  Sonth on the
 excision of the acromion, glenoid cavity,
 or coracoid process in amputation  at the
 shoulder-joint, iii.  718;  Liston, South,
 and Astley Cooper's cases, iii. 718; exar-
 ticulation of the fore-arm at the elbow, iii.
 718;  mode of operating according  to
 Textor, iii. 719; Brasdor, Jaeger, Hager,
 Rodger, Dupuytren, Velpeau, Cornuau,
 Textor, and Baudens' modes of operating,
 iii. 719 ; exarticulation of the hand  at the
 wrist, iii. 720  ; modes of operating, iii.
 720;  Lisfranc's mode, iii.  720; South on
 the precautions to  be taken in the  flap-
 amputations at the wrist, iii. 720; exarti-
 culation of  the metacarpal  bones  at their
junction with the carpus, iii.721; mode of
 operating in exarticulating the metacar-
 pal bone of the thumb, iii. 721; formation
 of the upper or under flap,  iii.  721; exar-
 ticulation of the metacarpal bones of the
 ring and middle fingers, iii. 721; Langen-
 beck and Scoutetten's mode of operating,
 iii. 721 ; Scoutetten's oval cut in exarti-
 culation of  the middle metacarpal  bone,
 iii. 721 ; mode of operating, iii. 721; in
 the exarticulation of both  middle meta-
 carpal bones, iii. 722; von Walther and
 Astley Cooper's modes of operating, iii.
 722;  Riadore, Guthri, von Graefe, von
 Walther, Jaeger, Astley Cooper, Larrey,
 Tyrrell, and Bennaben's cases of excision
 of part of the hand, iii. 722; mode of ope-
 rating in exarticulation of  the four meta-
 carpal bones, iii. 722; Troccon's mode of
 operating, iii. 722 ; when one metacarpal
 or metatarsal bone is diseased  alone, it
 should be alone removed, iii. 723;  exci-
 sion of the first metacarpal bone, iii. 723;
 of the  metacarpal bones,  iii.  723; of
 the first metatarsal bone, iii. 723; of the
 other metatarsal bones, iii. 723; exarticu-
 lation of the fingers, at their junction with
 the metacarpal bones, and  at  their own
 joints, iii. 723; Dupuytren and Lisfranc
 on exarticulation of the middle and ring
 fingers, iii. 723 ; Barthelemy on the sec-
 tion -of the palmar aponeurosis after exar-
 ticulation of the fingers from the  meta-
 carpal bones, iii. 723; mode of operating
 in exarticulation of the joints of the fin-
 gers from each other, iii. 723; with two
 Haps, iii.  724; Lisfranc's  flap operation,
 iii. 724; statistics of amputations, iii. 724;
 Immediate Amputation,  iii.  724; im-
 portance of the question, iii. 724; South
 on the comparative danger of primary 
ANALYTICAL  INDEX.                        779
  and secondary amputation in severe in-
  juries of the thigh, iii. 724; South's con-
  clusion in favour of primary amputation,
  in. 724; South  on the minor danger in
  injuries of the leg or upper extremities,
  and the consequent propriety  of immedi-
  ate amputation, iii. 724; John Hunter's
  preference  of secondary  amputation, iii.
  725; John Hunter's objections to primary
  amputation in severe injuries of the  ex-
  tremities, iii. 725; Astley Cooper's opin-
  ion in favour of immediate amputation in
  such cases, the constitution then having
  but one shock to sustain, iii. 725; Ruther-
  ford Alcock on the difference of the shock
  to the constitution in  such cases, when
  occurring in  civil life, and on the field
  of battle, iii.  725.
Amussat's M., case of  forcibly breaking
  through the anchylosis,  i. 275; on  the
  torsion of arteries, i. 341 ; on the mode
  of operating torsion, i.  342; on the divi-
  sion and thrusting back of  the arterial
  coats, ii. 502; operation  for imperforate
  anus, ii. 542; mode of operating for  the
  formation of an artificial anus at the lower
  end of the colon, iii. 38;  on the treat-
  ment  of complete retention of urine  in
  stricture, iii. 144 ; on the introduction of
  the straight catheter, iii. 149; on   the
  treatment to be adopted  when air enters
  a vein during an operation, iii. 603.
Anchylosis,  i.  208;  in  anchylosis   the
  opposed ends  of  the  bones  are  united
  either by a ligamento-fibrous structure or
  by bone, i. 268; South has seen the con-
  necting medium composed partly of liga-
  mento-fibrous and partly  of bony matter,
  i. 268;  John  Hunter  on anchylosis, i.
  268 ;  anchylosis  effected by the  whole
  substance of  the  articulation,  i. 268;  of
  two kinds, i. 269 ; Hunter on  the inflam-
  matory and scrofulous diseases of joints
  causing anchylosis, i.  269;  Hunter on
  soft anchylosis from granulations, i. 269;
  Hunter  on  bony anchylosis, i.  269;
  South's views on  anchylosis differ some-
  what  from those of  Hunter, i.  269;
  South on soft anchylosis from granula-
  tions,  i. 269;  Key on the formation of a
  vascular membrane in joints  as  a  pre-
  liminary to anchylosis, i. 270; SouuVs
  cases of fibrous anchylosis, i. 270; South's
  case of the complication of  bony  and
  fibrous anchylosis, i. 271; Hunter's case
  of soft anchylosis from the extension of
  inflammation from the surrounding parts
  to the joint, i. 272; Mayo's case of injury
  to the ankle, followed by the  absorption
  of the cartilages, and effusion and organi-
  zation of lymph between  the ends of the
  bones, i. 273; process of bony anchylosis,
   i. 274; the most important form of bony
   anchylosis, i. 274 ;  Cruveilhier's case of
   bony anchylosis of the right condyle of the
   lower jaw, i. 274; other kinds of anchylo-
   sis, i. 274 ; treatment of the soft or liga-
   mento-fibrous anchylosis, i. 274; Velpeau
   on the treatment of complete anchylosis,
   i. 274 ; Barton's operation of cutting out a
   wedge-shaped piece of bone, i. 275; also
   performed  by  Gibson, i. 275; operation
   for the establishment  of a false joint, i.
   275;  Velpeau favourable  to this pro-
   ceeding, i. 275 ; performed by Barton and
   Rodgers with success, i. 275; the opera-
   tion of breaking through the anchylosis,
   i. 275;  condemned by Velpeau, i. 275;
   Amussat's case, i. 275; Velpeau on the
   consequences of the adhesion of the knee-
   pan to the condyles of the femur, i. 276 ;
   Louvrier's apparatus  for the rupture of
   the anchylosis, i. 276; Velpeau's objec-
   tions to the use of that apparatus, i. 276.
Anchylosis, causes and  treatment, iii. 18.
Ankle-joint, dislocation  of, ii. 249;  exarti-
   culation of the foot  at, iii. 700; excision
   of, iii. 742.
Anderson, Dr., on the use of raw cotton in
   1>he treatment of burns, i. 13-1; employed
   by him in cases of old and recent burns,
   vesicated  and  sphacelated, i. 131; pre-
   paration of the cotton, i. 132.
Anderson's,  Mr., operation for tying  the
   common iliac, ii. 533 ; operation for tying
   the external iliac, ii. 534; on the ligature
   of the external  iliac, ii. 538.
Andkal's, M., objections to the term in-
   flammation' and substitution  of the term
   hyperaemia, i. 33.
Andrews' Mr., case of penetrating wound of
   the chest with injury to the lung, i. 485.
Anel's M., operation  for aneurism, ii. 487.
Aneurisms :—definition  and varieties, ii.
   468;  Galen, Aetius, and Paul of iEgina
   on aneurism, ii. 468 ;  John Hunter's de-
   finition of aneurism, ii. 469; distinction
   between true and false aneurism, ii. 469 ;
   Breschet on the four  principal kinds  of
   true aneurism,  ii.  469;  symptoms  of
  aneurism, ii. 469; John  Hunter on  the
   coagulation of  blood in an aneurism, ii.
   470 ;  John Hunter  and Hodgson  on the
   bursting of aneurisms, ii. 470 ;  bursting
   of aneurisms into mucous canals, ii. 471;
   Dr. Wells' case of an  aneurism bursting
  into another artery, ii. 471; distinguishing
  characters of circumscribed true and false
  aneurism, ii. 472; Lawrence  on the bruit
  de soufflet, ii. 472; South on the distin-
  guishing characters of circumscribed true
  and false aneurism, ii. 472; diagnosis of
  aneurisms from other swellings, ii. 472;
  Dupuytren, Ferrand, Astley (fooper,and. 
780
ANALYTICAL INDEX.
 South's cases of aneurism mistaken for
 abscess, ii. 474; Warner's case of abscess
 mistaken for aneurism, ii. 474; causes of
 aneurism,  ii. 474;  Richerand  on  the
 occurrence of aneurism in the dissecting-
 room servants, ii. 474; Guthrie  on the
 predisposing cause of aneurism, ii. 473;
 Astley Cooper on the age at which aneu-
 rism occurs, ii. 475; John Hunter, Astley
 Cooper, Hodgson, Guthrie, Lisfranc, and
 South on the relative frequency of aneu-
 rism in the sexes, ii. 475 ; relative fre-
 quency of  aneurism in  the arteries, ii.
 476 ; Hunter, Hodgson, and Lisfranc on
 the relative frequency of aneurism in the
 arteries, ii. 476; more than  one aneurism
 may  exist  at the same time, ii. 476;
 Cline and Astley Cooper's cases, ii. 476;
 Astley  Cooper, Tyrrell,  Pelletan, and
 Cloquet's cases of the existence of nume-
 rous aneurisms  in the same person, ii.
 477 ;  condition of the arterial'coats in an
 aneurism, ii. 477 ; John Hunter admits  a
 diseased condition of the artery  as the
 cause of aneurism, ii. 477; Scarpa's views
 respecting  the non-expansion  of all the
 arterial coats in aneurism not always cor-
 rect, ii. 477; spontaneous cure of aneu-
 rism, ii* 478 ; circumstances which favour
 spontaneous  cure, ii. 478;  John Hunter
 and  South on .the spontaneous  cure of
 aneurism, ii. 479; mode of cure of aneu-
 rism, ii. 479;  enlargement of the col-
 lateral circulation, ii. 479 ;  remedies for
 the treatment of aneurism, ii. 479 ; treat-
ment of internal aneurism op Valsalva's
 plan, ii.  479; application  of astringent
remedies to restore the  elasticity of the
arterial coats, ii. 480; Guerin, Richerand,
 and  Hodgson  on  the  application  of
 pounded ice  to aneurism, ii. 480 ; com-
 pression, ii. 480; of the swelling alone
 objectionable, ii. 480; of the artery above
 the swelling, ii. 481; of the whole limb,
ii. 481; Guattani's plan of treating aneu-
rism  by  compression,  ii.  481;  John
 Hunter, Sir W. Blizard, Freer, Hodgson,
Richerand,  Hutton, Bellingham, Liston,
Allan, Greatrex, and Crampton on com-
pression in the  treatment  of aneurism,
ii. 482, 483, 484, 4S5, 486; cases in
which compression may  be  had re-
course to,  ii. 486;  S.  Cooper  on the
effects of  compression in aneurism, ii.
487; ligature of the aneurismal artery, ii.
487; Anel's operation, ii. 487;  Desault's
case,  ii. 488; the Hunterian operation,
ii. 488; Hunter's claims to  originality in
reference to this operation, ii. 488; Ford's
eases of spontaneous cure, ii. 489; Sir E.
Home on  the Hunterian   operation, ii.
490;  indications  for the operation, ii.
 490; Sir E. Home on the non-necessity
 for  the   existence  of  large  collateral
 branches, to ensure success in this opera-
 tion ii. 491 ;  Hunter and  South on the
 size of the  aneurism best fitted for ope-
 ration, ii. 491; the operation for aneurism
 by opening  the sac, ii. 491;  the Hunterian
 operation, ii. 491; Scarpa  and Jones on
 the application  of the ligature, ii. 492;
 Jones, Hodgson, Travers,  Scarpa, Law-
 rence, Astley Cooper, Maunoir, and Aber-
 nethy on the effects produced by the liga-
 ture on the arterial coats, ii. 492,493; John
 Hunter's  operation for tying the femoral
 artery in popliteal  aneurism, ii. 493;
 Birch's case,  ii. 494; South on the im-
 portance of opening the sheath to the least
 possible extent, in  applying a  ligature
 round an artery, ii. 495 ; Cline's cases in
 which the femoral artery was tied with a
 broad tape,  the  ligature being removed
 some hours  after, ii. 496 ; Crampton and
 Dease's cases in which the  temporary
 ligature was employed!, ii. 496; Lisfranc
 on the ligature of a diseased artery, with-
 out opening the  sheath, ii.  496 ; Aberne-
 thy and Galen on the application of two
 ligatures, and the division  of the  artery
 between them, ii. 497; treatment after
 the operation, ii. 497; W'edemeier's case
 in which the aneurism burst after  the
 ligature of the femoral artery, and ampu-
 tation became requisite, ii.  497 ; Guthrie
 and South on  the return of pulsation in
 the aneurism for a short time, after the li-
 gature of the artery, ii. 497, 498; Green's
 Gase, ii. 498; accidents consecutive to the
 operation — secondary hemorrhage and
 mortification, ii. 498; circumstances un-
 der  which  secondary  hemorrhage  is
 likely to oceur, ii. 498 ; Hunter*s cases of
 secondary hemorrhage after the opera-
 tion, ii. 498  ;  Green's case of secondary
 hemorrhage  after the ligature of the sub-
 clavian, ii- 498; South on the treatment
 of secondary hemorrhage, ii. 499 ; Gun-
 ning and Briggs' cases of recurrence of
 the aneurism after the ligature of the ar-
 tery, ii. 499; occurrence of mortification
 of the limb,  after the ligature of its prin-
cipal arterial trunk,  ii. 500; causes,  ii.
500;  advantages and disadvantages  of
the old  operation for aneurism, ii. 501;
advantages of the Hunterian operation, ii.
501 ; the Hunterian operation not applica-
ble in certain forms ofaneurism, ii. 501;
Thierry and Lieber on  torsion  of  the
artery, ii. 501;  Amussat's division and
thrusting back the internal coats of  the
artery, ii. 502; mode of operating, ii. 502;
Tavignot's subcutaneous tying the super-
ficial  arteries, ii.  502;. changes effected 
ANALYTICAL INDEX.
781
 in arteries  by the application of a> liga-
 ture, ii. 502; cutting into and plugging
 the aneurism, ii. 50#; suture of arterial
 wounds, ii. 503 ; application of a ligature
 with a  running knot; ii. 503;  E. Home
 and Phillips on acupuncture of the aneur-
 ism, ii. 503 ; Velpeau on acupuncture of
 the artery, ii. 503; Pravaz on acupunc-
 ture of the sac, and  the application of
 galvanism,  ii.  503;  cauterization  with
 moxas, ii. 503; introduction of mechani-
 cal plugs into  the arteries,  ii. 503; of
 threads, ii. 503;  various modes of  com-
 pression, ii.  503; Brasdor's operation, ii.
 503; Deschamp's case, ii. 504; Astley
 Cooper's  case,  ii.  504;  Wardrop  and
 Lawrence on Brasdor's operation, ii. 504;
 aneurism of  the carotid artery and its
 branches, ii. 507 ;  situation and diagnosis,
 ii. 507; Burns'  and  Syme   on carotid
 aneurism, ii. 507; compensation of the
 cerebral circulation after ligature of the
 carotid, ii. 507 ;  Macgill and Mussey's
 cases of ligature of-both carotids, ii.  507 ;
 Abernethy's case of ligature of the inter-
 nal carotid on account of a wound, ii. 508;
 Fleming's case of ligature of the carotid |
 for secondary hemorrhage, ii. 508;  Ast-
 ley Cooper's case of ligature of the com-
 mon carotid, ii. 508;.Travers, Robertson,
 and Zfeis'cases of ligature of the carotid,
 ii. 508 ; Kurd's- case of ligature of  both
 carotids, ii. 508 ;  tying the common caro-
 tid  may be performed  at three different
 places, ii. 509-; mode of operating imme-
 diately  above the eollar-bone, ii. 509;
 Zang, Dietrich, and Coates on  ligature
 of the common carotid, ii. 509 ;  the ope-
 ration below the  omo-hyoideus, ii. 510;
 Astley Cooper on the  impediment to the
 operation offered by the internal jugular
 vein, ii. 511; if the vein be wounded, it
 must be tied, ii. 511 ;the operation above
 the omo-hyoideus,  ii. 511;  after-treat-
 ment, ii. 511; Astley Cooper on the post-
 mortem appearances in a case in whieh
 he had  tied the common carotid 13 years
 before, ii. 512; aneurism of the branches
 of the carotid, ii. 512; tying the external
 carotid, ii. 512; Dietrich on.the ligature
 of the external carotid, ii. 512;  Beclard
 and Dietrich on the ligature of the lingual
 artery, ii. 513; ligature of the external
 maxillary or facial artery, ii. 514;  Vel-
 peau and Dietrich on the ligature of this
 artery,  ii.  514;  aneurism of the tem-
 poral artery, ii. 515; ligature  of the ar-
 tery, ii. 515;  aneurism  of  the occipital
 artery, ii. 515; its ligature, ii. 515 ; liga-
 ture of the posterior aural, ii  515; Astley
 Cooper's case of aneurism of the posterior
aural, ii. 515; Begin's case of aneurism
                                     66
 of the middle meningeal artery, ii. 515;
 aneurism of the branches of the internal
 carotid in the skull, ii. 515 ; Sir Gilbert
 Blane's case of aneurisms of the internal
 carotid by the side of the sella turcica, ii.
 516; Hodgson's case  of aneurism of the
 anterior cerebral, ii. 516 ; Serres' case of
 aneurism of the basilar, ii. 516; aneurism
 of the subclavian and axillary arteries, ii.
 516; characters of axillary  aneurism,  ii.
 516; ligature  of the  axillary artery,  ii.
 546; two modes of Operating, ii. 516; the
 operation by cutting through the pecto-
 ralis major, ii.  516; the operation by di-
 vision  of the  tendinous interspace  be-
 tween the pectoral and  deltoid muscles,
 ii. 517; South's  objections  to both these
 operations,  ii. 517; ligature of  the sub-
 clavian  above  the collar-bone,  ii. 518;
 Dupuytren,  Hodgson,   Lisfranc,  and
 Graefe on the section of the scalenus an-
 ticus in  ligature  of the subclavian,  ii.
 518; Astley Cooper, Ramsden,  Sir W.
 Blizard,  T. Blizard,  Dr.  Colles, Dr.
 Post, and Liston's cases of ligature  of
 the subclavian above the clavicle, ii. 518;
 519; Green and South on ligature of the
 subclavian,  ii. 519; ligature of the sub-
 clavian on the tracheal side of the scale-
 nus, ii..519; the  operation very hazard-
 ous, ii. 520; mode of  operating, ii. 520;
 Dietrich's description  of the operation,
 ii. 520; South on aneurisms of the aorta
 and  origin.of the carotid and subclavian,
 liable to be  mistaken for aneurism of the
 subclavian,  ii. 521;  Allan Burns and
 Hodgson's  proposal to tie the innominata,
 ii. 521;  Mott and Graefe's operations, ii.
 521; Hodgson on ligature of the  innomi-
 nata, ii.  522; Bujalsky, King, Dietrich,
 and  Manec on ligature  of the innominata,
 ii. 522; compensation to the circulation,
 when the subclavian  is obliterated,  ii.
 524 ; Key on the post mortem appearances
 in a case in which he tied the subclavian
 12 years previously, ii.  524; South on
 the  results  of  injury  to  the  axillary
 nerves, ii. 525; ligature of the internal
 mammary, ii. 525; Dietrich's description
 of two  modes  of tying the vertebral ar-
 tery, ii. 526; Nuntiante Ippolito on liga^
 ture  of the vertebral artery,  ii. 527; Mo-
 bus' case of vertebral aneurism, ii. 527:
 case of vertebral aneurism, ii. 527; aneur-
 ism, of the brachial, ulnar, and radial ar-
 teries, ii. 527; causes of aneurism of the
 brachial, ii.  527;  Astley Cooper, Hodg-
 son,  and Liston  on  the  spontaneous
aneurism of the  brachial,  ii. 528; the
free  anastomosis  of the arteries of the
arm  requires the  ligature of the artery
near the sac, ii. 528; Astley Cooper and 
782
ANALYTICAL  INDEX.
Liston on ligature of the  arteries  of the
fore-arm, ii.  528; W. Cooper's case  of
radial aneurism, ii. 528; aneurism, on the
back or front of the hand, ii.  528; liga-
ture of the brachial, ii. 528;. the operation
in the arm-pit,.ii. 528;  in the middle of
the upper arm, ii. 529;  high  bifurcation
of the brachial, ii. 529 ;  Tiederaann on
the  high bifurcation of the brachial, ii.
529; ligature of the brachial, at the bend
of the arm, ii. 529";  of the radial in the
upper third of the fore-arm, ii. 529;  of
the ulnar,in the upper third of the fore-
arm, ii. 530;. in the lower part  of the
fore-arm, ii. 530;. in the region  of the
wrist, ii,  530;  ligature, of  the end  of
the  radial  artery, .ii.  530;;  compensa-
tion  to the circulation  after  ligature  of
the  brachial, ii, 530; White and South
on the compensating collateral branches,
ii., 531; aneurism of the external and inter-
nal iliac, ii. 531; Astley Cooper, James,
and   Murray's cases of ligature of the
aorta, ii. 531;. Guthrie on ligature  of the
aorta, ii, 532; Monteiro's  case of ligature
of the aorta,  ii. 532; ligature of the com-
mon iliac for aneurism, of the external  or
internal iliac,  ii. 532;  the operation for
ligature of the common  iliac,  ii. 532;
Mott, Crampton, Anderson and Salamon's
operations, ii.  533; ligature of the inter-
nal  iliac for aneurism of its branches, ii.
533; the operation for ligature, of the in-
ternal iliac, ii. 533;  Stevens, White, An-
derson and Bujalsky's operations, ii. 534;
Owen on the post-mortem appearancesin
Stevens' case, ii.  534;  ligature  of the
gluteal, ii. 535;  Carmiehael's case,  ii.
535; ligature  of the ischiatic, ii. 535;
of the  common  pudic, ii. 535; case of
aneurism of the  internal  pudic, ii. 535;
aneurysm of the femoral an4 popliteal ar-
teries and their branches  ii. 535; Aber-.
nethy's ease of ligature of the external
iliac in the  groin,  ii.  535;  Freer and
Astley Cooper's cases, ii. 537; Tait and
Arendt's cases, of ligature of both the. ex-
 terhal iliacs, ii,.537; cases in which the
 external  iliac should  oe, tied,.ii. 537;
 description  of the  operation,, ii..  538;
 Abernethy, Charles Bell, Scarpa, Astley.
 Cooper, Lisfranc, Anderson, Rust, Lang-
 enbeck, Delpech,Wright, Post,Bujalsky,
 and  Guthriq on the ligature of the exter-
 nal iliac, if  538;  the. operation for  liga-
 ture of the femoral below Poupart's liga-
 ment, ii.  539;. Textor and;  Froriep  on
 ligature of the femoral below Poupart's
 ligament, ii.  539;  compensation to the
. circulation after ligature of the external
 iliac, ii. 540; Astley Cooper on the post-
 mortem appearances after; ligature of, the
external  iliac,  ii. 540 ;• ligature of  the
femoral,  for aneurism in the  lower third
of the thigh, or at the knee-joiht, ii. 541;
John Hunter on ligature of the  femoral,
ii. 542; ligature of the popliteal danger-
ous, and-not to be practised, except for
wounds,  ii*  542;  the  operation in  the
middle of, the ham, ii.  542; in the upper
part of the  ham, ii. 542; in the lower
part, ii. 542; Jobert's case of ligature of
the  popliteal in the internal epicondyloid
pit, ii. 543; aneurism of the tibial artery,
ii. 543; Green's case of aneurism of  the
posterior tibial, ii. 543; Astley Cooper
and Cline jun.'s cases of aneurism of the
anterior tibial, ii. 543;  Astley Cooper on
the  treatment of aneurism of the anterior
tibial low down, by opening the sac, and
tying the artery above and below, ii. 544;
ligature  of the anterior tibial above  the
middle of the leg, ii. 544; in the neigh-
bourhood of the instep, ii. 544; of  the
posterior tibial in the middle  or upper
thirds of  the leg, ii. 544;  South on liga-
ture of the posterior tibial when wounded
ii. 544;  ligature of the peroneal artery
in  the  middle  of the  leg,  ii.  544;
aneurisms  in the sole and back of  the
foot, ii.  545;  compensation  to the cir-
culation, when   the femoral artery has
been tied, ii. 545; Astley Cooper  on
the post-mortem appearances after liga-
ture of  the femoral   artery, ii.  545;
aneurismal varix and varicose aneurism,
ii. 546; definition of an aneurismal varix,
Li. 546;  McMurdo's case of aneurismal
varix between  the internal jugular vein
and carotid artery, ii. 546 ; characters of
the disease, ii. 546; Breschet on the con-
dition of the artery and vein in aneuris-
mal varix, ii, 547; Sennertus, Galen, and
William Hunter on .aneurismal  varix, ii.
547; Lawrence and Liston on the  pecu-
liar, noise heard in an  aneurismal varix,
ii. 549;-Liston's case of aneurismal varix
in  the femoral  vein and artery, ii. 549;
W. Hunter  on the distinction  between
aneurismal  varix, and false aneurism.
ii.  549;  treatment, ii.  549; Breschet,
Stromeyer,  and  Astley Cooper on  the
treatment of aneurismal  varix,  ii.  550;
Atkinson's ligature of the brachial artery
for  aneurismal varix,  ii. 550;. varicose
aneurism, ii. 550; definition,  ii.  550;
W. Hunter on  varicose aneurism, ii.
550; the operation, ii. 551; Green's case
of  varicose aneurism,, ii. 551; Perry's
case of aneurism bursting into a vein, ii.
551 ;  South's comments on  the case,ii.
551; 'unnatural expansion in th&branches
and  ramifications  of arteries,  ii. 552;
branching aneurism, ij.  552;  seat  and 
ANALYTICAL  INDEX.                      783
characters, ii. 552 ; diagnosis from other [Arendt, M.'s, case of ligature of both the
 swellings, ii. 553; causes, ii. 553; prog-
 nosis, ii. 553; treatment, ii. 553; Graefe,
 Travers, Dalrymple,  Wardrop,  Rogers,
 and  Dupuytren  on  the  treatment  of
 branching aneurism, ii. 554; aneurism of
 the arteries of bone, or aneurism by, anas-
 tomosis  of  bone, ii. 554; symptoms, ii.
 554; post mortem appearances, ii. 555;
 situation,  ii, 555;  occasional  causes,
 ii. 555;  these aneurisms always preceded
 by inflammation  of the  bone, ii. 556;
 Stanley on pulsating tumours of bones,
 ii. 558; treatment, ii. 558; unnatural ex-
 pansion in  ihe  capillary-vascular  system,
 ii. 559 ; teleangiectasy, \u 559;: is con-
 genital, ii.  559 ; characters, ii. 559 ;  fun-
 gous gowths after rupture of the swel-
 ling, ii. 560;  nature of the disease, ii.
 560; complications, ii. 560; teleangiectasis
 lipomalodes, ii. 560; oauses,ii. 560; always,
 a local disease,  ii. 561;  prognosis, ii.
 561; treatment, ii. 561; by compression,
 ii. 561; Abernethy on  compression, ii.
 561; by extirpation  with the  knife,  ii.
 561;  with  the  ligature, ii. 562; ad-
 vantages of  the ligature, ii. 562; Law-
 rence, Brodie, and South on the appli-
 cation of the ligature, ii. 562; destruc-
 tion of teleangiectasy by caustie, ii. 563;
 South on caustic in teleangiectasy, ii. 564;
 various remedies  to induce inflammation
  and suppuration in the diseased growth,
  ii. 564; Pattison, Smith, and Tyrrell's
 cases, ii. 564;  tying  the principal trunk
  supplying the diseased growth, ii. 566;
  if the   teleangiectasy  be seated in the
  extremities, and  incurable, amputation
  must be performed,  ii. 566;  Pauli  on
  the  tattooing of  moles on the skin,  ii.
  566.
Ansiaux, M.,  on the application, of the ac-
  tual cautery in irreducible prolapse of the
  rectum, ii. 404.
Anus, artificial ii. 152 ; spasmodic contrac-
  tion of, and anal fissures, ii. 171; fiist
  clearly described by Boyer, Dupuytren,
  and Brodie, ii. 171; Boyer and Dupuy-
  tren on the  symptoms of  anal  fissure,
  ii. 171; Brodie on spasmodic contraction
  of the anus, ii. 172; Dupuytren on the
  three varieties of fissures, ii. 172; Brodie
  on  the spasmodic  contraction  of the
  sphincter, attended  with  ulceration  ii.
  172; Dupuytren, Brodie, and  Boyer on
  the treatment, ii. 172; Boyer's operation
  for  anal fissure, ii.  173; anus  imperfo-
  rate, iii. 34; congenital narrowing of, iii.
  38; spasmodic contraction of, iii. 39.
Aorta, cases of ligature of, ii. 531.
Arden, John of, mentions the chaudepisse,
  i. 184; prescription for an injection for
  gonorrhoea,  i.  190.
  external iliacs, ii. 537.
Arm, upper, amputation through, iii. 679;
  exarticulation of, at the shoulder, iii. 711.
Arnaud's, M., apparatus for fracture of the
  neck of the femur, i. 624; on the reduction
  en masse, ii. 274; on incision of the hernial
  sac, and introduction of lint-tents for its
  radical cure,  ii. 283;- on dilatation of the
  stricture in strangulated  hernia, without
  cutting, ii. 298.
Arnott's, Dr.,  oil-silk tube for strictures of
  the urethra,  iii. 77; on  cauterizing the
  walls of the  stricture, iii. 79 ;  operation
  of lithectasy, iii. 375-.
Arnott's, Mr., case of-liospital gangrene,
  i. 83 ; on severe phlebitis, i. 93; on the
  morbid appearances in phlebitis, i.  95 ;
  case  of foreign body in the vagina, the
  bladder injured, and formation of a  cal-
  eulus, iii. 249; case of malignant tumour
  of the tongue, in which that organ was
  removed by ligature, iii. 521; case of dis-
  eased undescended testicle, iii. 558.
Arteries, Wounds of, and  their con-
  sequences, i. 329;  closure of slight and,
  longitudinal  wounds of, i. 330; Saviard,
   Petit, and   Scarpa  on  the  healing  of,
  wounds of, i. 330; artery compressors  of
   Langenbeck, Verdier,Mohrenheim, Dahl,
  Wegehausen, Moore, Graefe, Scultetus,
   Heister,  Dionis,  Plattner,  Brambilla,
   Desault,  Leber, Ayres,  Bell,  Chabert,
   Lampe, Faulquier, Schendler, Hessel-
   bach, and Joachim, i. 331; von Winter's
   directions  for wounded arteries, i. 333;
   pressure  on the meningeal artery.inad-
   missible, and not requisite, i. 333; Aber-
   nethy's ease of wounded  meningeal ar-
   tery, i. 333; South on Wounds* of the
   pudic artery and artery of  the  bulb,
   during  the   lateral operation for the
   stone, i.  334;  South on the treatment
   of wounded arteries in the thick fleshy
   partsofthe  hand or foot, i. 334; ligature
   of arteries, i. 335;  South's  experiments
   on the carotid of a dog, Lj 335; Manec, Du-
   puytren, and Roux on the introduction of
   a.piece of bougie into an ossified artery,
   after amputation, i. 336;  treatment of a
   retracted artery, i. 337;  South on the
   ligature  of  large  arteries  above  and
   below the; wound, i. 337; South  on the
   necessity  for  cutting  down upon a
   wounded  vessel  on. the  sound side of
   a limb, if nearer the artery than, is the
   part wounded, i. 337; Travers' case  of
   wound of the  posterior tibial artery, i.
   338; Lawrence, Hennen, Delpech, Wal-
   ther, Haire, Guthrie, and' South  on the
   after-management of the ligature, i. 338,
   339; Dr. M'Sweeny on the silk-worm-gut
   ligature, i.  339; Physick on the animal 
)AL INDEX.
 784

   ligature,  i. 339; Astley Cooper on the
   catgut  ligature, i.  339; length of time
   before the separation of a ligature, i. 340;
   Callaway and Guthrie's cases, i. 340; se-
   condary haemorrhage on the separation of
   aligature,i. 340; Green's caseof secondary
   haemorrhage after ligature of the subcla-
   vian, i. 340;  torsion of twisting  or ar-
   teries, i. 341; Galen, Amussat, Thierry,
   Liber, Velpeau, Fricke, and Dieffenbach,
   on torsion, i. 341 ;  changes produced by
   torsion, i. 341; Palmar on the  torsion  of
   arteries, i. 341; Amussat, Thierry, and
   Fricke on the mode of practising torsion,
   i. 342; Dieffenbach's torsion-forceps, i.
   342; Kluges's torsion apparatus, i. 342;
   advantages of torsion, i. 342; Dupuy-
   tren, Lorch, Textor, Fricke, Elster, and
   Bramberger on the effects of torsion,  1.
   343; Dieffenbaeh,  Dupuytren,  and Che-
   lius' objections to torsion, i. 344;  South
   on torsion, i. 344;  Feme and Astley
   Cooper's  cases of  accidental  torsion,  i.
   344; cases in which torsion is preferable,
   i. 344; Kohler and  Fricke on the torsion
   of bony vessels, i.  344 ; Stilling on the
   interweaving of arteries, i.  344; use  of
   astringent styptics, i. 345;  effects  of
   cauterization on wounded vessels, i. 346;
   occurrenee and management of secondary
   haemorrhage, i. 346;   circumstances fa- <
   vouring   the  occurrence of  secondary
   haemorrhage, i. 346; Cline  jun.'s  cases
   of after-bleeding, in  which the actual
   cautery was employed, i.  347;  Cline
  jun.'s  clinical observations  on  after-
   haemorrhage, and the  use of the actual
   cautery in  such cases, i.  347;  Cline
  jun.'s  experiments  on  arteries, i. 351 ;
   South on  the  treatment of  bleeding os-
   sified arteries, ii. 352;  if a  large artery
  be wounded  from a bruise, it may be
  necessary to expose it and take it up,  i.
   369;  South on extensive  ecchymosis,
  and  the means of  diagnosis,  when an
  artery, of any  material  size  has   been
   wounded, i. 369; South on the danger
   of gangrene when a large artery has been
  wounded, from the  distention of the soft
  parts, L 369.
Arteriotomy, iii. 611.
Arteritis, Dupuytren and  Cruveilhier on, as
  a causa of dry gangrene, i.  72; South's
   case of,  without gangrene,  i. 73; in-
  flammation  of the  coats of arteries,  u
   88;  Bouillaud on arteritis, i. 89 ; Hodg-
  son's cases of, u 89; Portal's case of in-
  flammation of; the  aorta, consequent on
   the recession of measles, i. 89; South's
  case of arteritis, i. 89.
Arthur, Dr., on  the  use of the  seton  in
   gun-shot wounds,to bring away separated
   pieces of bone, L377.
 Assalini, M., on the stanching the bleeding
   from a wounded intercostal artery, i. 492;
 Ashwell, Dr., on the extirpation of ova-
   rian cysts, iii. 215; on the pain in cancer
   uteri, iii. 563; case  of  cancer uteri, iii.
   563; on the period of life at which can-
   cer uteri is generally developed, iii. 564.
 Astragalus, dislocation of, ii. 251; case of
   exarticulation of, iii. 703.
 Atkinson's, Mr., case  of ligature of the
   brachial artery, for aneurismal varix, ii.
   550.
 Attenburrow's Mr., case  of trepanning
   the spine, i. 500; cases  of old men ope-
   rated on for- stone, iii. 297.
 Atti, M., on the use of a canula, for main-
   taining the patency of the  artificial duct,
   in the operation for salivary fistula, ii, 148.
 Aube, M., on  the  contagion of itch*  de-
   pendent on the itch-mite, ii. 65.
 Aumont's, M;., operation for extirpating the
   testicle, iii. 556.
 Austin, Mr., on. the  formation of urinary
   calculi, iii. 237.-
 Autenrieth's,  M., opinion,  that  crusta
   serpiginosa  is connected  with itch, ii.
   63.
 Avenzor, on the acarus scabiei, ii. 66,
 Avicenna, on congenital dislocation of the
   hip, ii. 207; on the application of caustic,
,  for the fadieal cure of hernia, ii. 283.
 Axillary aneurism,  ii. 5,16.
 ---------artery, ligature of, if. 517.
 Ayres', Mr., arteryrcompressor, i. 331.

 Barington*s Dr., case of fatal bayonet-
   wound of the heart, i. 499<
 BabingtoN's, Mr.,  case, illustrative of the
   peculiar delirium of hydrophobia, i. 407;
   on the prernonitory^pains  of hydropho-
   bia, i. 408.
 Bach, M., on extirpation of bronehocele by
  ^ligature, iii.  398.
 Bacot's Mr., objection to the exhibition of
   corrosive  sublimate in cases of syphilis
   in infants, ii. .106 ;  on,erethismus mer-
   curialis, ii.  109;  on the  cachexia syphi^
   loidea, ii.-110; on the ecaema mercuriale,
   ii. Ill;  on the treatment of  mercurial
   sore-throat, iii 113,'
 Baillik's, Dr., case of obliteration of the
   vena cava  inferior, ii, 569..
 Baillie, Mr., on the  local treatment of
   fractured ribs, i. 599.
 Baillif's, M.,  apparatus  for fracture of
   the patella, i,. 633 ; artificial hands, iii.
   595.
 Baines, Mt., on  the  treatment of vesico-
   vaginal fistula, by drawing off the urine,
   and by  compression, ii. 189.
 Baker, Mr., on the existence of the acarus
   scabiei, ii. 65.
 Balanitis, or external gonorrhoea, i. T98; 
ANALYTICAL INDEX.                       785
   causes  and symptoms, i.  198; Hunter
   and South on balanitis, i. 198 ; treatment,
   i. 198; Ricord  and South on the treat-
   ment of balanitis, i. 199.
 Balfour's, Dr., case of reunion of divided
   parts, iii. 581.
 Balling, M., on  cutting away the tunica
   vaginalis, iii. 230.
 Banks', Sir Joseph, account of his suffer-
   ings, and  of Dr.  Solander's, from  ex-
   posure to cold, i. 145.
 Banner's, Mr. case of extirpation of the
   womb, iii. 570.
 Bardsley's, Dr., case of hydrophobia, oc-
   curring twelve  years  after the bite had
   been inflicted, i. 404 ; his opinion that
   the disease was  not hydrophobia,, i. 404;
   supports his views by the opinions  of
   Darwin,. Haygarth, and  R. Pearson, i,
   404;  case  illustrative of the peculiar
   delirium of hydrophobia, i. 407 ;  on the
   stages of hydrophobia, i.  408; on  the
   diagnosis of tetanus from  hydrophobia,
   i. 418.
 Barlow,  Mr., on the treatment  of torn
   muscles, i. 543.
 Barnes', Dr., case  of knife-swallowing, iii.
   103.
 Barnes', Mr.  obturator  for vesico-vaginal
   fistula, ii, 189.
 Baron's, Dr., case of hydrocephalocele, ii.
   470.
 Barry, Sir David, on the application of
   the cupping-glass over  snake-bites,  i.
   391.
 Barry's, Mr., case of accidental reduction
   of the dislocation in hip-disease, i. 299.
 Barthelemy, M., on  the  means  of pre-
   venting the retraction  of the urethra in
   amputation of the penis, iii. 546 ; case of
   reunion of divided parts, iii. 581; on the
   section of the  palmar, aponeurosis, after
   exarticulation of the  fingers  from the
   metacarpal bones, iii. 723.
 Barton's, Dr., operation, of cutting out a
   wedge-shaped piece of  bone for the relief
   of anchylosis, i.  275; operation  for the
   establishment of a false-joint, in treating
   anchylosis, i.  275;  on the  symptoms
   produced by the  bite of the rattlesnake,
   i.  392 ; on  the treatment of rattlesnake-
   bites, i. 395 ; on the employment of the
   ligature in snake-bites, i. 396; case of cure
   of ununited fracture, ii. 17; operation on
   the anchylosed femur, iii. 19;  operation
   to remedy  the opening of the rectum
   into the vagina, iii. 36.
Basedow, M., considers dissection wounds
  agree with malignant pustule, i. 385.
Bateman's, Dr.,  distinction between ery-
  thema   and  erysipelas, i.  116;  acute
  erysipelas,  the  vesicular erysipelas  of
   Chelius, i.  116; erratic  erysipelas, the
   erythema symptomaticum of Chelius,
   i.  118; cedematous erysipelas, the ery-
   sipelas  from scalp»wounds, L 118; on
   purpura  haemorrhagica, or land-scurvy,
   ii. 49;  on the  existence of the acarus
   scabiei, ii. 67; case of erythismus mer-
   curialis, ii. 108;  on eczema rubrum, ii.
   109.
 Baddelocque, M., on the mode of perform-
   ing the  Caesarian operation, iii. 162.
 Baudens', M., oblique cut in amputations,
   iii. 642; mode of amputating the leg in
   its lower third,  iii. 670; mode of ampu-
   tating at the-knee with the circular cut,
   iii. 700; at the ankle-joint, iii. 700;  mode
   of operating in exarticulation of the fore-
   arm at the elbow, iii. 720.
 Bauer, M., on the presence of globules in
   the serum, i. 56.
 Bayle,M.,on mortification from spurred rye,
   i. 74; on the pain in cancer uteri, iii. 562.
 Baynham's, Mr.,  case  of puncturing the
   womb, in retroversion, ii. 412.
 Beaumont, Mf., on increased pressure and
   supine posture in the radical cure of her-
   nia, iik 282.
 Beck's,  Mr., apparatus for fracture' of the
   neck of the femur, i. 624;  on accidental
   cerebral rupture, ii. 365.
 Beckett's, Mr., memorandum respecting
   gonorrhoea, i. 183;  prescription  for an
   injection for gonorrhoea, i. 190.
 Beclard,  M.,  distinctly  of opinion that
   cartilages are not vascular, i. 253 ; prac-
   tice in wounded intestine, ii. 509 ; on the
   treatment of fistula of the parotid duct, ii.
   149 ; on the ligature of the lingual artery,
   ii. 513 ;  modification  of Dupuytren's bi-
   lateral section for stone, iii. 327; mode of
   amputating at the hip-joint with two flaps,
   iii. 692;  mode of amputating at the shoul-
   der-joint, iii. 716.
 Bedingfield, Mr.,  on the  treatment of
   tooth-ache, ii. 138.
 Beer's, M., cases  of malignant pustule, i.
   79.
 Begin's, M., case of closing and wasting of
   the portion of intestine below the artificial
   anus, ii. 153; case of aneurism  of the
   middle meningeal artery, ii. 515 ; opera-
   tion for the division of the inner fold of
   the prepuce, iii. 57 ; directions for  ceso-
   phagotomy, iii. 100; on the treatment of
   complete retention of urine in  stricture,
   iii.  145; on the operation for cutting into
   the urethra in the perinaeum, iii.  147;
   mode of amputating at the hip-joint with
   two flaps, iii. 698; mode of operating in
  excision  of the knee-joint, iii. 740.
Beinl's,  M., opinion, that the   so-called
  lymph-swelling  is  an extravasation of 
786
ANALYTICAL INDEX.
  lymph, i. 60;  plan of opening a  cold
  abscess with a lancet, after the previous
  application of caustic, i. 105.
Bell,  Mr. Benjamin, denies the identity
  of gonorrhoea and syphilis, i.  185;  cases
  of gonorrhoea of the nose, i. 199; on alter-
  nate swelling of the testicles, i. 199 ; on
  tapping lumbar or  psoas abscess with a
  trocar, i. 212; on the stanching the bleed-
  ing from a wounded intercostal artery,  i
»  492 ; on the use of the suture in wounded
  intestine, i. 512; on the expulsion of the
  suture after union has taken place, i.  514 ;
  apparatus for fraeture of  the  patella,  i.
  633; objections to the use of the catheter
  in urethral fistula,  ii. 182; mode of am-
  putating by the circular incision, iii.  640;
  plan of amputating the  thigh with the
  flap from before, iii. 660; mode of ampu-
  tating  at the shoulder-joint with the cir-
  cular cut, iii. 715.
Bell's, Sir  Charles, opinions  relative to
  the formation of pus, i. 46; on tying the
  tonsils,!. 164; case of hysterical affection
  of the hip-joint, i.  277 ; explanation of
  the pain in the inside Of the knee in hip-
  disease, i. 280; on the pain in hip-disease,
  i. 289; on morbus  coxae senilis, i.  289;
  proposal to sawthrough the neck of the fe-
  mur in hip-disease,to promote anchylosis,
  i. 299 ; on the operation for  trepanning
  the spine, i. 590, 592; objection to laying
  open the fracture and using the elevator,
  or removing its edge by the lenticular, in
  order to raise the depressed  portion of
  bone in fracture of the sternum, i. 598 ;
  on the  bent position in fracture of the
  femur, i. 628; operation  for the  restora-
  tion of the canal of the urethra, ii.  181;
  on the mode of reducing the  dislocation
  of.the thumb, ii. 235 ; on the reduction en
  masse, ii. 274; on the ligature of the ex-
  ternal  iliac, ii. 538; oh  the  ligature of
  the spermatic veins in varicocele, ii.  578 ;
  on the seat of stricture in the  rectum, iii.
  44 ; mode of  amputating at the hip-joint
  with two flaps, iii. 692.
Bell, Mr. John, on  the  arrest  of haemor-
  rhage by nature, 329; artery-compressor,
  i.  331;  on  the  use of  the  suture in
  wounded intestine, i. 512.
Bellanger, M., on the reduction of the re-
  troverted womb, ii. 412.
Bellingham, Dr., on  compression  in the
  treatment of aneurism, ii. 486.
Bellini's, M., operation for prolapsus uteri,
  ii. 380.
Belmas', M., operation for the radical cure
  of hernia, ii.  286.
Belloq, M., on the stanching the bleeding
  from a wounded intercostal artery, i. 492.
Benaben's, M., case of excision of part of
  the hand, iii. 722.
Benedict, M., opposed to the radical'cure of
  umbilical rupture by ligature, ii. 346; mo-
  dification of the German operation of rhi-
  noplasty, iiL 590; stimulant treatment of
  stumps, iii. 648; mode of amputatingthe
  thigh with a flap from the outside, iii. 660.
Bennati, M., on cauterization of the uvula
  with nitrate of silver in relaxation, i. 166.
Bennett, Dr. J. H., on  the oscillation at-
  tending the recovery of the circulation in
  inflammation,, i.  41;  on the  process of
  resolution^ i. 43; on the process of effu-
  sion, i. 44; on the process of union by
  adhesion, i. 321 ; on the formation of new
  vessels,  i.  323;  on  the processes of
  granulation and  cicatrization, i; 325.
Bennett's, Mr., case of sarcomatous scro-
  tum, iii, 549.
Bent's, Mr., case of excision of a joint, iii.
  726;  mode of operating in excision of
  the head of the humerus, iii.  732.
Berard, M., on  the removal of the edges of
  the cleft in staphyloraphy, ii. 32; mode
  of passing the needle, ii. 33; fatal case
  from pneumonia, ii. 34 ;  on the ligature
  of the hernial  sac for  its radical cure, ii.
  283; case of femoral rupture, in which the
  Fallopian tube  was protruded, ii. 334;
  operation for  prolapsus  uteri, ii. 379;
  case of fungus of the dura mater  treated
  by operation,  iii. 425.
Berard's, M., jun., case of invagination of
  the rectum through the anus, ii. 398.
Berdot, M., on  dislocation  of the head of
  the thigh-bone downwards and inwards
  in hip-disease, i. 287 ; case of reduction
  of the consecutive dislocation in hip-dis-
  ease,  i. 297.
Berlichingen's, M.  Gotz von, artificial
  hands, iii. 595.
Berlinghieri's, M. Vacca, directions for
  oesophagotomy, iii.  100;  operation  for
  stone, iii. 347.
Bernstein's, M-> apparatus for fracture of
  the neck of the femur, i. 623,
Berrens', M., artificial leg, iii.  593.
Bertrandi's, M., mode of reducing disloca-
  tion of the humerus, ii. 225; mode of am-
  putating at the shoulder-joint with the
  circular cut, iii. 715.
Berzelius', M.,  opinion  relative to the
  formation of pus, i. 46.
Beynard, M.,on the treatment of spina bi-
  fida by closure of the sac, iii. 190.
Bibrach, M., on tying the tonsils, i. 164.
Bichat, M., on the vessels of  cartilage, i.
  252 ; on the changes which the substance
  of bone undergoes in advanced  age, i.
  545;  on the cause of death from the en-
  trance of air into a vein, iii. 603.
Biesse y's, M., plan of treatment of ingrow-
   ing of the nail by scraping its free surface
   till nearly its entire thickness is destroyed, 
ANALYTICAL INDEX.
787
  then touching it with lunar caustic until
  it contracts completely, i. 223.
Biett, M., on  the solution of chloride of
  lime in foul, gangrenous, and torpid ul-
  cers, ii. 45;  on iodine in hard swellings
  of the testicles, ii. 101.
Bigelow's,  Dr», employment  of ether by
  inhalation prior to the extraction  of  a
  tooth,  iii.  768; to the performance of
  more important surgical operations, iii.
  769 ; cases of injurious effects produced
  by the inhalation of ether, iii. 769.
Bile, retention  of, iii. 124.
Bilguer's, M., objection to amputation, i
  381.   .
Biliary fistula,  ii.  151.
Billard's, M., case of cure of cerebral rup-
  ture, ii. 365.
Birch's, Mr., case of fatal rupture of the
  uterus, subsequently to one previously
  recovered from, ii. 531; case of popliteal
  aneurism, ii. 494.
Bladder, prolapse of, ii. 391; puncturing
  of, iii. 151; above the pubes, iii. 151;
  through the rectum, iii. 152 ; through the
  perineum, iii. 152 ;.stone in, iii. 271.
Bladder, Wounds of, i. 527 ; nature and
  treatment of these wounds, i. 527 ; re-
  moval Of foreign bodies in wounds of the
  bladder, as their presence may cause the
  formation of a calculus, i.  528;  South
   on rupture pr laceration of the bladder in
  fracture  of the pelvis, i. 528; case of
   grape-shot wound of the pelvis, involving
  both the rectum  and  bladder, i.  528;
   Hennen's case of ball-wound of the pelvis,
   involving the bladder,  i. 528 ; Cline's
   sen. case of musket-shot wound of the
  bladder, the  ball  remaining,  and  after-
   wards extracted by operation, i. 529.
 Blagden's, Mr.,  case  of consecutive he-
  morrhage after the extraction of a  tooth,
  ii. 141.
 Blandin's, M., treatment of fracture  of the
   radiusor ujna near the wrist, i. 613; on
   hydrocele caused by gonorrhoea, iii. 223 ;
  mode  of amputating at the hip-joint with
   two flaps, iii. 692; at the knee-joint with
  the flap-cut,  iii. 699.
 Blane, Sir Gilbert, on  the period  of the
  accession of tetanus after the receipt of
   the injury, i. 415 ; case of aneurism of the
   internal carotid by the side  of the  sella
  turcica, ii. 516.
 Blasius, M., on  the nature  of. strangula-
  tion, ii. 269; on the causes of cl ub-foot, ii.
   446 ;  opposes tenotomy in  the treatment
   of club-foot, ii. 456 ;  operation of chilo-
   plasty, iii. 517; sloping cut in amputa
   tions, iii, 642; oblique cut  in partial am
   putation of the foot, iii. 705 ; mode  of am
   putating at the shoulder-joint, iii. 716.
Blechy, M., on the cause of the difficulty
  experienced in reducing dislocation of the
  thumb, ii. 235.
Blegny, M., on increased pressure and the
  supine posture for the radical  cure  of
  hernia, ii. 282.
Blizard's, Sir  W.,  case  of penetrating
  wound of the chest, i. 483 ;  on compres-
  sion in the treatment of aneurism, ii. 482;
  case of ligature of the subclavian above
  the clavicle, ii. 518.
Blizard's, Mr. Thomas, case of hydrocele
  in front of an inguinal rupture,  ii. 323 ;
  case of ligature of the subclavian above
  the clavicle, ii. 518; on the section of the
  prostate  in the Operation for stone, iii.
  320 ; case of simple serous cysts for the
  neck, iii; 432.
Blisters, application of, iii.  619.
Block's Mr., experiments on the effects of
  spurred rye on animals, i. 75.
Blood-letting, iii. 608; modes of opera-
  ting, iii. 608 ; opening veins, phlebotomy,
  iii. 60S ; situation where performed, iii.
  608 ; choice of a vein at the bend of the
  elbow, iii.  608; mode of opening a vein,
  iii. 608; South's directions for blood-let-
  ting from  a vein, iii. 609; dressing the
  wound,  and  applying  the bandage, iii.
  610;  accidents which  occur during the
  operation, iii. 610 ; faulty stab, iii.  610 ;
  formation  of two  small an opening, iii.
  610;  stoppage of  the  flow  of blood, iii.
  610; severe pain from wounding a nerve,
  iii. 610; wounding an artery,  iii. 610;
  wound of a lymphatic vessel, tendon, or
  aponeurotic expansion, iii. 610; accidents
  which may occur after the operation, iii.
  610; bleeding, iii. 610; inflammation and
  suppuration, iii. 610; inflammation of the
  veins or lymphatics, iii.  610; Abernethy
  on the  treatment of traumatic  phlebitis,
  iii. 611; severe pain and even convulsions
  from  partial divison of a nervous twig, iii.
  611; Abernethy on the complete section
  of the nervous twig in such cases, iii. 611;
  use of the snapper dangerous,  iii. 611;
  opening the veins of the fore-arm and hand,
  iii. 611; blood-letting in  the foot, iii. 61.1;
  blood-letting in the neck, iii. 611;  direc-
  tions  for  opening the external  jugular
  vein, iii. 611; opening arteries,  iii. 611 ;
  only  performed on the temporal, iii. 611;
   mode of operating, iii. 612; South and
   Cline jun. on arteriotomy, iii. 612;-appli-
   cation of leeches, iii. 612; mode  of apply-
   ing them, iii. 612; description of the
   blood-leech, iii. 612 ; of the horse-leech
   and common leech, iii. 612; means to in-
   duce leeches to bite, iii. 612; application
   of leeches to the mouth or near the anus,
   iii. 613; Crampton and  Osborne on the 
788
ANALYTICAL INDEX.
   application of leeches to the mucous sur-
   faces, iii. 613; treatment after the leeches
   have  dropped off, iii. 613; of the after-
   bleeding in children, iii. 613; Bricheteau,
   Lisfranc,  Green, and  Oliver's cases of
   fatal haemorrhage  from leech-bites, iii.
   614; South on the treatment of the after
   bleeding, 'iii. 615; treatment of  ecchy-
   mosis, inflammation arid  suppuration of
   leech-bites, iii. 615; scarification, iii. 615;
•  definition and employment of, iii. 615;
   cupping, iii. 615; mode of operating, iii.
   615;  dry cupping, iii. 611;  South on
   a substitute for cupping, iii.  616; Dr.
   Osborne's polytome, iii, 616; South on
   dangerous  haemorrhage from cupping,
   iii.  616; relative value of leeches and
   cupping, iii. 616; Junod's apparatus  to
   cause derivation of "blood, iii. 616; South
   on the relative value of leeches and cup-;
   ping, iii. 617; South's preference of cup-
   ping, iii. 617.
 Blundell, Dr., on prolapse of the womb,
   ii. 369;  on relaxation and incomplete
   prolapse of the  womb, ii. 370;  on the
   size of the prolapsed womb and vagina,
   ii. 371; on the cause of prolapse, ii. 372;
   case of removal  of the inverted womb by
   ligature, ii. 368; on the symptoms of pro-
   lapse of the vagina, ii. 399; on the local
   symptoms caused  by retroversion of the
   womb, ii. 407;  on partial retention of
   urine in  retroversion,  ii.  408 ;  on the
   prognosis in retroversion, ii. 411; on an-
   teversion, ii. 415; case of extirpation of
   the womb, iii. 570; apparatus for trans-
   fusion, iii, 628.
 Boerhaave's, M., opinions  relative  to the
   formation of pus, i. 46.
 Boggie's Staff-surgeon, cases of gun-shot
   wound, in which  a seton was used to
   bring away separated  pieces of bone, i.

 Boil or furuncle :—character and symp-
   toms of the disease, i.  150; Walther on
   the seat of the disease originally in the
   sebaceous glands of the skin, i. 150; other
   inflammatory affections of the sebaceous
   glands, i. 151; Gendrin on the nature of
   the cores of boils, i. 151; Alibert's-divi-
   sion of boils into fouTMnds, i. 151; the
   wasp-nest or malignant boil; i. 151; the
   pustular boil, i. 152; Dr. Copland's as-
   thenic boil—furoncle atonique of  Guer-
   saut$ i. 152; description of the disease,
   its symptoms and progress, U 152;  boils
   often occur in healthy persons without
   any apparent cause, i. 152; are occasion-
   ally critical, i.  152;  occut  after  sup-
   pressed perspiration,  from  neglect of
   cleanliness, in persons of irregular habits
   during menstruation, and  in the -spring.
   i. 153; they appear sometimes to he de-
   pendent on the state of the atmosphere,
   and  are also  met  with  in the chronic
   form in dyscratic individuals, i.  153;
   treatment, i. 153; South's plan of treat-
   ment by free  incision, i. 153;  general
   treatment rarely necessary, i. 153; Rit-
   ter's idea that  boils depend on the reten-
   tion of the animal refuse, i. 153 ; South
   recommends the employment of general
   treatment, i. 153.
 Boivin, Mad., on anteversion of the womb,
   ii. 412 ; case of spontaneous reduction of
   anteversion, ii. .413,
 Bonafont, M., on the treatment of salivary
   fistula, ii. 149.
 Bone, aneurism of the arteries of, ii. 554.
 Bonfil's, M., operation when  the cleft  in
   the soft palate  is very large and compli-
   cated,  ii. 34;  mode of treating ovarian
   dropsy, iii. 211; case of spontanous  rup-
   ture of the ovarian cyst, iii. 214; mode
   of amputating  at the shoulder-joint, iii.
   716.
 Bonnet,  M.,  on  the chemical and micro-
   scopic characters of pus, i. 46; on the
   effects of the resorption of pus, i. 48; ope-
   ration for the radical  cure of hernia, ii.
   285; on the application of caustic in varix,
   ii. 573; on injections of iodine in hydrar-
   thrus,  iii. 1^4;  operation for the sub-
   cutaneous division of the nerve in mental
   neuralgia, iii. 636 ; on the nature of the
   uniting medium between the two ends of
   a divided nerve, iii. 636.
 Bosch's, M., explanation of wounds from
   the wind of a ball,  i. 374;  apparatus
   for the re-breaking a badly*»nited bone,
   i. 576.
 Bossau, M., mortification from spurred Tye
   noticed, by, i. 75.
 Bottchek^s, M., apparatus  for fracture of
   the olecranon,  i. 614;  apparatus  for
   fracture  of  the neck  of  the femur, i.
   623.
 Bouillaud, M., on  arteritis, i. 89 ; on the
   redness of the  internal membrane  of ar-
   teries, i. 89; on severe phlehitis, i. 93.
 Boullay, M., on the solution of the  chloride
   of lime  in the treatment of foul, gani
   grenous, or torpid ulcers, ii. 49.
 Bourgeois', M., observations on malignant
   pustules,!, 81.
 Bouvier, M., on  the section of the  tendo
   Achillis in club foot, ii. 453.
 Bowman, Mr. considers there is a difference
   betwen  temporary and articular cartilage,
   i. 250.
Boyer, M., on the lengthening of the limb
   in hip disease,!. 285; on dislocation into
   the foramen ovale in hip disease, i. 287;
   objectsto the^ubdivision of fractures into 
ANALYTICAL INDEX.
789
  complete and  incomplete, u 545;  infers
  the impossibility of simple dislocation of
  •  |QSPine' u 5865 case mentioned by him,
  l. 586;  apparatus  for fractured clavicle,
  l. 604; opposed to Astley Cooper's views
  on the union of fractures of the  neck of
  the femur, i. 620;  apparatus for fracture
  of the neck of the femur, i. 625; on per-
  manent extension in fracture of the femur,
  i. 628 ; apparatus for fracture of the pa-
  tella, i. 633; on rubbing the ends of the
  broken bones together in cases  of false
  joint, ii. 15;  on the treatment of  ulcers
  by sticking  plaster, ii.  47; on dressing
  the wound  after the operation for rectal
  fistula, ii. 167; on the symptoms of anal
  fissure, ii. 170; on their treatment, ii. 173;
  operation for the cure of anal fissure, ii.
  173; on dislocation of  the upper end of
  the radius forwards, ii. 231; on reduction
  of dislocation of the astragalus, ii. 253;
  on the nature of strangulation in rupture,
  ii. 269; on increased pressure and the su-
  pine posture for the radical cure of hernia,
  ii. 282; on cutting away the tunica vagi-
  nalis, iii. 230; mode of using FrereCome's
  lithotome, iii. 327; on wens,  iii. 450;  on
  the cancerous degeneration of steatoma,
  iii. 453; mode of amputating by the cir-
  cular incision, iii. 640.
Brachial aneurism,  ii 527.
----artery, ligature  of, ii. 527.
Bradley, Dr., on the blood-fungous, iii.
  461.
Braid's, Mr., case of re-union of divided
  parts, iii. 582.
Brain,  and its membranes,  injuries of, i.
  436; inflammation of, i. 440; compression
  of, i. 444; concussion of, i. 449.
Bramberger, M., on the effects of torsion,
  i. 343.
Brambilla's, M.,artery-compressor, i. 552.
Branching aneurism, ii. 552.
Brande's, Mr., analysis of the earthy con-
  cretions in arteries, i. 91.
Brasdor's, M., bandages for fractured cla-
  vicle, i. 604 ;  objected to, i. 603; opera-
  tion  for aneurism, ii. 503; mode of ope-
  rating  in exarticulation of the fore-arm
  at the elbow, iii. 718.
Braun's, M., apparatus for fractures of the
  leg,  i.  637.
Breast,  Inflammation of; situation and
  character of, i. 170, causes, i. 170;  South
  on the arrest of the secretion of milk, and
  its absorption, i. 170; treatment of inflam-
  mation of the breast, i.  170; abscess of
  the breast, i.  170;  treatment of fistulous
  openings, i. 171; opening the abscess only
  advisable when it is very deep, has pro-
  ceeded slowly, the pain is great, and fever
  high, i. 171; Langenbeck's treatment of
     Vol hi.—67
  lengthy fistulae* i. 171; the introduction
  of tents injurious, i. 171; South's recom-
  mendation that abscess of  the  breast be
  opened freely and early, i. 171; advan-
  tages of the proceeding, i.  172; condem-
  nation of Langenbeck's plan of treating
  the fistulae, i. 172; South's treatment Of
  fistulae, i. 172; milk-knots, i. 172; termi-
  nations and treatment, i. 172;  inflamma-
  tion of the breast, unconnected with suck-
  ling, i. 172;  causes, i. 173; treatment, i.
  173; deep-seated abscesses in the gland,
  or between it and the pectoral muscles,
  i.  173 ; to be opened early, i. 173 ; fistu-
  lous passages to be laid open throughout
  their whole length, i. 173; Astley Cooper
  on chronic abscess of the breast, i. 173;
  South's case of chronic abscess operated
  on by mistake for scirrhus,  i. 173; im-
  perfection of the nipples, i. 174 ; inflam-
  mation of the nipple, i. 174;  treatment, i.
  174;  Cooper and Hanney on  the treat-
  ment of fissured nipples, i. 174.
Breast, cancer of, iii. 526; chronic inflam-
  mation of the lymphatics, or of the breast-
  gland,  iii. 530;  scrofulous  tumours, iii.
  530; herpetic and psoric  affections, iii.
  533; encysted tumours, iii. 533; vesicu-
  lar scirrhus, iii. 533; hydatid swellings,
  iii. 534; serocystic  tumours, iii. 535;
  medullary fungus, iii 536;  blood swel-
  lings, iii. 536;  hypertrophy, iii. 537.
Brefeld's M., apparatus for fractured cla-
  vicle, i. 603; perferred, i. 605;
Brera's, M., plan of treatment preventative
  of hydrophobia,  i. 412.
Breschet, M., on the membrane  of the
  fistulous passage, i. 108 ; experiment on
  the communrcability of hydrophobia from
  man to  man, and from man to beast, i.
  403; on the re-union of fractures,  i. 548;
  on the double formation of bony substance
  in fracture, i. 549 ; on the  production of
  callus, i. 549; on the reduction of old dis-
  locations, ii. 206; on the causes of con-
  genital dislocations, ii. 207 ; cases of dis-
  placement of the heart, ii. 361; on the four
  principal kinds of true aneurism, ii. 469;
  on the condition of the artery and vein in
  aneurismal varix, ii.547 ; on the treatment
  of aneurismal varix, ii. 549; on spermato-
  cele, ii. 576; operation for varicocele, ii.
  577;  directions for its performance, ii.
  579; on the nature of corns,  iii. 403.
Bretonneau's, M., treatment of erysipelas
 ■ by moderate  compression, i. 125; con-
  demned by  Lawrence and  Duncan, i.
  125;  on pressure in the treatment of
  burns, i. 134 ;  on tracheotomy in  croup,
  iii. 115.
Bricheteau's, M,, case  of  fatal haemor-
  rhage from leech-bites, iii. 614. 
AL INDEX.
790                        ANALYTIC,

Briesche's, M., case  of  softening of the
  callus, by the internal use of the Carlsbad
  waters, i. 576.
Briggs', Mr., case  of recurrence  of the
  aneurism after the ligature of the artery,
  ii. 499.
Brodie, Sir B. C, on sudden loss of blood,
  a cause  of  mortification,  i. 68 ; case of
  dry gangrene  from inflammation of the
  principal artery and vein  of the limb, i.
  72; on the cause of the distinction between
  dry and moist gangrene, i. 72 ;  gangrene
  from arterial  inflammation a  compara-
  tively rare disease, i. 73 ;  this statement
  denied by Cruveilhier and Dupuytren, i.
  73; ease of fatal haemorrhage consecutive
  to opening a tonsillar abscess, i. 162 ; on
  the rarity of affections of the ligaments
  independent of other structures,  i. 230;
  on the diseases of the synovial membranes,
  i. 238;  on the two varieties of synovial
  inflammation, i. 238; case of acute syno-
  vial inflammation  terminating in  suppu-
  ration and ulceration, i.  238 ; on the sub-
  acute or chronic form of synovial  inflam-
  mation,  i.  239;   on gonorrhceal rheu-
  matism and ophthalmia, i. 242;  on the
  pulpy degeneration of the synovial mem-
  brane, i. 242 ; on the causes and progress
  of the pulpy degeneration, i. 243 ; on the
  local treatment of synovial inflammation,
  i. 245; on the use of friction to promote
  the absorption of the effused fluid, i. 246;
  opinion that cartilages  are vascular, i.
  253 ; on the ulcerative absorption of car-
  tilage, i. 255;  considers that absorption
  of the cartilages may take place  under
  such circumstances, as to admit of no
  other agency than that of  the  vessels of
  the cartilage, i. 259 ; considers ulceration
  of cartilages differs from common syno-
  vial inflammation, and from inflammation
  of the spongy ends of bones, i. 262;  on
  the degeneration of cartilage into a fibrous
  structure, i.  263; on the period at which
  ulceration of the articular  cartilages may
  occur,  i. 264;  on  inflammation  of the
  joint-ends of bones, its symptoms, and
  progress, i. 264;  on the consequences of
  this inflammation, i. 264 ;  on1 the period
  at which it is likely  to occur, i. 266; ob-
  serves that it is likely to occur in several
  joints at once, or in succession, i. 266  ;
  opinion that the occurrence of scrofulous
  disease  in the joints has  suspended the
  progress of some other and perhaps more
  serious disease elsewhere, i. 266; on the
  diagnosis between scrofulous disease of
  the joint-ends of bones and ulceration-of
  the articular cartilages, i. 267;  on the
  removal of the articular cartilages in old
  age, as the result of previous ulceration,
 i. 268;  on the symptoms of  hysterical
 affections  of the joints, i. 277;  on the
 local applications  in  such  disorders, i.
 278; on ulceration of the cartilage, the
 primary affection in diseased hip-joint, i.
.280; on the difference between  hip-dis-
 ease  from  ulceration  of  the  cartilages,
 and that from  scrofulous deposit in the
 cancellous structures of the bones, i. 282;
 explanation of the lengthening of the limb
 in hip-disease,  i. 285 ;  on dislocation into
 the foramen ovale in hip-disease, i. 287;
 on the influence of the primary irritation
 of the issue and the maintaining it by re-
 peated applications of caustic potash, or
 sulphate of copper, i.  295; approved of
 by South,  i. 295; on the use of a seton in
 the groin,  i. 295;  on  warm bathing, i.
 296; on the importance of rest and posi-
 tion, i. 296; 'on  the treatment of abscesses
 at the hip, i. 298;  recommends free in-
 cisions in opening these abscesses, i. 299;
 on the management of abscesses at the hip,
 i. 299; on the diagnostic symptoms of the
 diseases of the  knee, i. 302; on ulceration
 of the cartilages of the knee, i. 302; on
 scrofulous  disease in the cancellated struc-
 ture of the bones of the knee, i. 304; pro-
 gress of the caries, i. 304; on curvature
 of  the spine from caries, i 308 ;  on the
 occurrence of suppuration in caries of the
 vertebrae, i. 309 ; on the disappearance of
 psoas abscess, and its re-appearance else-
 where, i. 309 ;  on  the pain  in vertebral
 caries, i. 309; on the extent of the. curva-
 ture  in  dorsal  caries, i. 309;  on  the
 pathology  of  spinal caries,  i. 310; on
 chronic  inflammation   of the  vertebrae,
 with ulceration of the inter-vertebral car-
 tilage, i. 311 ;  on the diagnosis between
 curvature of the spine from caries and
 that from rickets, i. 312; on the applica-
 bility of issues in this disease, i. 313; on
 the manner in which the disease is cured
 by anchylosis, i. 314;  on vertebral caries
 in  the neck, i. 315;   on  abscess  con-
 nected with vertebral caries in  the neck,
 i. 315 ; on  the period of the accession of
 tetanus after the  receipt of  the  injury,
 i. 415; on  the  removal of foreign bodies
 in injuries  of the brain, i. 438; on punc-
 turing  the dura mater when the extra-
 vasation lies   beneath  it, i. 447; only
 employs trepanning in injuries  of  the
 head, when secondary symptoms of irri-
 tation and  pressure require it, i. 454; on
 softeriing of the spinal cord after a severe
 blow, i. 588;  on  the  attempt to set a
 fracture  through the body of a vertebra,
 i. 588 ;  on the  operation for trepanning
 the spine, i. 589; on fracture of the lower
 end of the  radius, i. 611; on the formation 
ANALYTICAL INDEX.
791
of a false joint, with a fibro-ligamentous
capsule and a lining membrane, ii.  14;
on the operation of sawing off the ends of
the broken bone, ii. 18;  on  the  impro-
priety of operating for fistula in phthisical
subjects, ii. 164; on the treatment of large
abscesses high up by the side of the rec-
tum, ii. 165; on internal erysipelas follow-
ing the operation for fistula, ii. 168;  on
spasmodic contraction of theanus, ii. 171;
on spasmodic contraction of the sphincter,
attended with ulceration, ii. 171; on the
treatment,  ii. 172; on incomplete internal
urinary fistula, ii. 175 ;  on the causes of
fistula in perineo, ii  181; on the causes of
perineal abscess, ii. 181; on the treatment
of fistula in perineo, ii.  183 ; case of ma-
lignant disease consecutive on neglected
perineal  fistula, ii. 183 ; on the treatment
of prolapsus ani in children,  ii. 401;  on
the treatment of prolapsed rectum with
piles  in the adult, ii. 403; case  of wry-
neck  alternating with insanity, ii. 422;
on the application of the ligature in  te-
leangiectasy, ii. 563 ; on the effects of in-
flammation on the blood in veins, ii. 588;
case of varicose veins of the fore-arm, ii.
569;  cases of varicose veins  of  the arm
and chest  from  compression of the sub-
clavian vein, ii.  569 ; on  the  application
of adhesive plasters  in the treatment of
varix, ii. 770 ; on the subcutaneous divi-
sion of the vein  in varix, ii. 572 ; on the
application of caustic in varix, ii. 572 ; on
the removal of internal piles by ligature,
iii. 10; cases in which severe symptoms
followed the application of the  ligature for
piles, iii. 11 ;  on the application of the
ligature for piles, iii. 11 ;  on  excision of
piles, iii. 12; on  ulceration  of the rectum,
in connexion with spasmodic  contraction
of the sphincter, iii. 41;  on  the occur-
rence of symptoms of strangulated hernia
in some cases of stricture,  iii. 44; on the
post-mortem appearances  in  stricture of
the rectum, iii. 44 ;  on  the seat of stric-
ture in the rectum, iii. 46; on the neces-
sity of early treatment in stricture of the
rectum, iii. 48;  on the  distention of the
bowel above the stricture  by faeces, iii.
48;  on the use  of  bougies,  iii. 49;  on
the internal appliction of  mercurial oint-
ment in  stricture of the rectum, iii. 50;
on incision of the stricture, iii. 51; on in-
continence of urine  in stricture of  the
urethra, iii. 64; on extravasation of urine
from ruptured urethra in stricture, iii. 64;
on  abscesses  communicating with  the
bladder in old cases of stricture, iii. 64; on
the complication of stricture with enlarged
prostate, iii. 65; case of enlargement of
the urethra from stricture, iii.  65 ; on the
formation of cysts of the urethral mucous
membrane in stricture, iii. 66; on the oc-
currence of rigours and fever in stricture
iii. 66;  on the existence of an indurated
mass at the  lower portion of the penis in
old strictures, iii. 67; on the original seat
of stricture, iii. 67 ;  on the use of a full
sized bougie in  determining  the  seat of
stricture, iii. 70; on the passing a bougie,
iii. 70; on the treatment of stricture with
bougies, and on their applicability to the
various  kinds of  stricture, iii. 71; direc-
tions for the introduction of bougies, iii.
73 ;  on  the destruction of stricture by
ulceration, iii. 78; on the use of thearmed
bougie, iii.  79 ;  case of apple-core in the
rectum, iii.108; case of abscess by the side
of the rectum from  the irritation of a fo-
reign body,  iii. 108; case of foreign body
in the bronchus, iii. 117; on abscess of the
prostate, iii. 137; on catheterism in in-
flammation  of the prostate, iii. 137 ; on
chronic  enlargement  of the  prostate,
iii. 138 ; on the characters of enlarged
prostate, iii. 141 ; on the rare occurrence
of ruptured  bladder from  retention of
urine in enlarged prostate, iii. 141; on the
treatment of enlarged  prostate, iii. 142;
on the treatment of retention of urine from
enlarged prostate, and on catheterism in
such cases,  iii. 142; on effusion of blood
into  the cellular tissue of the scrotum, iii.
175; on haematocele complicated with
dydrocele, iii. 176; case of haematocele in
which the tunica vaginalis ruptured, iii.
176; on hydrarthrus, iii.  182;  case of
hour-glass hydrocele, iii. 221; case of very
large hydrocele, iii. 221; on the  sponta-
neous cure of hydrocele, iii. 223 ; case of
relapse  of a hydrocele  a longtime after
the operation, iii. 228;  case  of  foreign
body the nucleus of a stone, iii. 249; on
the treatment of uric acid gravel, iii. 266;
on the connexion between uric acid calculi
and  gout, iii.  266;  on  renal  calculi of
oxalate of lime, iii. 266; on the symptoms
of renal calculi, iii. 267;  case of renal
calculus, iii. 268 ; on the passage of renal
calculi into  the bladder, iii. 268; cases of
renal calculus communicating with ab-
scess in  the loins, iii. 268;  on the treat-
ment of  renal calculi, iii. 268; on gouty
inflammation of the kidneys, iii. 269; on
the symptoms of stone in the ureters, iii.
269 ; case of inspection of calculus in the
ureter, iii. 270 ; on the prevalence of cal-
culi in different classes of society, and at
different ages, iii. 271; case  of encysted
calculus, iii.  274; on the spontaneous
breaking up of calculi in the bladder, iii.
274 ; on  sounding, iii. 277 ; on the exist-
ence of calculous symptoms, without the 
792                        ANALYTICAL  INDEX.
   presence of a stone in the bladder, iii. 277;
   on the use of stone solvents, iii. 281; on
   the dilatation of the urethra, iii. 283; on
   the dilatation of the female  urethra, iii.
   283; case of enoysted  calculus removed
   by the lateral operation, iii. 310; on the
   external incision in lithotomy, iii. 311; on
   the section of the prostate and bladder, iii.
   318; on contraction of the bladder during
   lithotomy, iii. 331;  on the effects of he-
   morrhage in  lithotomy, iii. 334 ; case of
   fatal venous hemorrhage in lithotomy,iii.
   334 ; case of secondary hemorrhage after
   lithotomy, iii.  335; on  the  dangerous
   symptoms which follow the incision of the
   prostate extending into the loose cellular
   texture surrounding the neck of the blad-
   der, iii. 341; on thereoto-vesical operation,
   iii. 344; on the expulsion of small calculi
   from the bladder in women, iii. 349 ; case
   of ulceration of the bladder and vagina
   from the pressure of a large calculus, iii.
   349 ;  modification of the vertical cut up-
   wards,  iii. 350; on the  incontinence of
   urine consequenton lithotomy in women,
   iii. 353; on the occurrence of hemorrhage
   and of rigors after lithotrity, iii. 359 ; on
   the cases in which lithotrity should be
   performed, and on those in which litho-
   tomy should  be preferred, iii. 360; on the
   nature of corns, iii.  403 ;  on  lipoma dif-
   fusum, iii. 426 ; case of fatty tumour con-
   nected with the spermatic cord within the
   abdominal ring, iii. 428; on inflammation
   of fatty tumours running on to abscess, iii.
   429; opinion that fatty tumours sometimes
   take on a malignant degeneration, iii. 429;
   case of fatty tumour  partially removed by
   liq. potassae,  iii. 429; on simple cysts in
   the femaw breast,  iii. 432 ; case of long-
   standing scirrhus, iii. 509; on scirrhus of
   the breast, iii. 527; on  scirrhus of the
   nipple,  iii. 529; on the  puckering in of
   the skin in mammary cancer, and on its
   cause, iii. 529; on sero-cystic tumors of the
   female breast, iii. 535; on'the question as
   to the propriety of removing a  scirrhous
   breast, iii. 539;  on the circumstances per-
   mitting the operation, iii.  539.
Bromfield, Mr., on incisions and injections
   of bark and tincture of myrrh in carbun-
  cle, i. 157 ; invention of the tenaculum,
  i. 355; case of necrosis from irritation, ii.
   121; operation for stone in the bladder,
  iii.  317; on  amputation just above the
  ankle,  iii. 674.
Bronchocele, iii. 385; definition and cha-
  racters, iii. 385; symptoms when the bron-
  chocele is large, iii. 385; varieties, iii. 385;
  symptoms and treatment of inflammation
  of the thyroid gland, iii. 386 ; vascular or\
  aneurismatic bronchocele, iii. 386 ; charac-
  ters, iii. 386; lymphatic bronchocele, iii. I
   386; characters,iii.387; seat of the disease,
   iii. 387; South on lymphatic bronchocele
   and serous cysts in the neck, iii. 387;
   scirrhous bronchocele, iii. 388; characters,
   iii. 388; causes of bronchocele, iii. 388;
   M'Clellan on the cause of bronchocele, iii.
   388; Inglis and  Copland  on the age at
   which bronchocele is most usual, iii. 389;
   Dr. Robertson and  M'Clellan on  bron-
   chocele as a variety of scrofula, iii. 389;
   prognosis, iii. 389; treatment, iii. 390; in
   vascular bronchocele, iii. 390; ligature of
   the  superior thyroideal  artery, iii. 390 ;
   mode  of operating, iii.  391; after-treat-
   ment, iii. 392 ; relative value of this ope-
   ration,  and  other  modes  of  treatment
   formerly recommended, iii.  392 ; the tu-
   mour may increase in size after this ope-
   ration from the enlargement of the inferior
   thyroid, and  its communicating with the
   superior, iii. 392; Coates and Wickham's
   case in which the bronchocele ultimately
   enlarged, after the ligature of the superior
   thyroid, iii. 392; ligature of the inferior
   thyroid  artery, ii'.  392;  treatment  of
   lymphatic  bronchocele, iii. 392 ;  exhibi-
   tion of burnt sponge and iodine, iii. 392;
   dangerous  symptoms caused  by  large
   doses of iodine, and  their treatment, iii.
   394;  contra-indications  to  the  use  of
   iodine,  iii. 394;  Graefe's  treatment  of
   bronchocele,  iii. 394 ; Inglis' objections
   to Coindet's mode  of exhibiting iodine,
   iii. 395; Dr. Gairdner on the dangerous
   symptoms occasionally caused by iodine,
   iii. 395 ; South on the exhibition of iodide
   of potassium, iii. 395 ; external remedies
   for bronchooele, iii. 395; South on the
   employment of iodide of potassium in the
   form of ointment, iii.  396; ligature of the
   superior  thyroid  artery  in  lymphatic
   bronchocele,  when it presents a  cartila-
   ginous hardness, iii. 396; employment of
   the seton, iii. 396; mode of applying it,
   iii. 396; fatal results have occasionally
   followed its use, iii. 397 ; incision of the
   bronchocele,   iii.  397;  puncturing the
   bronchocele, iii. 397; Maunoir's treatment
   by puncture,  and irritating injections, and
   by seton, iii.  397 ;  extirpation  very dan-
   gerous, and  to be almost  entirely for-
   bidden, iii. 398; cases in which extirpa-
   tion is admissible, and mode of operating,
   iii. 398; Green's case, iii. 398; Mayor and
   Bach's extirpation of bronchocele by liga-
   ture, iii. 398; Regal de Gaillac's extirpa-
   tion of bronchocele by subcutaneous liga-
   ture, iii. 398.
Brown's, Dr., case of a piece of broken delf
   plate in the oesophagus, iii.  98.
Brown's, Mr., treatment of ovarian dropsy,'
   iii. 210.
Brown, Mr., removal of the acromion and 
ANALYTICAL  INDEX-
793
  glenoid cavity in amputation of the shoul-
  der-joint, iii. 717.
Bruckner, M., on the causes  of club-foot,
  ii. 446.
Brugman's, M., opinions  relative to the
  formation of pus, i. 52.
Briinninghausen's, M., straps for fractured
  clavicle, i. 603; objected to, i. 603; ap-
  paratus for fracture of the  neck of the
  femur, i. 624; on  permanent extension
  in fracture of the femur, i. 628; on the
  spontaneous cure of umbilical rupture, ii.
  346 ; artificial leg, iii. 593 ; recommenda-
  tion to swathe a limb in flannel, prior to
  amputation, to diminish the loss of bjood,
  iii. 638; mode of amputating by the cir-
  cular incision, iii. 640 ;  management of
  the periosteum, iii. 642.
Bryce's, Dr., mode of amputating at the
  hip-joint with the flap-cut with a single
  flap, iii.  691.
Buchanan's, Mr., operation of puncturing
  the  abdomen  through the  bladder for
  dropsy, iii. 208.
Bucking's, M., apparatus for fracture of the
  patella, i. 633.
Bujalsky, M., on ligature of the innomi-
  nata, ii.  522; operation for tying the
  internal iliac, ii. 534;  on the ligature of
  the, external  iliac, ii 538 ; case of  exci-
  sion of a portion of the accessory nerves
  of Willis, iii. 636.
Bulley, Mr., on simultaneous dislocation
  of the radius forwards and  of the  ulna
  backwards, ii. 232.
Bullock's, Mr., case of a  quartz pebble
  in  the upper  part of the  larynx, iii.
  111.
Burchard's, Mr., obturator for vesico-va-
  ginal fistula, ii. 189.
Burder, Mr., on  erethismus  mercurialis,
  ii. 109.
Burns,  Mr. Allan,  on the  spontaneous
  bursting of a  tonsilar abscess, i.  161 ;
  attended with much danger, i. 161  ; de-
  tails of a case in which  the trachea was
  deluged with purulent matter, and  death
  by suffocation ensued, i. 161;  advice in
  such cases to tap the  abscess with  trocar
  and canula, i. 162; directions for opening
  a tonsillar abscess, i. 162;  case of fatal
  hemorrhage  consecutive to opening the
  abscess, i. 162 ;  on, the formation, of cal-
  culi in the tonsils, i. 162; on the fre-
  quency of congenital rupture in the fe-
  male, ii. 328; on carotid aneurism,ii..507;
  proposal to tie the innominata, ii.  521 ;
  on the difference between.fungus hema-
  todes and  sarcoma medullare,  iii. 460;
  on extirpation of the parotid, iii. 524.
Burns, Mr. John, on the treatment of scro-
  fulous ulcers, ii. 53 ;  on prolapse of the
  vagina,  ii.  389; on the  anteversion of
  the womb,  ii. 412.
Burns :—causes of burns, i. 126; different
  degrees of burns, i.  126; Dupuytren's
  subdivision of burns, i. 126 ; first degree
  of burn, a bright uncircumscribed redness
  of the skin, i.  126 ; second degree, vesi-
  cation, i. 126 ; third, more intense burn,
  with destruction of the cuticle and rete
  mucosum, i. 126 ; fourth,  gangrenous de-
  struction of the parts, i. 126; symptoms
  of each degree of burn, i. 126, 127; South
  on burns, i. 127;  burns  generally more
  dangerous  than scalds, i.  127 ; complete
  immersion  of  a  person in boiling water
  fatal in ten or fifteen minutes, i. 128;
  persons whose  entire surface has been
  charred by  fire may live for several hours,
  i.  128:; the danger of burns and scalds is
  the greater in reference  to the part in-
  jured, i. 128 ;  treatment  of the slightest
  degrees of burns, i.  128; treatment  of
  parts deprived of the cuticle, i.  128; after
  suppuration is established, i. 128; when
  mortification is caused by the burn, i. 129;
  various remedies  for  burns, i.  129;
  Fricke's solution of lunar caustic, i. 129;
  Larrey's plan of treatment, i. 129 ; Lis-
  franc's employment of the solution of the
  chlorate of lime, i. 129 ; Earle on  cold
  moistapplications, i. 129; Hunter on cold,
  i.  129; Kentish's plan  of treatment,  i.
  130 ;  mode of application as stimulants,
  i.  13ft; disapproval of frequent dressings,
  i.  131 ;  application of raw cofcton.,i. 13:1;
  Gibson, Dallam, and Anderson  on raw
  cotton, i. 131; only applicable in snper-
  ficial burns, i. 131; employed  by  Ander-
  son in recent and old burns, vesicated and
  sphacelated, i. 132;  preparation of the
  cotton, i. 132; application of flour, i. 132;
  Dr. Ward  on  the  application of flour,  i.
  132; mode of application, i. 132; Ward's
  objection  to liquid applications, i. 132 ;
  modus operandi of the flour, i. 133; Mar-
  shall on the application of the flour, i. 133;
  South on the  use of flour, i. 133; Hunter
  on, the primary treatment of burns, i. 133;
  Bretonneau and Velpeau on pressure in
  the treatment  of burns, i. 13.4; Velpeau
  considers  compression best adapted  to
  cases  of   burn  in the third and fourth
  degrees, but also applicable in those of
  the second degree, i. 135; mode of appli-
  cation of compression, i.  135; advantages
  of this plan  of treatment according to
  Velpeau,  i. 135;  Earle  on the removal
  of the clothes after burns and scalds,  i.
  135; South on the treatment of burns and
  scalds, i. 135; Higginbotham's treatment
  by the nitrate  of silver, i. 136;  immediate
  amputation inadmissible, even when  an
67 
794
ANALYTICAL INDEX.
  entire limb has perished; the line of de-
  marcation must  be first formed, i. 136;
  when the destruction of skin on a limb
  has been very extensive,  leaving large
  wounds without a disposition to heal, and
  exhausting the strength by the extent of
  suppuration, amputation should  be per-
  formed, i. 137;  burns from gunpowder,
  i. 137; the grains of powder to be picked
  out of the face with a lancet or needle, i.
  137; employment  of internal remedies,
  i. 137 ; the antiphlogistic treatment re-
  quisite if the inflammation  be high, i.
  137; opium  required to relieve the pain,
  i. 137; South on the internal treatment
 of  burns  and scalds, i.  137; the occur-
  rence of rigors to be met with stimulants,
  and external warmth, i. 137 ; exhibition
  of opium, i. 187; objections to its use, i.
  137; protracted sickness and vomiting
  an  unfavourable  sign, i. 138; treatment
  of  febrile excitement, i. 138; support to
  be  given  during suppuration, or the se-
  paration  of sloughs, i. 138; great care
  required during the process of cicatriza-
  tion, i. 138;  tendency of the cicatrix to
  contract,  i. 138; Earle on the  contraction
  of  the cicatrices, i. 138; the  contraction
  the result 6f a  natural process, i. 138;
  Hunter on the contraction of the granula-
  tions during cicatrization,!.  138; South
  on  the  effects of this contraction, i. 139;
  Earle on  the effects of the contraction, i,
  139; division of the  contracted cicatrix
  followed  by the reproduction  of the con-
  traction when the wound had healed, i,
  139; the same effect followed the removal
  of  the webbed portion of the scar, i. 139;
  Earle's operation for the removal of the
  entire  cicatrix,  i.  139;  Earle's  case in
  which this operation was performed, i.
  139;  case  by South, i.  14C;  Mutter's
  plastic operations for the relief of defor-
  mities from burns, i, 142 ; occurrence of
  abdominal disorder and diarrhoea during
  the cicatrization of extensive burns, i,
  143.
Bursae mucosae, dropsy of, iii.  178,
Bush's, Mr., apparatus for fracture of  the
  lower jaw, i. 580.       ^
Bushe,  Dr., describes  two forms  of pro?;
  lapsed rectum, ii.  398; on the characters
  of prolapse of the rectum, ii.  395); on  the
  diagnosis between prolapsed  rectum and
  haemorrhoids  and  intusrsusception  ii
  399; on the changes in the mucous mem-
  brane of the rectum in old prolapses, ii.
  400; on relaxation of the anus, ii. 405;
   on relaxation of the rectum  with invagi-
  nation of the mucous membrane, ii. 405;
   on the local symptoms of piles, ii. 582;
   on the effeets of loss of blood from piles.
  ii. 582; on the removal of internal piles
  by ligature, ii. 583 ; on the treatment of
  haemorrhage after the removal of piles,
  ii. 585; on spasmodic  contraction of the
  anus, iii. 41;  on stricture of the rectum,
  iii. 46; on the  seat of the  stricture, iii.
  47.
Butt's, Dr., case of excision  of the lower
  part  of the  ulna on account  of necrosis,
  iii. 735.

Cachexia syphiloidea ormercurialis, i. 110.
Caesarean operation, iii.< 155.
Calculus, urinary: Magendie, von  Wal-
  ther, Austin, Wetzler, Willis, and Jones,
  on the formation of calculi, iii.  237 ; ge-
  neral constituents of calculi, iii. 241; other
  and more rare constituents, iii. 241; Tay-
  lor on  the rarity of carbonate of lime cal-
  culi, iii. 242; uric acid and uriate of am-
  monia, iii. 242 ; the combination of, uric
  acid  with ammonia, and its  precipitation
  in the free state on the cooling of the urine,
  iii. 244; the development  of free acids in
  the urine, iii. 244; oxalate of lime, iii. 244;
  frequently forms the nucleus of a calcu-
  lus but not uncombined, iii. 244; a cal-
  culus of almost pure oxalate of lime has
  been met with, iii. 244; Prout and Walther
  on the origin of oxalic acid in the urine,
  iii. 244; presence of free oxalic acid in
  the urine, iii. 244; combinations of oxalic
  acid, iii. 245; cystin, iii. 245; calculi of
  cystic  oxide rare, iii. 245;  usually consist
  entirely of this substance, but occasionally
  met  with  as nuclei of other calculi, iii.
  245;  formation of cystic  calculi, iii.
  245; chemical composition, iii. 246; xan-
  thic oxide, uric oxide, iii. 246; of very rare
  occurrence,iii.246;chemical composition,
  iii. 246; never occurs  in solution, or as a
  precipitate from the urine, iii. 246; phos-
  phate of ammonia and magnesia, iii. 246;
  causes of its formation, iii. 246; Jones on
  the  phosphatic diathesis, iii. 247;  con-
  necting material of calculi, iii.247; causes
  of the production of gravel and calculi,
  iii. 247; remote causes, iii. 247; Taylor on
  the  calculi  of children,  ii.  248; foreign
  bodies in the bladder act as the nuclei of
  calculi,  iii.  24-; foreign bodies rarely
  coated with uric aoid, iii. 246;  South on
  foreign bodies as the nuclei of stones, iii.
  218; Astley Cooper, Brodie, and Everard
   Home's cases, iii, 249; A. White and Ar-
  not?s oases  of foreign bodies  in the va-
  gina,  the bladder injured, and formation
  of calculi, iii. 249; varieties of calculi, iii.
  250; characters, iii.  250;  characters of
   uric acid calculi, iii. 250; of uriate of am-
   monia, iii. 250 ; of mulberry stones, iii.
   250; of hempseed calculi, iii. 250; of the 
ANALYTICAL INDEX.                        795
earthy phosphates, iii. 250; of the phos-
phate of lime, iii.250; of the fusible stone,
ui. 250 ; of the eystic oxide, iii. 250 ;  of
xanthic oxide,  iii. 251 ;  of carbonate  of
lime, iii. 251; physical characters of cal-
culi, iii. 251; division of calculi according
to their chemical composition, iii. 252 ;
frequency of the  different kinds of cal-
culi, iii.  252 ;  amorphous urinary sedi-
ments, iii. 253;  Dr. Prout on lithic or uric
acid sediments, iii. 253; characters of yel-
low sediments, iii. 253; of red or lateri-
tious sediments, iii.  253; of pink sedi-
ments, iii. 253; white lithate or urate of
soda sediment, iii. 254;  characters and
accompanying  symptoms of  the  phos-
phatic sediments, iii. 254 ; causes of the
phosphatic sediments, iii.  255;  oxalate
of lime sediment, iii. 255; characters of
the  urine  in cystic  oxide  calculus, iii.
255; gravel, iii. 256; definition and cha-
racters, iii.256; Magendie on hairy gravel,
iii. 256; symptoms  of gravel, iii. 256;
 Prout on the characters and symptoms of
crystallized  uric  acid  gravel, iii. 256;
 Prout on the crystallized phosphatic se-
diments, iii. 256; Prout  on the rarity of
crystallized  oxalate  of lime gravel, iii.
257; symptoms of the oxalate diathesis,
iii. 258; causes and treatment, iii. 258;
treatment of gravel, iii. 258 ; of uric acid
 gravel, iii. 258 ;  Wetzlar, Jones, Wil-
 son Philip, and Brodie on the treatment
 of uric acid gravel, iii.  259; Prout  on
 the  treatment of a fit of the gravel, iii.
 260;  Jones on the treatment of uric acid
 gravel;  iii. 260;  treatment  of  cystio
 oxide gravel,  261;  of oxalate  of lime
 gravel, iii. 261; of phosphate  of lime
 gravel, iii. 262; Prout on the treatment of
 cystic oxide gravel, iii. 262;  Prout and
 Jones on the treatment of the oxalate of
 lime diathesis, iii,a62 ; Prout and Jones
 on the treatment of the  phosphatic dia-
 thesis, iii. 263; stones in the kidneys, iii.
 265;  situation, iii.  265;  Prout on the
 formation of uric acid calculi  in the kid-
 neys, iii. 265; Brodie on the oonnexion
 between uric  acid calculi  and gout, iii.
 266 ; Prout and  Brodie  on renal calculi
 of oxalate of lime, iii. 266; Prout on renal
 calculi of cystic oxide, iii. 267; Prout on
 the rarity of phosphatic renal  caleuli, iii.
 267 ; diagnosis, iii. 267  ; symptoms, iii.
 267;  Brodie on  the symptoms  of renal
 calculi, iii. 267;  Astley Cooper and Bro-
 die's cases, iii. 267 ; progress of stone in
 the kidney, iii. 267; Brodie on the  pas-
 sage of renal calculi into the bladder, iii.
 267; Hevin, Astley Cooper and  Brodie's
 cases of renal calculi communicating with
 abscess in the loins, iii. 268; Crisp's case
of fracture of a renal calculus by sudden
exertion, iii. 268; treatment, iii. 268 ; re-
moval of the calculus by nephrotomy, iii.
268 ; directions for the operation, iii. 268;
Brodie  and South  on the treatment of
renal calculi, iii. 268; Prout on the treat-
ment of nephritis complicating renal cal-
culi, iii.  268; Brodie on gouty inflamma-
tion of the kidneys, iii. 269 ; stone in the
ureters, iii. 269; symptoms, iii. 269; treat-
ment, iii. 269; Brodie on the symptoms of
stone in  the ureter, iii. 269 ;  Brodie and
Travers' cases of impaction of calculi in
the ureters, iii.  270; Cline  and  Astley
Cooper's cases of suppuration of the kid-
ney from impaction of calculi in the ure-
ters, iii.  270; Astley Cooper on the treat-
ment of calculi in the  ureters, iii. 270;
stone in  the bladder, iii. 271} origin and
varieties, iii. 271 ; Brodie  on the  preva-
lence of calculi in different classes of so-
ciety, and at different ages,iii. 271; Smith
on the  statistics of lithotomy, iii. 271;
Copland Hutchinson on the rarity cal-
culus among seamen, iii. 271; forms of
calculi in the bladder, iii. 272; characters
and situation, iii. 272; sacculated and  ad-
herent oalculi, iii. 272 ; Taylor on  hour-
glass calculi, iii. 273; Cline, Mayo,Astley
Cooper, Smith and Cheselden's oases of
large calculi, iii. 273 ; Martineau's cases
of very  small  stones,  iii. 273;  Astley
Cooper's ease of a great number of calculi
in the bladder, iii. 273;  Pott's case of fu-
sible calculus in a vesical rupture,iii. 273;
Brodie's case of encysted calculus,iii,274;
Wickham's case of caloulus enclosed  ina
hag of  lymph inorusted with oaloulous
matter, iii. 274; Brodie, Proutand Crosse
on the spontaneous breaking up of cal-
culi in the  bladder, iii. 275; symptoms
of vesical calculus, iii. 275; Prout on the
symptoms of vesical calculus, iii, 275;
sounding the  bladder,  iii. 277;  Klein,
 Brodie, and  South on sounding, iii. 277;
 Brodie and South on the existence of cal-
 culous symptoms, without the presence of
a stone  in the bladder, iii.  277 ; South on
 the  simulation   of  caloulus by  vesical
 polypus, iii. 277; measuring the  size of
 the calculus, iii. 278 ; South on measuring
 the calculus, iii. 278; various modes of
 treatment, iii. 278 ;  internal  use of stone-
 solvents, iii. 279 ; empirical remedies, iii.
 279;  efficacy of stone-solvents, iii. 279;
 Liston's case of partial sol ution of a stone
 in the bladder,  iii.-280; injection of  sol-
 vents into the bladder, iii. 280; directions
 for the use of solvent injections, iii. 280;
 difference of opinion as to the value of
 these modes of treatment, iii. 980;  Pe-
 louze's experiments, iii. 281;  Prout  and 
796
ANALYTICAL  INDEX.
Brodie on  the use of stone-solvents, iii.
281;  dissolving stone by means of the
galvanic pile, iii. 282; the apparatus and
its application, iii. 282;  extraction of the
stone through the urethra, iii. 283; by di-
latation, iii. 283; principally applicable to
females,  iii. 283;  mode  of effecting the
dilatation, iii. 283;  Brodie on the dila-
tation  of the urethra, iii. 283;  Astley
Cooper, Liston and  Brodie on the dila-
tation of the female urethra, iii. 283;
crushing the stone,—lithotrity, iii. 2W5;
Gruithuisen, Eiderton,  and  Sanctorius'
lithotritie instruments, iii. 285;  case  of
the Monk of Citeaux, iii.  286; General
Martin's case, iii.  286; improvement of
lithotritie instruments,  iii.  286; three
classes of lithotritie instruments, iii. 287;
relative value of these  instruments,  iii.
287; advantages and disadvantages of the
three-limbed perforating forceps, iii. 288;
of Jacobson's  instrument, iii. 288;  of
Heurteloup's percuteur,  iii.  288; treat-
ment prior to the operation, iii. 288 ; posi-
tion of the patient, iii. 289; mode of ope-
rating, iii. 289 ;  with the three-limbed
perforating forceps of Civiale and Leroy,
iii. 289;  with Jacobson's instrument, iii.
289; with Heurteloup's percuteur, iii. 291;
duration  of a lithotripti© sitting, iii. 292;
treatment after the  operation, iii. 292 ;
escape of sand and calculous fragments,
iii. 292;  arrest of fragments in the  ure-
thra, iii.  293; breaking up the fragments
in the bladder, iii. 293 ; treatment of frag-
ments of calculus fixed in the urethra,
iii. 293 ;  by extraction, iii. 293 ; removal
by incision, iii. 294; examination of the
bladder when the calculous  symptoms
have ceased,iii. 294; lithotrity in women,
iii. 294 ; cuttpigfor the stone,—lithotomy,
iii.' 296 j definition,  iii,  297; should be
performed early, iii.  297  ; circumstances
contra-indicating, the  operation, iii. 297;
Cline,. Attenburrow and ^ Astley Cooper's
cases of  old  men operated on for stone,
iii. 297; Keate, Hunter and Civiale's ope-
rations on infants, iii. 2.97; Green's case of
lithotomy in a fat man of 50 years of age,
iii. 298;  preparation  of the patient for the
operation, iii. 298; cutting for the  stone in
man, iii.  298 ;  with  the little or Celsian
apparatus, iii. 299; mode of operating, iii.
299 ; objections to the operation, iii. 299 ;
cutting for the stone with the great appa-
ratus, iii. 299; mode of operating, iii 299 ;
advantages of this operation over the little
apparatus,  iii.  300;  the  high operation,
iii. 301; mode of operating, iii. 302; modi-
fications  of the operation, iii. 303 ; dress-
ing the wound, iii.  304; the prevention
of infiltration of urine from this operation,
 iii. 305; treatment of the wound for some
 days, iii. 305 ; untoward  circumstances
 during and after the operation, iii. 305;
 advantages and disadvantages of the ope-
 ration, and cases in which it is applicable,
 iii. 305; Cheselden on the high operation,
 iii. 306;  the lateral  operation, iii. 307;
 Rau's mode of operating, iii. 307; Chesel-
 den's operation for stone, iii.  309; pre-
parations for the operation, iii. 309; South
 on the binding a patient prior to the ope-
 ration, iii. 310; mode of operating, iii.
 310 ; Brodie's case of encysted calculus
 removed by the lateral operation, iii. 310;
 South's case  of stone undetected  by the
 sound during eight years, iii. 310; Brodie
 and  South on  the external incision, iii.
 311 ; Scarpa  on the division of the pros-
 tate, iii. 312;  Key and  Liston's  modes
 of operating for stone, iii. 313, 314 ; Dr.
 James Douglas and Sharp on Cheselden's
 operation, iii. 314; Douglas on the dis-
 section of the parts concerned in this ope-
 ration, iii. 315; "Martineau and  Brom-
 field's operations, iii. 317; Brodie on the
 section  of the  prostate and  bladder, iii.
 318 ; use of Langenbeck's knife, iii. 319;
 Thomas Blizard, Astley Cooper,and Tyr-
 rell on the section of the prostate, iii. 320;
 extraction  of the  calculus, iii. 320; use
 of the cutting gorget, an improvement on
 Cheselden's bluntgorget, iii. 321; Cline's
 gorget, iii. 321; Scarpa's gorget,.iii. 321;
 Astley Cooper  on opening the membran-
 ous part of the urethra, iii. 321 ; South on
 the use of the cutting gorget, iii. 321; ob-
jections to the  cutting gorgets, iii. 324;
 South's opinion that these objections are
 groundless, iii. 324 ; Le Cat  and Pajola's
 mode of operating for stone,  iii. 324; ob-
jections to the  operation, iii, 325;  Frere
 Come's operation with the lithotome cache,
 iii. 326 ; disadvantages of the instrument,
 iii. 326;  Boyer's  mode of  using Frere
 Come's lithotome,?iii. 327; Dupuytren's
 bilateral section, iii. 327 ; mode of operat-
 ing, iii. 327; Beclard's modification of the
 operation, iii. 327; advantages and disad-
 vantages of the operation, iii. 328; extent
 of the incision in the prostate and neck
 of the bladder, iii. 329 ; extraction of the
 stone, iii. 329 ; obstacles to the extraction
 of the stone, iii. 330 ; taille on deux terns,
 iii. 330 ; Brodie and South on contraction
 of the bladder during lithotomy, iii. 331;
 extraction of  the  stone when enclosed
 by a contracted bladder, iii. 331; of an en-
 cysted  stone, iii.  332 ; of a stone lodg-
 ing in the,ureter, and  projecting into the
 bladder, iii. 332; of a stone lying in a
 hollow,  iii. 332 ; of a stone covered with
 fungosities, iii. 332; of a brittle and easily 
ANALYTICAL  INDEX.                        797
 breaking stone, iii. 332 ;  dressing the
 wound, iii. 332; haemorrhage during the
 operation, iii. 333 ;  from the branches of
 the  superficial  perineal artery, iii.  333 ;
 from the inferior haemorrhoidal, iii. 333 ;
 from the internal haemorrhoidal, iii. 333;
 from the internal pudic, iii. 333; from
 the  vesical, iii. 333;  treatment  of the
 haemorrhage, iii. 333 ; Erard, Dupuytren,
 and von  Graefe's compressors, iii. 333;
 Shaw's case of fatal haemorrhage in litho-
 tomy, from wound of the dorsal artery of
 the penis, iii. 334; Brodie on the effeots of
 haemorrhage in lithotomy, iii. 334 ; South
 on the treatment of haemorrhage  during
 and after the operation, iii. 334; Brodie's
 case of fatal venous haemorrhage in litho-
 tomy, iii. 334; symptoms of haemorrhage
 into  the  bladder after  the  operation, iii.
 334;  South on secondary haemorrhage
 after lithotomy, iii. 335;  Brodie,  Earle,
 Travers,  Green, and South's cases, iii.
 336; wounding the rectum, iii. 336; South
 on wounding the rectum,  iii. 337 ; con-
 vulsions and fainting, iii. 337 ; after-treat-
 ment, iii. 338 ;  South on the treatment to
 be adopted after the operation for litho-
 tomy, iii. 338;  causes and  treatment of
 inflammation after the operation, iii. 340 ;
 of spasm, iii. 340; Key on suppurative in-
 flammation of  the  cellular  tissue  sur-
 rounding the  bladder the  most frequent
 cause of  death  after lithotomy, iii. 340 ;
 Brodie on the dangerous symptoms which
 follow the incision of the prostate exten-
 ding into the loose cellular texture sur-
 rounding the neck of the bladder, iii. 341;
 treatment of the conseoutive haemorrhage,
 iii. 342 ;  abscesses about the neck of the
 bladder,  iii. 342; incontinence of urine
 and  impotence, iii.  342;  disposition to
 lithogenesis, iii. 342; opening the bladder
 from the perinaeum, iii. 343; Foubert's
 operation, iii. 343; cutting for the stone
 through the rectum, iii. 343 ; Brodie on
 the recto-vesical operation, iii. 344 ; Sol-
 ly's case of recto-vesical  operation, iii.
 344; Sanson's two modes of operating, iii.
 344; description of the operation, iii. 344;
 modifications of the  operation, iii. 345;
 after treatment, iii. 345 ; advantages and
 disadvantages of the recto-vesical opera-
 tion, iii.  346 ; results of recto-vesical li-
 thotomy, iii. 346; Vacca Berlinghieri and
 Dupuytren's operations for stone, iii. 347;
cutting for the stone in women, iii. 348 ;
various modes of operating, iii. 348; Ast-
ley Cooper  on the symptoms of stone in
women, iii.  348; Brodie on the expulsion
of small calculi from the bladder  in  wo-
men, iii. 349; Brodie and Astley Cooper's
cases of ulceration of the bladder and va-
 gina by the pressure of large calculi, iii.
 349 ; cutting for the stone in women by
 the lateral operation, iii. 349 ;  mode  of
 operating, iii. 349; the horizontal cut on
 one or both sides, iii. 349; Liston's ope-
 ration, iii. 350; the vertical cut upwards,
 iii. 350 ; Brodie's modification of the ver-
 tical cut upwards, iii. 350; advantages of
 the vertical  cut  upwards, iii. 351; the
 vertical cut downwards, iii. 351; the cut
 below the pubic symphysis, iii.  351; ob-
jections  to the operation, iii.  351;  Lis-
 franc's vestibular cut,  iii. 351;  mode  of
 operating, iii. 352 ; objections to the ope-
 ration, iii. 352; von Kern's operation, iii.
 352 ; the vagino-vesical cut, iii.  353 ; ad-
 vantages of this operation, iii. 353; Astley
 Cooper,  Brodie,  Liston, Hey, and South
 on the incontinence of  urine consequent
 on the operation, iii. 353 ; South on dila-
 tation of the female urethra for the extrac-
 tion of calculi, iii. 354;  opening  the blad-
 der above the pubic symphysis,  iii. 354 ;
 comparison of lithotomy and lithotrity, iii.
 354 ; equality of the possible evils after
 the two operations, iii. 354; possible evils
 from  lithotrity, iii. 355; Liston on the
 breaking or bending of lithotritie instru-
 ments in the bladder, iii. 356 ; Brodie on
the occurrence  of haemorrhage  and  of
rigors after lithotrity, iii. 356; comparison
of the results in lithotomy and lithotrity,
iii. 356 ;  cases in which lithotrity is inap-
plicable, iii. 357; lithotomy preferable for
children, iii.  357  ; lithotrity preferable  in
advanced  age, females,  and in very stout
persons, iii. 357 ; stones of moderate size,
and  round  or  oval in  6hape,  best for
crushing, iii. 357; cases in which litho-
trity is  preferable, and  cases in which
lithotomy should be performed,  iii. 357 ;
stricture of the urethra only a temporary
contra-indication  to lithotrity, iii.  357;
palsy of  the  bladder not a contra-indica-
tion, iii. 357; Key on the advantages and
applicability of lithotrity, iii. 357; Key on
lithotrity with reference to the size of the
calculus, iii. 3")8; Key  on the  applica-
bility of lithotrity or lithotomy according
to the age of the calculous patient, iii.
358 ; Key on the requisite condition of the
bladder for the operation of lithotrity, iii.
358; Key on irritability of the bladder, iii,
35-'; Brodie,Liston,andSouth on the cases
in which lithotrity should be performed,
and on those in which  lithotomy should
be preferred, iii. 360; stone in the urethra,
iii. 363 ; consequences  of the impaction
of stones or other foreign bodies in any
part of the urethra, iii. 362 ; Travers' case
of calculus in the urethra, iii. 362; Home's
case of retention of urine, and consequent 
798
ANALYTICAL INDEX.
   mortification from the impaction of cal-
   culi in the urethra, iii. 362; Liston's case
   of a small brass ring encircling the penis,
   iii. 363; symptoms of stone at the neck of
   the  bladder, iii. 363 ; treatment  and  re-
   moval by operation, iii. 363; South on the
   treatment of stone in the urethra, iii. 364;
   symptoms and treatment of stone in  the
   membranous part of the urethra, iii. 364;
   of stone in the spongy part of the urethra,
   iii. 364; in the fossa navicularis, iii. 364;
   the entire urethra, in rare cases, blocked
   up with calculi, iii. 364; South on the  ex-
   traction of calculi in the urethra  in front
   of  the  scrotum without. incising  the
   canal, iii. 364 ; urinary calculi external to
   the urinary passage, iii. 365 ; are met with
   in the perinaeum or scrotum from  the  de-
   struction  of the walls of the  urethra,  iii.
   365 ; consequences, iii. 365 ; may also  oc-
   cur in the vagina or rectum by  the  de-
   struction  of their parietes, iii. 365 ; Vin-
   cent's case of calculi in the perinaeum, iii.
   365 ; Vincent's case  of calculi between
   the  prepuce and  glans penis,  iii.  366;
   treatment of these calculi, iii. 366; pros-
   tatal stones,  iii. 366; varieties, iii.  366;
   Astley Cooper's case, iii. 367;  treatment
   by  operation, iii. 368;  Green's  case of
   encysted  stone, iii. 368; Travers' case of
   stone broken up  under the use  of con-
   stitutional stone solvent, iii. 368; statistics
   of the operations of lithotomy at St. Tho-
  mas' hospital from 1800 to 1846, iii. 368 ;
  lithectasy, cystectasy, iii. 375 ; object of  the
  operation, iii. 375 ;  originally  proposed
  by John  Douglas, iii. 375 ;  Dr.  Arnott
  and  Astley  Cooper's  case, iii. 376;
   Elliot,  Dr.  Wright, and Fergusson's
  cases, iii. 376.
Callaway, Mr., on the haemorrhage  follow-
  ing the extirpation of the tonsils,  i.  166 ;
  case of retention of a ligature on an artery
  for four months, i. 340 ; case of reduction
  en masse, ii.  274;  case of removal of de-
  generated omentum, ii. 300 ;  on the seat
  of femoral rupture, ii. 333.
Callisen, M., on the removal of the entire
  skin covering a cold abscess,  i.  105 ; ex-
  planation  of the lengthening  of the limb
  in hipfldisease, i.  285 ; on the reduction
  of the consecutive dislocation, i. 297;  on
  the premonitory pains of hydrophobia, i.
  408 ; mode of operating for the formation
   of an artificial anus at the lower end of
  the colon, iii. 37.
Callosities,  iii. 400.
Camper's, M., explanation of the lengthen-
   ing of the limb in hip-disease, i. 285 ;  on
   the causes of club-foot, ii. 446.
Camus', Mr.,  mode  of treating  ovarian
   dropsy, i. 488; case of spontaneous rup-
   ture of the ovarian cyst, iii. 214.
!ANCER,iii. 496; definition, iii. 496; origin,
 iii. 496; symptoms of scirrhus, iii. 496;
 progress of the disease, iii. 496; concealed
 cancer, iii. 496; ulcerated cancer, iii. 496;
 condition of the parts in scirrhus, iii. 497;
 in concealed cancer, iii. 497; microscopic
 elements of scirrhus, iii. 497 ; Muller on
 the four several kinds of  carcinoma, iii.
 497 ; Muller on carcinoma simplex and
 fibrosum, iii. 498; Muller on carcinoma
 reticulare, iii. 498 ; Muller on carcinoma
 alveolare, iii. 498 ; Muller on carcinoma
 fasiculatum, iii. 498 ; Dr. Hodgkin on the
 development and progress  of scirrhus, iii.
 499 ; secondary development of cancerous
 ulceration, iii. 500; seat of cancer, iii. 501;
 difference in the progress of cancer  in
 different persons, iii. 501 ;  Alibert on the
 varieties of cancer, iii. 502 ; diagnosis of
 scirrhous tumours, iii. 502  ; Scarpa on the
 diagnosis between scrofula and scirrhus,
 iii.503; Hodgkin on the diagnosisbetween
 scirrhus and medullary fungus, iii. 503;
 Foy's analysis of scirrhus, iii. 504; cancer
 in the skin, 504 ; origin and seat, iii. 504 ;
 symptoms, iii. 504 ; occurrence of ulcera-
 tion,  iii. 505 ; origin  of cancer in glands,
 iii. 505;  characters of cancer in mucous
 membranes, iii. 505 ; cancer in the bones,
 iii. 505; characters of cancer in the nerves,
 iii. 505; other tumours in nerves, and
 their treatment iii.506;Cheselden'scases,
 iii. 506; Astley Cooper's case of tumour in
 the popliteal nerve, iii. 506 ; Liston on tu-
 mours of nerves, iii. 506;Langstaff,South,
 Astley Cooper,  Cline, and Mayo on tu-
 mours in nerves of stumps,  iii. 507; cancer
 a specific disease, iii. 508; cancerous dys-
 crasy, iii. 508;predisposingand occasional
 causes ofcancer,iii.508; Hunter on the dis-
 posing causes of cancer,iii. 508; prognosis,
 iii. 509 ; Scarpa on the nature of scirrhus,
 iii. 509 ; Travers on the occasional inert-
 ness of scirrhus during life, iii. 509; Bro-
 die and South's cases, iii. 509  ; treatment
 of scirrhus and cancer, iii. 509;  Leroy
 d'Etiolles on the statistics of operations for
 cancer, iii. 510; treatment for effecting
 dispersion of the tumour, iii. 510; Young,
 Recamier, and South on compression of
 scirrhus, iii. 511; removal of the diseased
 part with the knife or by escharotics, iii.
 512;  contra-indications, iii. 512; prelimi-
 nary treatment iii 512;necessary to remove
 all the diseased parts iii 512; destruction of
 a cancerous part by caustic, iii. 512; mode
 of applying the caustic, and the resulting
 symptoms, iii. 513;  Canquoin's employ-
 ment of chloride of zinc as a caustic for
 cancer, iii. 513 ; Hellmund's mode of ap-
 plying Cosme's powder, iii. 514; duration
 of the treatment, iii. 514; symptoms occa-
 sionally produced by the arsenical caustic, 
ANALYTICAL INDEX.                        799
iii. 514; internal treatment of cancer, iii.
514;  exhibition  of  narcotics to relieve
the pain, iii. 515 ; cancer of the lips and
cheek, iii. 515 ;  seat  and  characters  of
cancer of the  lip, iii.  515; microscopic
characters of the disease, iii. 515 ; malig-
nant but non-cancerous ulceration of the
lips, iii.  515 ;  treatment of cancef of the
lips by extirpation, iii. 515 ; contraindi-
cations of the operation, iii. 516 ; mode of
operating when  the  cancer does  not
spread down beyond the red part of the
lip, iii. 516 ; South  on the operation  in
such cases, iii. 516; the operation when
the cancer  has  spread  beyond the red
edge  of the  lip, 516;  union  of the
divided parts,  even when there has been
great loss of substance, iii. 517 ; the ope-
ration of chiloplasty,  or making a  new
lip, iii. 517 ; various modes of operating
for chiloplasty, iii. 518 ; Dieffenbach and
Blasius' operations, iii. 518 ; treatment of
cancer of the lip connected with the bone,
iii. 518; by operation,  iii. 518 ; of cancer
of the cheek, iii. 518 ; cancer of the tongue,
iii. 518; characters, iii. 518; prognosis, iii.
518 ;  treatment, 518 ;  by operation, iii.
519 ;  mode  of operating, iii, 519 ; after-
treatment, iii.  520 ; treatment of fungous
growths, iii. 520 ; ligature of the lingual
artery, prior to  the amputation of the
scirrhous portion of the tongue improper,
iii. 520 ; removal of the tongue by liga-
ture, iii. 520; Mirault's operation for liga-
ture  of the  tongue,  iii.  521 ; Regnoli's
operation for the extirpation of the tongue,
iii. 521 ; Arnott's  case of  malignant
tumour of the  tongue in which that organ
was removed by ligature, iii. 521 ; cancer
of the parotid gland, iii. 522 ; diseases  of
the parotid, iii. 522; characters of swelling
of the parotid, iii. 522; diagnosis between
the several  tumours of  the  parotid, iii.
523;  treatment  in scirrhus and medul-
lary fungus  of the parotid, iii. 523 ; ex-
tirpation of the gland a doubtful remedy,
iii. 523; arteries in  danger  of  being
wounded during  the operation, iii.  524 ;
Allan Burns on extirpation of the parotid,
iii. 524 ; mode of operating for the extir-
pation of the parotid,  iii. 524 ;  Goodlad
and Langenbeck  on the prior ligature  of
the carotid, iii. 525 ; after-treatment, iii.
525 ; cancer  of the breast, iii. 525 ; symp-
toms, characters, and  progress, iii. 526;
Brodie  and South  on  scirrhus of the
breast, iii. 527 ; characters of scirrhus and
cancerous ulceration of the breast, iii. 527;
development of cancer of  the breast  as
skin cancer, iii. 527 ; characters of cancef
of the areola,  iii. 528 ; of  cancer of the
nipple, iii. 528; Astley  Cooper on fungous
 degeneration of the nipple, iii. 528; Astley
 Cooper on the development of the nipple
 in the foetus and its subsequent changes,
 iii. 528 ; Brodie on scirrhus of the nipple,
 iii.  528; symptoms of  cancer of the
 breast, iii. 529 ; of acute cancer, iii. 529;
 of chronic cancer, iii. 529 ; Brodie on the
 puckering in  of the skin in mammary
 cancer, and  on its cause, iii. 529 ; appear-
 ance of scirrhus when cut into,  iii. 530;
 diagnosis between scirrhus  and chronic
 inflammation of the lymphatic vessels, or
 of  the breast  gland, iii. 530; symptoms
 and treatment of  the inflammation, iii.
 531; symptoms and characters  of milk-
 knots, iii. 531 ; malignant appearance of
 milk-knots in old women, iii. 532; Scarpa
 and South's cases of lacteal swelling, iii.
 632;  diagnosis  between scirrhus  and
 scrofulous tumours of the breast, iii. 533 ;
 and herpetic and psoric affections, iii. 533;
 and encysted tumours, iii. 533; characters
 of vesicular scirrhus of the breast, or car-
 cinoma mammae hydatides, iii. 533 ; this
 disease a steatomatous degeneration of the
 gland, iii. 533 ; Astley Cooper on hydatid
 swellings of the breast, iii. 534  ; Astley
 Cooper on the symptoms and treatment
 of cellulous hydatids of  the breast, iii.
 534 ; Astley Cooper on polypoid  hydatids
 of the breast,  iii. 534 ; Astley Cooper on
 the lobular hydatids of the breast, iii. 535;
 Brodie on the serocystic  tumours  of the
 female breast, iii. 535 ;  characters of me-
 dullary fungus of the breast, iii. 536 ; of
 the blood-swelling of the breast, iii. 536;
 ecchymosis of the breast in girls prior to
 menstruation, iii. 537 ;  characters of hy-
' pertrophy of the female breast,  iii. 537 ;
 anatomical appearances of the hypertro-
 phied breast, iii. 538 ;  causes,  iii. 538 ;
 treatment, iii. 538;  causes  of scirrhus
 of  the breast, iii.  538; prognosis, iii.
 539;  the  question  as to propriety of
 removing a scirrhous breast, iii. 539 ; opi-
 nions of  Cline,  Home, Astley Cooper,
 Brodie and  South, iii 539; Brodie on the
 circumstances permitting the operation,
 iii.  539;  extirpation of  the  breast, iii.
 539 ; mode of operating, iii. 541 ;  South
 on  the position of the patient during the
 operation, iii. 541 ; South's case of fatal
 venous haemorrhage from the extirpation
 of the breast, iii. 541 ; South  on the after-
 treatment, iii. 541 ;  amputation of the
 breast, iii. 542; South's opinion thatampu-
 tation is not preferable to extirpation, iii.
 542; relative value of these operations, iii.
 542; requisite to remove all  diseased
 Structures, iii. 542 ; operation for relapse
 of scirrhus after the removal of the dis-
 ease, iii. 543 ; cancer of the penis, iii. 543 ; 
800
ANALYTICAL  INDEX.
origin, symptoms, causes, and results, iii.
544; diagnosis, iii. 544; treatment,iii. 544;
by operation, iii. 544 ; amputation of the
penis, iii. 544; South on the recurrence of
cancer after amputation  of the penis, iii.
544; Cline the younger's case, iii. 544;
examination of the organ preliminary to
the operation,  iii. 544; amputation of the
penis by the knife, iii. 545 ; of the glans
alone, iii. 545; in the middle of the organ,
iii. 545 ; Schreger's  mode of amputating
the penis near the pubic bones, iii. 545;
Langenbeck's operation, iii. 545; Barthe-
lemy on the  means  of preventing  the
retraction of the urethra, iii. 545 ;  occur-
rence of after-haemorrhage, and its treat-
ment, iii. 546 ; after-treatment, iii. 546 ;
amputation of the penis by ligature, iii.
546; relative value of the two operations,
iii. 546; South  on the  relative value of
the two operations,  iii. 546;  Lisfranc's
operation for the removal of cancer of the
corpora cavernosa, iii. 547 ;  cancer of the
testicle, iii.  547;  definition of sarcocele,
iii  547; symptoms and progress of scir-
rhus of the testicle, iii.  547;  characters
and  appearances  of sarcomatous degene-
ration  of the testicle, iii. 548 ; these dis-
eases occasionally complicated with hy-
drocele, iii. 548 ; diagnosis of scirrhous
and sarcomatous degenerations  of the
testicle from other swellings of that organ,
iii. 548; from thickening of the cellular
tissue of the scrotum, iii. 548 ; characters
and causes of that disease, iii. 54* ; treat-
ment, iii.  548;  by  operation, iii. 549;
Liston,  Key,  O'Ferall,  and Bennett's
cases  of sarcomatous scrotum, iii. 549 ;
diagnosis  of sarcocele  from simple hy-
drocele, iii. 553 ; from cystic swelling of
the  testicle, iii.  553 ; characters and ap-
pearances  of  cystic  swelling, iii. 553;
Astley Cooper on the nature-of the cysts
in cystic swelling, iii,  553; removal  of
the  disease by operation, iii. 553; hyda-
tids of the  testicle, iii. 553; diagnosis of
sarcocele from thickening of the tunica
albuginea, iii. 553 ;  scirrhus of the tunica
albuginea, iii. 553; diagnosis of sarcocele
from  fungus  of the testicle  or  tunica
albuginea, iii. 554; from induration of
the testicle,  iii. 554;  from  scrofulous
swellings, iii. 554 ; from syphilitic swell-
ings, iii. 554; from medullary fungus, iii.
554; extirpation of the  testicle a doubtful
remedy in cancerous  degeneration, iii.
555;  indications and  contra-indications
of the operation, iii. 555;  Walther and
 Maunoir on ligature of the spermatic artery
 in sarcocele, iii.  555; mode of operating,
 iii. 555; mode of operating for extirpation
 of the testicle, iii. 556; Aumont's opera-
tion, iii. 556; South  and Astley Cooper
on the retraction  of the  cord during  the
operation, iii. 556;  degeneration of the
spermatic cord, and the operation, iii. 556;
South and Cline junior on ligature of the
spermatic cord, iii.   557; dressing  the
wound, and subsequent treatment after
extirpation,  iii. 557; treatment of after-
haemorrhage, iii.  557 ; treatment of  un-
descended testicle, iii. 557; by operation,
iii. 558 ; extirpation of undescended tes-
ticle, iii. 558 ; South on  the treatment of
undescended testicle, iii. 558 ; Paget and
Arnott's cases of  diseased undescended
testicle, iii. 558;  cancer  of the  scrotum,
iii. 559 ; characters of chimney-sweep's
cancer, iii. 559; Pott and Paris on cancer
of the scrotum, iii. 560;  Earle's case of
chimney-sweep's cancer  on the wrist, iii.
560; Astley Cooper  and Keate's cases
of chimney-sweep's cancer on the cheek,
iii. 560; Earle and South on  the exten-
sion of the.  disease to the neighbouring
parts, iii. 560;  Travers on the resem-
blance of the disease to  lupus, iii. 560 ;
cause and treatment,  iii.  561 ;  South on
the cause of the disease, iii. 561; Pott and
Earle on the age at which the disease
generally occurs, iii. 561; South's case of
recurrence of the disease, iii. 561; cancer
of the womb, iii. 561; origin of the disease,
and  primary symptoms,  iii. 562; indica-
tions on vaginal  examination,  iii. 562;
Montgomery on the origin of the disease
in the ova Nabothi, iii. 562 ; progress of
the disease, iii. 562; results of the vaginal
examination in the advanced state of the
disease,  iii. 562; Ashwell, Bayle,  and
Cayol on the pain in cancer uteri, iii. 562;
Montgomery and Ash well's cases of can-
cer  uteri, iii. 563 ;  diagnosis,  iii. 563;
Simpson on cauliflower excrescence from
the  os uteri, iii.  563;  period of life at
which cancer uteri is generally developed,
iii.  564; causes, iii. 564; Ashwell on
the period of life at which cancer uteri is
developed,  iii. 564;  treatment, iii. 564;
by internal and  external treatment, iii.
564 ;  can only be palliative in true scir-
rhus, iii. 564; examination of  the parts
in cancer uteri by the speculum, iii. 565;
mode of introducing the speculum, iii.
565; Simpson on the mode of  using the
speculum vaginae, iii. 565 ; Osiander on
the  extirpation of the cancerous neck of
the  womb,  iii. 566 ;  modes of operating,
iii. 566 ; Dupuytren's operation, iii. 566 ;
 Cancella and Hatin's specula vaginae, iii.
567 ; von Walther's case of excision of
 the  cervix uteri, preceded by excising the
 pubic arch, iii. 567; Recamier's opera-
 tion when the neck of the womb is soft- 
ANALYTICAL  INDEX.                        801
  ened  or destroyed, iii. 567; Lisfranc's
  operation, iii. 567;  Colombat's hystero-
  tome, iii. 567 ; destruction of the degene-
  rated womb by caustic, iii. 567 ; Mayor's
  ligature of the neck of the womb, iii. 567;
  mode of applying caustic potash to destroy
  the cancerous cervix uteri, iii. 567; cases
  in which this proceeding is applicable,
  iii. 568; extirpation of the whole womb,
  iii. 568;  Struve, Gutberlat, and Wenzel
  on extirpation  of the womb, iii. 568;
  Langenbeck and  Laud-Wolfs  cases of
  extirpation of the cancerous womb, iii.
  569; Recamier's cases, of removal of the
  womb by ligature, iii. 569;  Sauter's di-
  rections for the operation of extirpation,
  iii. 569; dressing and after-treatment, iii.
  569; von  Siebold, Langenbeck, Paletta,
  Holcher, Blundell, and Banner's cases,
  iii. 570; Delpech, Dubled, and Recamier
  on the extirpation of the womb, iii. 572;
  Roux' cases, iii. 577;  the difficulty and
  danger of the operation, iii. 577; Gendrin's
  directions  for the  operation,  iii.  578;
  Heath's case of excision of the uterus by
  the abdominal section, iii. 578 ;
Cancrum oris.  Fide Mortification.
Canella's M., speculum vaginae, iii. 567;
Canquoin, M., on the use of the chloride
  of zinc as a caustic in cancer, iii, 513.
Canton, Mr. on the existence of the acarus
  scabiei, ii. 67.
Capuron,  M.,  on  an  epidemic vaginal
  catarrh, i.  182.
Carruncle :—nature of the disease, i. 154;
  distinguished   from boil  and malignant
  pustule, i. 154; symptoms, i. 154; varie-
  ties, i. 154; Hunter on the inflammation
  that produces carbuncle, i. 154; his obser-
  vation, that there are generally more car-
  buncles than one, not confirmed by South,
  i. 155; his opinion that carbuncle has some
  affinity to boils, i. 155 ; Copeland on an-
  thrax, i.  155 ;  Perrez on the physiology
  of carbuncle, i. 155; benignant carbuncle,
  i. 155 ; carbuncle, the consequence of me-
  tastasis  of deleterious matter, i.  155;
  malignant   carbuncle   never connected
  with previous  fever, i. 156 ; English sur-
  geons do not admit the  metastatic origin
  of carbuncle, i. 156; Rayer says it occurs
  most frequently in spring and summer, i.
  156;  danger of carbuncle depends on its
  size, seat, presence of  many such swell-
  ings,  the constitution of the patient, and
  the connecting general disease, i.  156 ;
  Astley Cooper on the danger of carbuncle
  on the head and neck, i. 156;  South on
  the rareness of carbuncle  on  the head, i.
  156; general and  local treatment of be-
 nignant carbuncle, i. 156; von Walther
 on incisions in carbuncle, i. 156; Wise-
     Vol. in.—68
 man  on incisions in carbuncle, i.  156;
 Bromfield on incisions and injections of
 bark and tincture of myrrh, i. 157; Cooper,
 Abernethy,  Dupuytren,  and  Rayer,  on
 incisions, i.  157 ; Pearson against inci-
 sions, i. 157; South's treatment of car-
 buncle,  i.  157;  Physick's  treatment of
 carbuncle, i.  157; Coates on the applica-
 tion  of blisters  in  carbuncle,  i.  157;
 Perrez on the treatment of carbuncle, i.
 158 ; Pouteau on the application of caus-
 tic, and the actual cautery, i. 158 ; treat-
 ment of malignant carbuncle, i. 158.
&.ries, ii. 114; nature and appearances of
 the disease, ii. 114; Lawrence's definition
 of caries, ii. 114 ;  Miescher on the granu-
 lations attending caries, ii. 114 ; Syme on
 the distinguishing character of caries, ii.
 115 ; Mayo on the progress of caries, ii.
 115; symptoms,ii. 115; diagnosis, ii. 115;
 Miescher and Syme  on the characters of
 caries, ii. 115,116 ; causes, ii. 116 ; Del-
 pech  on the  diseased condition  of the
 bones in syphilis, not caries, but necrosis,
 ii.  117; Mayo  on inflammation as the
 cause of caries, ii. 117; Miescher on the
 seat of the various kinds of caries, ii. 1.17;
 prognosis, ii. 117; general and local treat-
 ment, ii. 118; Rust,  Fricke, Mayo, Law-
 rence, and Syme on the treatment  of
 caries, ii. 118, 119;  removal of the dis-
 eased bone, ii. 119; caries of the skull bones,
 ii. 131; situation, causes, and symptoms,
 ii.  131; South on the consequences of
 caries, or necrosis in the mastoid process,
 ii.  132 ;  South on necrosis of the vault of
 the skull, ii.  132; South's case of exten-
 sive destruction of the vault of the skull,
 ii. 132 ;  South on Caries of the bones of
 the face, ii. 132 ; South on the disease in
 bones from mercury and syphilis, ii. 132 ;
 Syme's case of destruction of the bones of
 the face, ii. 133; causes and prognosis of
 caries of the  skull-bones, ii.  133 ; treat-
 ment, ii. 133; caries of the teeth, ii. 133 ;
 characters and situation of the caries, ii.
 134;  South on inflammation  and  suppu-
 ration in the tooth-socket without caries,
 ii. 134; symptoms of caries at the root of
the tooth, ii.  135; caries of the alveolar
process, ii. 135 ; diseased changes in the
maxillary antrum, ii. 135; epulis, ii. 136 ;
South on the  symptoms and treatment of
sympathetic disease of the antrum, ii. 136;
Liston and South on epulis, ii. 136; causes
of caries, ii. 136 ;  Coffiniere on toothach
as a counter irritant, ii. 137; treatment, ii.
137;  remedies to resist  the further de-
struction of carious teeth, ii. 137;  filing
and stopping  the teeth, ii. 137; destruc-
tion of the nerve of the diseased tooth by
the actual cautery, or sulphuric acid, ii. 
-802
ANALYTICAL  INDEX.
  137;  South on  the  stopping a carious
  tooth, ii.  137;  preventive treatment of
  caries, ii. 137; treatment of toothach, ii.
  138 ; South and  Bedingfield on the treat-
  ment  of toothach, ii. 138;  extraction of
  the tooth sometimes necessary, ii. 138;
.  excision  of the  carious crown, ii. 138;
  the different instruments used in the ex-
  traction of teeth, ii. 138; extraction of the
  front teeth, ii. 139 ; of the back teeth with
  the key, ii. 139 ;  with the pelican, ii. 139;
  use of the  punch, ii. 139;  extraction of
  stumps and roots of teeth; ii. 140; acci-
  dents which may  occur  in  extracting
  teeth, and their  treatment, ii. 140; occa-
  sional consecutive haemorrhage, ii. 140;
  inflammation and suppuration of the gum,
  ii. 141 ; caries of the alveolar process, ii.
  141;  South on  the consecutive haemor-
  rhage in  the haemorrhagic diathesis,  and
  its treatment by the actual cautery, ii. 141;
  Blagden, South and Davenport's cases, ii.
  141;  Cortez,   Cullen,  Kendrick,  and
  Dr. Ryan on the treatment of the conse-
  cutive haemorrhage, ii.  143 ; South on the
  necessity of adopting preventive measures
  immediately  after  the extraction of a
  tooth, when the haemorrhagic diathesis is
  known to exist, ii. 144  ; tooth-fistulas, ii.
  144 ;  carcinomatous excrescences on the
  gums, ii. 144 ; treatment, ii. 144.
Carlisle's,  Sir A.,  tourniquet, and   its
  mode of application, i.  332.
 Carmichael, Mr., on severe phlebitis i. 93;
  injection of a strong solution of nitrate of
  silver in gonorrhaea, i. 191 ;  objections to
  the  terms ■ syphilis,  syphyloidal,  and
  pseudo-syphilis, ii. 82; bases his arrange-
  ment of venereal complaints on the cha-
  racter of the  eruption, ii. 82 ; does not
  admit the existence of mercurial disease,
  ii. 107 ;  on eczema mercuriale, ii. 110;
  case of ligature  of the gluteal artery, ii.
  535 ; case  of excision of the head of the
  femur, iii.  736.
 Carotid aneurism, ii. 507.
 —-------artery,  common, ligature  of, ii.
  509 ; tying the external carotid, ii. 512.
 Carpue's Mr., cases of the Taliacotian  ope-
  ration, iii. 577.
 Carpus, fracture  of the bones of, iii. 615 ;
  exarticulation of  the  metacarpal bones
  at, iii. 721.
 C arswell, Dr., on the gewuscarcinoma, iii.
   445.
 Cartilage,  Inflammation  of.   See  In-
   flammation of the Joints.
 Cartilages of the larynx, fracture of, i.  581.
 ---------costal dislocation of, ii. 216.
 Catheter, introd'uction, iii. 148 ; straight in-
   troduction of, iii. 148; female introduc-
   tion of, iii. 150.
Catheterism, forcible, iii. 145.
Cauterization, iii. 630.
Cautery, actual, iii. 631.
Cayol, M., on the pain in cancer uteri, iii.
  562.
Celsus, on the extirpation of the tonsils by
  cutting and by tearing out, i. 164 ; on the
  removal of the relaxed uvula by cutting,
  i.  166;  on the  use of the ligature for
  wounded vessels, i. 354 ; on the applica-
  tion of a ligature above a  viper's bite,  i.
  390; observations on the innocuous quali-
  ties of the poison of serpents when intro-
  duced into the mouth confirmed by Rus-
  sell, i. 390 ; on  rubbing the ends of the
  broken bone together in cases of false
  joint, ii. 15.
Cerebral Hernia, ii. 362.
Cestoni, M., on the acarus scabiei, iii. 67.
Chabert's M., artery-compressor, i. 331.,
Champesme's, M., mode of amputating at
  the shoulder joint, iii. 713.
Chauliac's, Guy  de, account of the opera-
  tions of the Arabian physicians in false
  joints, ii.  18 ;  on ligature of the hernial
  sac for its radical cure, ii. 283.
Chaussier's, M., cases of actual protrusion
  of the heart, ii. 361 ; experiments on the
  excision of joints, iii. 727.
Chaumet's M., case of partial resection of
  the clavicle, iii.  764.
Cheek-bones, fracture of, i. 578,
Cheek, cancer of, iii.  518.
Cheselden, Mr., on ligature of the tonsils,
  i.  164;  his operation preferred by Else,
  i.  164; on  the  immovable apparatus for
  fractures, i. 553; case of  large urinary
  calculus,  iii. 273 ;  on the high operation
  for stone, iii. 306 ; operation for stone, iii.
  309 ; cases of tumours on nerves, iii.  506.
Chesman's, Mr., case of spina bifida, iii.
  186.
Chest, Wounds  of   the,  i. 481;  either
  superficial or  penetrating, i.  482; treat-
  ment of superficial cuts and sabre wounds,
  i.   482; consequences and treatment  of
  bruises and shot Wounds of the coverings
  of the chest, i. 482 ; penetrating wounds
  of the chest, i. 482 ; indications of a pene-
  trating wound, i. 482;  South on the ex-
  amination with  the probe, &c, in pene-
  trating wounds of the chest, i. 482 ; South
  on the condition of the lungs when the
  chest is opened, i. 483 ; Williams' experi-
  ments and conclusions, i. 483; Astley
   Cooper on the signs of wounded lungs,i.
  483; Hennen on the course taken by balls
  in wounding the chest, i. 483 ; Maiden
  and Sir  W. Blizard's case of penetrating
   wound of  the  chest, i.  483 ;  Andrews'
  case of  penetrating wound of  the chest,
   with injury to the  lung, i. 485 ; Astley 
ANALYTICAL  INDEX.
803
Cooper's case of wound of the intercostal
muscles by an iron spindle, i. 487 ; Ever-
ard Home on the appearances in the lungs
thirty-two years after their having been
wounded by a ball, i. 487; Hennen and
Gregory  on the prognosis  of wounds of
the chest, i. 489 ; varieties of penetrating
wounds of the chest, i. 488 ; simple pene°
trating wounds of the chest, and their treat-
ment, i. 488; penetrating wounds of the
chest complicated by the presence of
foreign bodies, i. 488 ; Larrey's case of ex-
cision of a portion of a rib for the removal
of a ball, i. 489 ; presence of bullets in the
chest without causing inconvenience, i.
489 ; instance of a ball remaining in the
lungs for twenty years without causing
mischief, i. 489 ; occurrence of  haemor-
rhage in penetrating wounds of the chest,
i. 489 ; symptoms of haemorrhage, i. 489 ;
the most certain and determinate signs of
extravasation of blood in the chest, i. 489 ; I
the less certainand constant symptoms, i.
490 ; effects of the extravasation of blood
into  the cavity of the chest, i. 490 ; Hen--
nen  on the  occurrence  of priiriary and I
secondary haemorrhage in incised or punc-
tured wounds of the chest, i. 490 ; very
difficult to determine the  source of the
haemorrhage in penetrating wounds of the
chest,  i.  490 ; injury of the intercostal
artery, i. 490;  Richter's piece  of  card-
board, and  Reybard's canula useless in
such cases, i. 490, 491; Graefe's case of
fatal gun-shot wound of  the intercostal
artery, i. 491; various plans for stanching]
bleeding from the intercostal artery pro-
posed  by Gerard, Goulard, Leber, Rey-
bard, Nevermann, Benj.  Bell, Lottery,
Quesnay* Bellocq, Harder, Desault, Sa-
batier, Medin,  Assalini, and Grosheim,
i. 491, 492 ;  Nevermann's mode of ope-
rating, i. 492 ; objections to these modes
of proceeding, i. 492  ; treatment of bleed-
ing  from an  intercostal artery, i. 492 ;
wounds  of the internal mammary artery,
i. 493; wounds of  the large  vessels in
the cavity of  the chest speedily fatal, i.
493;  stanching of bleeding  from  a
wounded lung, i. 493; Vering's objec-
tions to  the union of penetrating wounds
of the chest, i. 494; Astley Cooper  on
the danger attending wounds of the lungs,
i. 494; Hennen on  the immediate treat-
ment of penetrating wounds of the lungs,
 i. 494,  emphysema, i. 495; causes  of
 emphysema,  i.  495 ;  Astley  Cooper,
 Hennen, and  South on  emphysema,  i,
495; the escape of air from the  lungs
into the cavity of the pleura, i. 496 ; Hen-
nen's  case oi secondary  emphysema, l.
496; treatment of emphysema, i.  497;
Abernethy on the use of a broad  chest-
 bandage in emphysema,i. 497 ; South on
  the practice of sucking or pumping to ex-
  tract the air in the cavity of the chest, i.
  497 ; Hennen on the healing of w'oupded
  lung, i. 497 ; protrusion of a portion of
  lung in wounds of the chest, i.  497;
  Hennen on  the protrusion of a portion of
  lung, i. 497;  treatment  of the  conse-
  cutive  inflammation  of  the lung and
  pleura, i. 498; consequences of the in-
  flammation, i.  498 ;  Astley Cooper on
  the treatment of traumatic pneumonia, i.
  498 ; wounds of the heart, i. 498 ; symp-
  toms of wounds of the heart, i.  498 ;
  Speyer on the peculiar causes of death at
  different periods in wounds of the heart,
  i. 499 ; case of fatal wound of the heart
  by a broken rib, i. 499; Featherstone and
  Dr.  Babington's cases of fatal  bayonet-
  wound  of the heart, i. 499 ; case of lace-
  ration of the pericardium,  and superficial
  wound  of the heart, 500; Hennen, Four-
  nier, and Ploucquet's cases of foreign
  bodies in the heart, i. 500; treatment of
  wounds of the heart, i. 500 ; wounds of
  the  pericardium, i. 500; Astley Cooper
  and  Hennen's  cases of wounds  of the
  pericardium, i. 500, injuries of the gullet,
  thoracic  duct,  diaphragm, and  spinal
  marrow, i. 501 ; symptoms of wounds of
  the  diaphragm, i. 501.
Cheston's  Mr.,  case of gangrene  of the
  bladder from retention, iii. 128.
Chevalier, Mr.,  on tying the tonsils,  i.
  164 ; case of puncturing the dura mater,
  to remove effused blood from beneath it,
  i. 447.
Chevalier's, M., case of removal  of the
  inverted womb by ligature, ii. 388.
Chiloplasty, the operation of, iii.  517.
Chilblains:—i.  149; symptoms and
  results, i. 149 ; Hunter mentions another
  inflammation very like chilblains, i. 149 ;
  seat of chilblains, i.  149; treatment, i.
  149 ; South on the mustard liniment  of
  St. Thomas' Hospital in the treatment of
  chilblains, i. ISO ; treatment of ulcerated
  chilblains, i. 150 ; of gangrenous chil-
  blains, i. 150 ; prevention of chilblains,
  i. 150.
 Chimney-sweep's cancer, iii. 559.
 Chopart's, M., case of inclusion of a nerve
  in  the noose of a ligature placed  on an
  artery, i. 339 ; case of simple dislocation
  of the  spine, i. 586; mode of  operating
  in ovarian dropsy, iii. 209.
 Choulart, M., on the influence  of spinal
  curvature on the transverse diameter  of
  the pelvis, ii. 427.
 Chrestien,  M., on  gold and its prepara-
  rations in primary and secondary syphi-
  lis, ii. 101. 
804
ANALYTICAL INDEX.
Church, Mr., on tartar emetic in strangu-
  lated hernia, ii. 292.
Churchill, Dr., on the treatment of lace-
  rated perineum, ii. 37.
Cirsocele, ii. 575.
Cittadini's, M.,  case of false joint, in
  which rubbing the ends of  the  broken
  bone together was practised, ii. 15 ; suc-
  cessful operation for sawing off the ends
  of the broken bone, ii. 20.
Civiale, M.,  on the introduction  of the
  straight catheter, ii.  149 ; operations for
  stone on infants, iii.  297.
Clanny's, Dr., case of enlargement of the
  tongue, iii. 384.
Clarke, Sir J. M.,  on  the length of time
  during which prolapse  of  the womb is
  forming, ii.  371 ; on the size and shape
  of the prolapsed'organ, ii. 371 ;  on the
  consecutive  ulceration of the vagina, ii.
  371; case of procidentia uteri, with se-
  paration of the pelvic bones,  ii. 374 ;  on
  the after-treatment of procidentia uteri,
  ii. 375; on the application of injections,
  ii. 376 ; on the treatment of the ulcerated
  vagina, ii. 376;  objections  to sponge as
  a pessary, ii. 376; on  the corrosion of
  pessaries  in the passage,, and  on the
  deposit of calculous matter on them, ii.
  378; on polypus of the fundus uteri as a
  cause of  inversion, ii. 384 ;  on the cha-
  racter of the discharge in inverted uterus
  ii. 385;  on the  treatment  of  chronic
  inversion, ii.  387;  of recent inversion,
  ii. 387 ; on the diagnosis between chronic
  inversion  and polypus uteri, ii. 387;  on
  the  treatment of the inverted  womb,
  complicated  with procidentia, ii.  388;
  case  of removal  of  the inverted  womb
  by ligature, ii. 38s; on prolapse of the va-
  gina, ii. 389; on the symptoms of prolapse
,  of the vagina, ii.  389; on the causes and
  symptoms of posterior prolapse of the va-
  gina, ii.  390; on the treatment  of pos-
  terior prolapse, ii. 390.
Clarke's,  Dr. J., case of removal of the
  inverted  womb by ligature, ii. 388.
Clavicle, fracture of, i. 602; dislocation of,
  ii. 217; resection of, iii. 763.
Clay,  Dr.,  on the  large   operation  for
  ovarian dropsy,  iii. 212.
Clement?s, Mr., case of successful opera-
  tion  for  strangulated  umbilical  rupture
  during pregnancy, ii. 340.
Cline's, Mr., experiments to cause the  ab-
   sorption of the  pus in  lumbar or psoas
   abscess, i. 211;  on  the lengthening and
   shortening  of the diseased limb in  hip
   disease, i.  284; experiments with  the
   broad ligature on arteries, i.,386 ; case of
   musket-shot wound of the bladder, the ball
  remaining in that viscus, and being after-
  wards extracted by operation, i. 529;
  case of fracture of the spine without dis-
  placement,  i. 585;  case of cure  of un-
  united fracture,  ii.  18;  ease  of  double
  umbilical rupture, ii. 344; case  of the
  existence of  several aneurisms  in the
  same person, ii.  477; cases in which the
  femoral  artery was  tied with a  broad
  tape,  the ligature being removed some
  hours afterwards, ii.  496; case of obli-
  teration  of  the  vena eava inferior, ii.
  569 ; case of varix of a deep-seated vein,
  ii. 570;  on excision of  piles, ii. 585;
  case of  impending  suffocation from ra-
  nula,  iii.  121  ; case  of stone in  one of
  the submaxillary ducts, iii. 122; case of
  very large hydrocele, iii. 221; case of
  suppuration of the kidney from impac-
  tion of calculus in the  ureter, iii. 271;
  case of large  calculus, iii. 273 ; case of
  on old man  operated on for  stone, iii.
  297;  gorget, iii. 321;   on  the  ques-
  tion  as  to  the  propriety  of removing
  a  scirrhous breast,  iii,  539;  the first
  experimenter  with vaccine lymph, iii.
  622.
Cline's, Mr., jun., eases of after-bleeding,
  in which the actual cautery  was em-
  ployed, i. 347; clinical observations  on
  after-hemorrhage, and on the  use  of the
  actual  cautery in such  eases, i. 347;
  experiments on  arteries, i. 351 ;  on the
  disposition  of hydrophobic  animals to
  use their weapons  of  offence, i. 407;
  directions for the excision of the part
  bitten by a mad dog, i. 411; on punc-
  turing the brain in wounds of the dura
  mater, i.  439;  case in  which he per-
  formed   the   operation   for  trepanning
  the spine, i. 590; details of the case, i.
  590;  clinical  observations on  the case, i.
  590 ;  on the use of caustics to destroy the
  cartilaginous  ends of broken bones in
  false joints, ii. 17; case  of cure of false
  joint by caustic potash, ii. 17 ; reduction
  of an old dislocation of the humerus, ii.
  204;  case of hydrocele in front of an
  inguinal rupture, ii. 323; case of aneurism
  of the  anterior tibial artery, ii.  543;
  on tumours of nerves in  stumps, ii. 507;
  case of amputation of the penis, iii. 544;
  on ligature of  the  spermatic cord,  iii,
  557 ; on arteriotomy, iii. 612.
 Clitoris, enlargement of, iii. 399.
 Cloquet's, M., treatment of fractured cla-
  vicle, i.  605;  on  the  solution  of  the
  chloride of lime in the treatment of foul,
  gangrenous, or  torpid ulcers, ii. 44; on
  the statistics of rupture, ii. 265; explana-
  tion of the manner in which reduction en
   masse takes place, ii. 275; on thesponta- 
ANALYTICAL INDEX.
805
  neous return of the hernial sac into the ab-
  domen, ii. 281; on Nuck's canal, ii. 328;
  case of lumbar rupture, ii.  348 ; on thy-
  roid rupture, ii. 352;  on elongation of
  the womb in cases  of prolapse, ii. 372 ;
  on  the formation of calculi in the  dis-
  placed bladder, consequent on prolapsus
  uteri,  ii.  372;  on consecutive  displace-
  ment of the rectum, ii. 372 ; case of the
  existence of numerous aneurisms in the
  same person, ii. 477.
Clossius', M., explanation of the lengthen-
  ing of the limb in hip-disease, i. 285.
Club-foot, ii. 445.
Coates, Dr., on the application of blisters
  in the treatment of carbuncle, i. 157; on
  ligature of the common carotid, ii. 564;
  case in which the bronchocele ultimately
  enlarged, after the ligature of the superior
  thyroid, iii. 393.
Coccyx, fracture of, i. 595; dislocation of,
  ii. 215.
Cock, Mr.,  on the reduction of  the  dis-
  located femur by placing the foot between
  the thighs and making extension  and
  rotation, ii. 242;  case of sixpence in the
  hvrynx, iii. 114.
Cephalaematoma, iii. 167.
CoFFiNiiiRE,  M., on toothach  as a counter-
  irritant, ii.  137.
Coherence,  unnatural :—definition,  iii.
  13; causes  and mode  of union, iii.  13;
  contraction and closure of the outlets of
  the body, iii. 13; congenital closure of
  the outlets, and congenital union of parts
  which should be separate, iii.  14 ;  con-
  dition of  the parts when  an  outlet is
  closed, iii. 14; treatment of parts  pre-
  ternaturally united, iii.  14;  treatment
  of deforming cicatrices, iii. 14;  treat-
  ment  of  narrowing and closure of the
  outlets,  iii.  15;  of  imperforation,  iii.
  15; union of the fingers and  toes,  iii.
  16; causes,  iii.  16;  the  operation for
  its  treatment,  iii.  16; circumstances
  which contra-indicate the operation, iii.
  16; after-treatment, iii.  16;  result  of
  the operation often unsatisfactory,  iii.
  16; mode  of operating, and  treatment
  to prevent reunion, iii. 17; Dupuytren
  and  Rudtorffer's plans  to  prevent re-
  union, iii. 17; Zeller's operation,  iii.
  17; the growing together of the joint-ends
  of bones, or anchylosis, iii. 18; defini-
  tion,  iii.   18;  sub-divisions,  iii.   18;
  causes, iii. 18; nature of the connecting
  substance,  iii.  19; treatment,  iii.  19;
  Dr. Barton's  operation  on the anchy-
  losed  femur,  iii.  19;  von  Wattman^s
  operation on  the humerus m anchylosis
  of the elbow, iii. 19; treatment of the
  slighter degrees of false anchylosis, iii.
20;  of the more severe forms,  iii.  19;
the operation in contraction of the knee-
joint, iii. 20; occasional results, iii. 20;
growing together and narrowing of the
nostrils, iii. 21  ; characters, iii.  21 ;  the
operation for contracted nostrils, iii. 21;
after-treatment, iii. 21 ; unnatural adhe-
rence of the tongue, iii. 22; direct causes,
iii.  22; diagnosis,  iii. 22;  treatment,
iii. 22 ; of the  tumour under the tongue,
iii. 22; division of  the frenum, iii. 23;
treatment of adhesion of the tongue  to
the cheek, iii. 23; South on adhesion  of
the tongue to the cheek, iii 23; consecu-
tive  accidents,  iii. 23;  haemorrhage from
the  raninar artery,  iii. 23;  danger  of
suffocation   from the  tongue  turning
backwards, iii.  23;  growing  together
of the gums and cheeks, iii. 24;, causes,
prevention, and treatment, iii. 24 ;  nar-
rowing and  closure of the  mouth, iii-
24;  complete  closure   a very rare mal-
formation,  iii. 24; causes of narrowing,
iii. 24; symptoms, iii. 24 ; treatment, iii.
24;   Dieffenbach and  Werneck's  ope-
rations,' iii. 25; treatment of narrowing
of the mouth, with loss of  substance  of
the  lips, iii.  2"); narrowing of  the  oeso-
phagus, iii. 26; causes, iii. 26; conse-
quences, iii. 26;  symptoms  of simple
or membranous stricture, iii. 26;  cal-
lous  narrowing  of  the  oesophagus, iii.
27;   of  scirrhous   hardening,  iii.  28;
expansion of the walls and its causes, iii.
28;  ulceration  of scirrhous  and callous,
cartilaginous,  and  bony  stricture, iii.
28 ;  Meyer and Gendrin's cases of stric-
tured oesophagus communicating with the
bronchus  or  trachea, iii. 28; narrowing
of the oesophagus from fungous growths,
iii. 28;  from  swellings  in  the neigh-
bourhood,  iii.   29;  symptoms  of dy-
sphagia  lusoria,  iii.  29; spasmodic
stricture, iii. 29; angina impetiginosa,
symptoms, characters, and treatment, iii.
29;  prognosis  in stricture  of the oeso-
phagus, iii. 29; Astley Cooper's case  of
stricture of  the oesophagus  ulcerating
externally, iii.  30; treatment of stricture
caused by chronic inflammation, iii. 30;
introduction of  the oesophageal sound, iii.
30;  mode of  operating,  iii. 31;  intro-
duction of the  sound through the nostril
improper, iii. 31; use of a  sound with
a lead stilette, iii, 31 ;  South's objection
to the protrusion of  the tongue prior  to
the passage of the oesophagus-bougie, iii.
32;  Astley  Cooper's  case  of  stricture
of the oesophaguS, in which a false pas-
sage was made through into the anterior
mediastinum, iii. 32;  dilatation of the
stricture, and subsequent treatment, Hi. 
806                        ANALYTICAL INDEX.
32;  use  of  caustic  bougies very dan-
gerous, iii. 32 ; Jameson and Fletcher's
instruments, iii. 32 ;  general treatment
for callous,  scirrhous, and  spasmodic
stricture, and for dysphagia lusoria, iii.
33;  use  of  the  oesophageal sound for
the passage  of strong broths,  iii. 33;
dysphagia  paralytica  atonica,  iii. 33;
narrowing and closure of the rectum, iii.
33; closure of the rectum always a mal-
formation, iii. 34; stricture rarely con-
genital, iii. 34;  congenital closure  of
the rectum, iii. 34; symptoms, iii. 34;
Wolff's case of imperforate anus, iii.
34; the operation for imperforate anus, iii.
34; the operation  to be performed when
there is not any trace  of an  anus, iii. 35;
Amussat's, operation,  iii.  35;  South's
case ofadherence of the two portions of the
ileo-colic valve, causing obstruction to the
passage of the meconium,  iii. 35;  the
operation for the rectum opening into the
vagina, iii. 36;  Barton and Dieffenbach's
operations, iii.  36; opening of  the rec-
tum into the  urethra, iii. 37;  the opera-
tion, iii. 37;. opening of the rectum into
the urinary bladder, iii,, 37 ; Fergusson's
case of opening of the rectum into the
bladder, iii. 37;   Cruveijhier's  case of
opening of the rectum under the  glans
penis,  iii. 37;  the formation of an ar-
tificial anus at the lower end  of the colon,
iii. 37; the mode  of operating, iii. 37;
Callisen and Amussat's. mode  of ope-
rating, iii. 38; Pi'lore's case, in which
he made an artificial anus  in the right
side, by opening  the caecum,  iii. 38;
Freer and Pring's  cases, of operation for
artificial anus at the  lower end of the
colon,  iii. 38; congenital  narrowing of
the amis, iii. 33;.  South's  case of im-
perforate anus, opening under, the glans
penis,  iii.. 39 ;> stricture of  the  rectum,
iii.  39;  spasmodic  contraction of the
anus, iii. 39 ;. causes* iii. 39 ; symptoms,
iii.  39;  examination  of the anus, iii.
41;  fissure  of the  rectum,  iii.  41;
Brodie  on ulceration  of the  rectum -in
connexion with spasmodic- contraction of
the .sphincter, iii. 41;. Bushe on the spas-
modic  contraction  of the anus,  iii. 41 ;
spasmodic contraction distinguished from
narrowing, iii. 41 * treatment,, iii. 41;
division of; the sphincter, iii. 42;  after-
treatment,  42;  narrowing  of the rec-
tum, depending on chronic inflammation,
iii. 43 ; characters, iii. 43 ;  progress and
terminations of the disease,f ii^ 43 ; local
results of stricture, j ii. 44; Brodie on the
occurrence of symptoms of strangulated
hernia  in some cases of stricture, iii. 44;
Astley Cooper's case of stricture of the
rectum, iii. 44; changes produced in the
tissues of the gut by chronic  inflamma-
tion, iii. 44; Brodie on the post-mortem
appearances in stricture of the rectum, iii.
44;  Lawrence  on  the  spongy excres-
cence of the rectum, iii. 44 ; situation of
the stricture, iii. 44; excrescences grow-
ing from the valvulae conniventes, iii. 45;
examination of the rectum for stricture,
iii. 45 ; Lawrence and Bushe on stricture
of the rectum, iii.  46;» White, Salmon,
Charles Bell,Colles,Allan, Liston,Syme,
Brodie and Bushe on the seat of stricture
in the  rectum, iii. 46; immediate cause
of stricture, iii. 47 ;  prognosis, iii.  47 ;
Brodie on the necessity of early  treatment
in stricture Of the rectum, iii. 48 ; treat-
ment, iii. 48;  Brodie on the distention of
the bowel above the stricture by faeces, iii.
48; stretching the contracted part, iii. 48;
introduction of bougies, iii. 49 ; Brodie
and Lawrence on the use of bougies, iii.
49,50 ; Bxodie on the internal application
of mercurial ointment in stricture of the
rectum,, iii. 50;  dilatation  by prepared
gut, and by metallic dilators, iii. 50; in-
cision of the stricture, iii. 51;  Copeland
and  Brodie on incision of the stricture,
iii. 51  ;  extirpation of tuberculous  ex-
crescences, iii. 51;  use of the  caustic
bougie,  iii.  51; treatment  of  fistulae
complicating  the  stricture,  iii. 52; of
cancerous  stricture, iii.  52;  operation
for the removal of cancerous  stricture,
iii. 52;  stricture caused  by a cicatrix,
iii. 53; narrowing of the anus from Union
between, the nates, iii. 53; treatment of
closure of the rectum from stricture, iii.
53 ; growing together, and unnatural clo-
sure of ihe prepuce, iii.  53 ; phimosis and
paraphimosis, iii. 53; phimosis conge-
nital or acquired, iii. 53 ; consequences,
iii. 53; after  puberty, iii. 54;  causes of
accidental phimosis, iii. 55; symptoms,
iii. 55 ; consequences of venereal ulcers
on the  corona  glandis, complicated with
phimosis, ii. 55 ; treatment of  phimosis,
iii. 55  ;  operations  by circumcision  and
slitting up  the prepuce, with or without
removal of the flaps, iii. 55 ; , circum-
cision, iii. 55  ; the Jewish operation, iii.
55; South on the Jewish  operation, iii.
55;  slitting  up  the  prepuce, iii.  56;
after-treatment, iii.  56;  the preference
given  to the latter  operation, iii.  56;
vision of the inner fold of the prepuce, iii.
57; Langenbeck, Begin,, and  Vidal de
Cassis' operations, iii. 58; treatment of
phimosis, complicated with union, partial
or complete, of the prepuce of  the glans,
iii. 58 ; connexion of the glans with the
prepuce, by bands, iij. 58;  treatment of 
ANALYTICAL INDEX.
807
 phimosis  from  inflammation,  iii.  59;
 from excoriation  or putrefaction of the
 cheese-like matter, iii. 59 ;  treatment of
 syphilitic phimosis, iii. 59 ;  Pigne on the
 treatment of syphilitic  phimosis, iii. 59 ;
 the operation rarely required for inflam-
 matory and venereal phimosis, iii.  59;
 the introduction of the catheter requisite,
 when the issue of the urine is impeded by
 the constriction  of the phimosis on. the
 urethra, iii. 60; the origin and  symptoms
 of paraphimosis,  iii. 60; treatment, iii. J
 60;  reduction of  the  prepuce, iii.  60; j
 treatment of  the  accompanying inflam-
 mation, iii.  61 ; South  on the  reduction
 of paraphimosis, iii. 61; the  operation
 for paraphimosis,  iii.  61;  treatment  if
 suppuration have occurred, iii. 62; after-
 treatment,   iii. 62; constriction of the!
 penis by threads, tape,  rings, &c, iii. 62;
 symptoms and  treatment, iii.  62;. nar-
 rowing and closure  of  the urethra,  iii.
 62;  stricture of the urethra  of more fre-
 quent occurrenc than in any  other outlet,
 iii. 63; symptoms, iii.  63; Brodie on
 incontinence ofurine in stricture, iii. 64;
 extravasation  of urine from rupture or
 sloughing of the urethra behind the stric-
 ture,  iii. 64; Brodie on extravasation of
 urine from  ruptured urethra  in stricture,
 iii. 64 ; Brodie on  abscessses communi-
 cating with  the  bladtfer in old cases of
 stricture, iii. 64; changes in the urethra
 in old strictures, and the attendant symp-.
 toms, iii, 65; Brodie on the complication
 of stricture  with enlarged prostate, iii.
 65;  Brodie's case of enlargement of the
 urethra from stricture, iii. 65;  Brodie on
 the formation of cysts of the urethral mu-
 cous  membrane in stricture, iii.  66; Bro-
 die on the occcurrence of rigors and fever
 in cases of stricture, iii. 66 ;  causes of
 stricture, iii. 66; Brodie on the existence
 in old strictures of an indurated mass at
 the lower portion of the penis, iii. 67;
 seat  and characters of  stricture, iii.  67;
 Hunter's description of  three  forms of
 stricture, iii. 67 ; Brodie  on  the original
 seat of  stricture, iii. 68;  diseases liable
 to be  confounded with  stricture, iii.  68;
 diagnosis,  iii. 68;  prognosis, iii.   68;
 treatment, iii.  69 ; mode  of determining
 the seat of  the  stricture, iii.  69 ;   Bro-
 die on the  use of a  full-sized  bougie in
 determining the seat of the stricture, iii.
 70 ; preparation of common  bougies, iii.
 70 ; Astley  Cooper, Abernethy and Bro-
die on the  passing  the bougie, iii. 71 ;
Astley Cooper and Abernethy on the use
of metallic  bougies, iii.  71;  Brodie on
the treatment of  stricture with bougies,
and on their applicability to  the respec-
   tive  kinds of stricture, iii. 71; Brodie's
   directions for the  introduction  of  the
   bougie, iii. 73 ;  South on the danger of
   using plaster bougies, iii. 73 ; South on
   the introduction of the  bougie,  iii.  74 ;
   South on  the general  treatment of stric-
   ture, iii. 75;  the time the bougie should
   be left in  the urethra, and  the frequency
   of its introduction, iii. 75 ; precautions to
   be taken when the instrument is left in
   the urethra, iii. 76 ;  gradual increase in
   the size of the  intruuient  used,  iii.  76;
I   Arnott's oil-silk tube, iii.. 76;  action of
   the bougie, iii.. 771 symptoms occasion-
   ally  produced   by it, iii.  77;  Astley
   Cooper and Abernethy on  haemorrhage
   from the urethra.after passing the bougie,
   iii. 77 ;  Astley Cooper and South on the
   practice to be adopted when a laceration of
   the urethra by the bougie  is suspected,iii.
   77; destruction of the stricture by caustic,
   iii. 78; by ulceration to be  rejected as
   dangerous, iii. 78; Brodie on the destruc-
   tion of the stricture by ulceration, iii. 78;
   cauterizing a stricture from before back-
   wards,  iii. 78;. preparation of  armed
   bougies, iii.  78;  Hunter,  Home  and
   Whately on the use of the armed bougie,
   iii. 79; objections to this modeof cauteriza-
   tion,  79; cauterizating the walls of  the
   stricture, iii. 79; Whately and Arnott on
   cauterizing the walls of the stricture, iii.
   79; use of bougies armed with  caustic
   potash, iii, 80; Whately and Lawrence
   on the use of bougies armed with  caustic
   potash, iii. 8Q; Ducamp's mode of cau-
   terizing  the urethra, iii. 80 ;  subsequent
   treatment,  iii. 81; Ducamp's mode of di-
   lating the  urethra after cauterization, iii.
   81 ;  Ducamp's  caution  respecting  the
   use of caustic,.iii. 82; Lallemand, Segalas
   and Tanchou's caustic-holders,  iii.  83;
   relative  advantages of the  treatment by
   bougies  and by caustic,  iii.  83;  Astley
   Cooper, Brodie, Lawrence and South on
   the use of the armed bougie,  iii. 84; cut-
   ting  into the  stricture,  and  subsequent
   dilatation,  iii. 85; Jameson's treatment of
   stricture, iii. 85; formation of false pas-
   sages, iii.  86; treatment, iii.  86; South
   on  the treatment  of false passages, iii. 86;
   congenital closure of the  urethra, ii.  86;
   treatment,  iii. 86;  hypospadias and  its
   treatment,  iii. 87 ; closure and narrowing
   of the vagina, iii. 87; congenital or acci-
   dental, iii. 87; symptoms  of congenital
   closure of  the vagina, iii. 87; narrowing
   of the vagina, i!i. 88 ; treatment, iii. 88 ;
   operation for complete closure of the va-
   gina  by the hymen, iii. 88;  division of
   the united labia, iii. 88; South on  the
   treatment of closed vagina in  infants, iii. 
808
ANALYTICAL  INDEX.
  89; the closure more or less deep in the
  vagina, iii. 89; complete closure of the
  vagina without signs of menstruation, iii.
  89;  partial closure or bands of the va-
  gina, iii.  89; Locock's case of bands in
  the vagina from previous difficult labour,
  iii.  89;  Kennedy  and Labat's  cases,
  iii.   90;   treatment  of narrowing  of
  the vagina, iii. 90; treatment after the
  escape of the retained catamenia, iii. 90;
  closure and narrowing of the mouth of the
  womb, ii. 90 ; congenital or acquired, iii.
  90; characters, iii. 91; consequences-of
  the retention of the catamenia, iii. 91;
  treatment by  operation,  iii,  91; after-
  treatment, iii. 91;  operation for closure
  of the os uteri from scirrhous degenera-
  tion, iii. 91 ;  the operation when  the os
  uteri is completely closed, or cannot be
  felt, iii. 92.
Cole's, Mr.,mode of am putating at the hip-
  joint by the circular cut, iii. 689.
Colles, Mr., on the ingrowing of the nail,
  i. 222; on the disease of the nail liable to
  be mistaken for gout,  i. 222 ; condemns
  Cooper's operation  for ingrowing of the
  hail, i. 224 ; operation  for the treatment
  of that disease,.i. 225; on onychia ma-
  ligna, i. 226; plan of treatment, i. 226 ;
  doubts whether  a  syphilitic  infant can
  infectits nurse,unless she have ulceration
  of the nipple, ii. 105;  case of ligature of
  the subclavian above the clavicle, ii. 519;
  on the seat of stricture in the rectum, iii.
  46.
Colomhat's,  M , mode of reduction of dis-
  located femur, ii. 241; hysterotome, iii.
  567.
Colomre's, M., experiments respecting sta-
  phyloraphy on the dead body, ii.  30.
Come's, Frere, operation with the lithotome
  cachi, iii. 326.
Compression: Pressure on the Brain, i.
  445; causes, i. 445~; symptoms,  i. 445;
  Guthrie on the stertor an uncertain sign
  of compression, i. 445; Guthrie on a pe-
  culiar whiff or puff from the corner of the
  mouth a sign of compression, i. 445; prog-
  nosis, i. 446; treatment, i. 446 ; South on
  mercury in compression, i. 446; removal
  of extravasated blood either by absorp-
  tion or trepanning,  i. 447 ; signs  indica-
  tive of the propriety of trepanning, i. 447;
  removal  of the  extravasation after the
  performance  of  the  operation,  i. 447;
  South on the removal of the extravasated
  blood after the operation, i. 447;  South,
  Pott and  Brodie  on puncturing the dura
  mater,when the extravasation lies beneath
  it, i. 447 ;  Pott on  the extravasation be-
  tween the meninges, or on the surface of
  the brain, i. 447; Chevalier and  Ogle's|
  cases, i. 447;  Hunter, Astley  Cooper,
  Abernethy and  Lawrence on puncturing
i  the dura mater to evacuate the effused
  blood, i. 448;  South on the operation of
  trepanning to  remove effused  blood, i.
  448.
Concussion of  the Brain, i. 449; symp-
  toms, i. 449; Astley Cooper and South
  on the state of the pulse in concussion, i.
  449;  Astley  Cooper and Larrey's cases
  of loss of memory, &c, after concussion,
  i.  450; Hennen on  the  loss of certain
  faculties from concussion, i. 450; Astley
  Cooper on the condition of the alimentary
  canal and bladder during concussion, i.
  450;  the diagnosis of concussion from
  compression, i.  451; concussion and com-
  pression may  occur  together,  i.  451;
  difficult to distinguish between drunken-
  ness and concussion or compression, i.
  451; in drunkards delirium tremens may
  succeed concussion, i. 451; inflammation
  of the brain may be connected with con-
  cussion, i. 451; primary and consecutive
  changes in the  brain from concussion, i.
  451;  Dupuytren distinguishes  between
  commotion and contusion of the brain, i.
  451;  Walther and Astley Cooper on the
  symptoms  of laceration of the  brain, i.
  451;  Astley  Cooper on the condition of
  the brain in moderate concussion, i. 451;
  causes  of  concussion, i. 452; Astley
  Cooper on the causes  of concussion, i.
  452 ;  Schmucker's case of concussion, i.
  452; prognosis, i. 452;  treatment, i. 452;
  South on the  treatment of concussion, i.
  452;  Astley  Cooper's case of enormous
  blood-letting  in concussion, i. 453; after-
  treatment, ii 453.
Cook's, Dt.,  case of fistulous opening in
  the stomach,  i.  523.
Cooper* Sir Astley, on the effects of frost-
  bite, ii 145;  observations on the effects
  of too suddenly warming a frozen or be-
  numbed limb, i. 148;  on the danger of
  carbuncle on  the head and neck, i. 156;
  on incisions in  carbuncle, i. 157; did not
  consider any  benefit  was derivable from
  the excision of  the relaxed uvula, i. 166;
  on chronic abscess of the breast, i. 173;
  on the treatment of  fissured nipples, i.
  174;  on the period when gonorrhoea first
  shows itself  after infection, i,  176;  or.
  the primary symptoms of gonorrhoea, 1.
  176;  on the actual seat of the discharge,
  i. 176;  on the post-mortem appearance?
  in gonorrhoea, i. 177; on the occurrence
  of haemorrhage jn severe gonorrhoea, i.
  177;  on the  influence of constitutional
  causes on  gonorrhoea, i. 179;  on the
  sympathetic bubo of gonorrhoea, i. 188 ;
  on the treatment of gonorrhoea, i. 191; 
/
ANALYTICAL  INDEX.                        809
observes that gonorrhoea is difficult to cure
in strumous subjects, i. 192;  on the re-
medies for chordee, i. 192; on gleet and
its infectious nature, i.  195;  on the dis-
tinction between gonorrhoea or gleet, and I
abscess of the lacunae, i.  195; on  the |
treatment of gleet, i. 195;  on the use of
cubebs in gonorrhoea, i. 197; on syphi-
litic swelling of the testicles, i. 200;
mentions enlargement of the  prostate in
old age, inflammation of the neck of the
bladder, a stone passing through the ure-
ter, or pressing on the commencement of
the urethra from  the  bladder, as causes
of swelled testicle, i. 200 ;  on the symp-
toms and progress of orchitis, i, 201; on
adhesion  and  thickening  of the tunica
vaginalis, i. 202; on suppuration of the
testicle, i. 202; on wasting of the testi-
ticles, as-caused by inflammation, i. 202;
on the more frequent seat of the disease
in the globus major, i. 202.;  on the symp-
toms  of psoas abscess, i.  208; on  the
origin of psoas and lumbar abscess  in
inflammation of the spine and inter-ver-
tebral  substance,  i. 209;  remarks that
lumbar abscess must be allowed to take
its  course, i. 211; this opinion contro-
verted by  South,  i. 211;  recommends
Abernethy's plan of treatment,  i.  213;
on  the treatment of the  sinuous cavities
resulting from lumbar abscess by injec-
tions, i. 214; says the  application of a
blister will often  bring  away the nail in
cases of its ingrowing,  i. 224 ;  this opi-
nion contravened by South, i. 224; ope-
ration  for the removal  of  the  diseased
portion of nail,  i. 224; condemned by
Colles and South,' i. 224; on the removal
of the nail with its secreting surface in
onychia maligna,  i. 226 ; on gonorrhceal
rheumatism and ophthalmia, i. 241; case
of gonorrhceal rheumatism and ophthal-
mia, i. 242 ; on the second stage of hip-
disease,  i. 280; on the bursting of  ab-
scesses of the hip-joint, i. 281; on  the
lengtheningof the limb from effusion into
the joint, i. 286; on morbus coxae senilis,
i. 289; on the manner in which vertebral
caries  is cured by anchylosis, i. 314; on
vertebral caries in the neck, i. 315; on
the union of wounds, i. 320; on adhesive
inflammation, i. 321; on the cat-gut liga-
ture, i. 339; case of accidental  torsion,
i. 344; on the application  of a ligature
above  a viper's bite, i. 3.90; on fracture
of the frontal sinuses, i. 431; on apparent
fracture and depression of the skull, i.
431;  on the treatment of simple fracture
with depression without the trephine, i.
431 ;  on the necessity for  raising  or re-
moving the depressed bone in compound
fracture, i. 433; case of lodgment of  a
ball in the frontal sinuses, i. 435; case
of fatal perforation of the orbitar plate of
the frontal bone, i. 436; on the removal
of foreign bodies in injuries of the brain,
i. 438; on puncturingthe brain in wounds
of the dura mater, i. 439; case of chronic
inflammation of the  dura mater,' i. 440;
on puncturing the dura mater to evacuate
effused blood, i. 448; on the state of the
pulse in  concussion, i. 449; cases of loss
of memory, &c, after concussion, i. 450 ;
on the condition of the  alimentary canal
and  bladder  during  concussion, i. 450;
on  the symptoms of laceration of  the
brain, i. 451;  on the condition of the brain
in moderate  concussion, i. 451; on  the
causes of concussion,  i. 453;  case  of
enormous blood-letting in concussion,  i.
453 ; only employs trepanning in injuries
of the head when secondary symptoms of
irritation and pressure require it, i. 453 ;
case of suspended  intellect, the conse-
quence of an  injury to the head, cured by
the application of the trephine, i. 460; on
wounds  of the throat,  i. 474;  case of
fistulous opening in the thyroid cartilage,
i. 477; objection to the use of  the osce-
phagus-tqbe, i. 478;  on the  signs  of
wounded lung, i. 483;  case of wound of
the intercostal muscles by an iron spindle,
i. 487; on the danger attending wounds
of the  lungs, i. 494; on emphysema, i.
495 ; on the treatment of traumatic pneu-
monia, i. 498; case of wound of  the
pericardium,  i. 500;  mode of practice in
small wounds  of the intestines, i. 515;
on  stabs  of  the liver,  i. 525;  case  of
wound of  the  spleen,  i, 526;  cases  of
separation of the spleen from its attach-
ments, i. 527;  on wounds of joints, and
their results, i.536; treatment of wounded
joints by a fine suture,  i. 538; on  the
effect of  compound fractures on the con-
stitution, and the reduction of a compound
to a simple fracture, i. 559; on  dressing
the wound in compound fractures, i. 563;
on  the union of compound  fractures, i.
565; on  the question of immediate am-
putation, i. 568; considers simple dislo-
cation  of the spine  to  be of very rare
occurrence, i. 536;  says fracture with
displacement above  the fourth  cervical
vertebra is immediately fatal, i. 588 ; on
softening of the spinal cord after a severe
blow,  i.  588; on the operation  for tre-
panning the spine, i. 590 ; on fracture of
the anatomical neck of the humerus, i.
606; on fracture of the  surgical neck, i.
607; on the union of fracture of the con-
dyles of the  humerus, i. 610; apparatus
for fractured  clavicle, i.  614;  first de- 
810                        ANALYTICAL  INDEX.
scribes  fracture of the coronoid process
of the ulna, i. 615;  on its union by liga-
ment, i. 616; on the distinction between
fracture of the neck of the femur within
and without the capsular ligament, i. 618;
on the in-locking of the  broken ends of
the bone, i.618; on inversion of the foot,
i.  619;  on interstitial absorption in  the
neck of the femur, i. 620; admits bony
union in fractures external to, but not in
fractures internal to, the capsular liga-
ment, i. 620; on the  treatment of frac-
tures  of the  neck of the femur,  i. 624;
bandage for the treatment of oblique frac-
ture through the trochanter major, i. 626;
on the bent position  in  fracture  of  the
femur, i.  628;  apparatus for fracture of
the patella, i. 633;  on tiie causes of the
non-union  of fractured bones, ii,  14; on
salivary calculi, ii. 150;  case of artificial
anus in the jejunum terminating fatally,
ii. 153; case of fistula in  ano, ii. 153; on
the impropriety of operating for fistula in
phthisical  subjects, ii. 164; on dressing
the wound after the operation, ii. 167; on
the treatment of callous  urinary  fistula,
ii. 177; on the suture of  urethral  fistula,
ii. 178; on urethroplasty, ii. 179; opera-
ration for  recto-urethral  fistula, ii. 186;
cases of dislocation from a lax condition
of the ligamentous capsules of the joints,
ii. 202; on laxity of the ligaments of the
lower jaw, ii. 211;  on dislocation of the
costal cartilages, ii. 216; on the symptoms
of dislocation of the  sternal end of the
clavicle backwards, ii. 217; on a partial
dislocation of the humerus, ii. 221; case
of reduction of an old dislocation of the
elbow, ii. 230; mode of reduction  in dis-
locations of the elbow, ii, 231; on dislo-
cation of the  upper  end of the radius  for-
wards, ii. 231; on the difficulty attending
the reduction of this dislocation, ii. 232;
on the cause of the difficulty experienced
in reducing the dislocation of the thumb
from the metacarpal bone, ii. 235; on the
relative frequency of dislocations of the
femur, ii. 236;  on the reduction  of  dis-
location of the femur downwards, ii. 241;
on dislocation of the semilunar cartilages,
ii. 247; cases of dislocation of the great
cuneiform  bone, ii. 256;  case of disloca-
tion of the toes, ii. 256; on the  double
hernial sac,  ii. 261; on the nature of
strangulation, ii.269; on the complication
of strangulated hernia by the presence of
an irreducible  rupture,  ii. 271; case in
which the entire hernial  sac was  ineffec-
tually removed, ii. 288; objections to liga-
ture of the sac, ii. 288; case of sloughing
of the  omentum, ii. 301;  on the operation
of dilating the abdominal ring, the hernial
sac not being opened, iiv303 ; reasons io
recommending the operation of dividing
the stricture without  opening the sac, ir
large and old ruptures, ii. 303 ; case
sloughing of the intestine after it ha
been returned into the abdomen, ii. 310;
case  of  tetanus  after the operation foi
strangulated hernia, ii. 310 ; on encys e
hernia of the tunica vaginalis, ii. 321 ; or
the seat of  femoral rupture, ii. 333 ; oi
the presence of other tumours  in the fe-
moral region, liable  to be mistaken foi
femoral rupture, ii. 333 ; on the varieties >
femoral rupture, ii. 335 ; case of umbili
cal rupture,  in which  the  sac was eith
absorbed, or burst, ii. 344 ; on  the occa-
sional enormous size of umbilical rupture
in women,  ii. 344;  on  the danger
sloughing of the integuments in strangu-
lated  umbilical rupture, ii. 346 ;  on sup-
puration of  the omentum in strangulated
umbilical rupture, ii.  346; case  of suc-
cessful operation for strangulated umbili-
cal rupture  during pregnancy, ii.  346:
opposed to  the radical cure of  reducible
umbilical rupture by ligature, ii. 347:
the operation  for strangulated  ischiatic
rupture,  ii.  351; on  the operation  foi
strangulated thyroid rupture, ii. 353 ; < >i
pudendal hernia, ii. 355; case of phrenic
rupture, depending on  malformation
the diaphragm, ii. 357; on internal stran
gulation, ii. 359 ;  case of aneurism mis
taken for abscess, ii.  474 ; on the age i
which aneurism occurs, ii. 475; on the
relative frequency of aneurism  in the
sexes, ii. 475; cases of several aneurisms
in the same person, ii. 476 ; on the effects
produced  by the ligature on the arteri
coats, ii. 493; case in  which  Brasdor'i
operation was performed, ii. 504 ; case o
ligature of the common  carotid, ii. 508:
on the impediment to ligature of the com
mon carotid offered by the internal jugu
lar vein, ii.  511; on the post-mortem ap
pearances in a case in which he had tie*.'
the common carotid 13 years previously
ii. 512 ; case of aneurism of the posten
aural, ii. 515 ; case of ligature of the sub
clavian above the clavicle, ii.  518; oi
spontaneous aneurism of the brachial, ii
528; on ligature of  the arteries of th<
fore-arm, ii. 528; case of ligature of th
aorta, ii. 528; case of ligature of the e\
ternal iliac  in the groin, ii. 531 ; on 1 i«_»•»
ture of the external iliac, ii. 539 ; on th<
post-mortem appearances after ligature o
the external iliac, ii.  540 ; case of  antu
rism  of the anterior tibial,  ii. 543;  oi
the treatment of aneurism of the anterio
tibial low  down in  the leg, by openinj
the sac, and  tying the artery above ani 
ANALYTICAL INDEX.
811
 below, ii.  544 ; on the post-mortem  ap-
 pearances after ligature of the femoral, ii,
 545; on the treatment of aneurismal va-
 rix, ii. 550; on the causes of varicocele,
 ii. 576 ;  operation for varicocele, ii. 577;
 on  the excision of piles, ii. 586; case of
 stricture of the oesophagus ulcerating ex-
 ternally, iii. 30; case  of stricture of the
 oesophagus in which a false passage was
 made through into the anterior mediasti-
 num, iii. 32; case of stricture of the rectum,
 iii. 44 ;  on the passing a bougie in stric-
 ture of the urethra, iii. 71; on the use of
 metallic bougies, iii. 71; on haemorrhage
 from the urethra after passing the bougie,
 iii.  77 ;  on the  practice  to  be adopted
 when a  laceration  of  the  urethra by
 bougie is suspected,iii. 77 ; on the use of
 the armed bougie, iii.  84;  case of a ball
 lodged in the  frontal sinus, iii. 94 ;  case
 of  fish-bone at the glottis,  iii. 98 ; on
 chronic enlargement of  the prostate, iii,
 139 ; on the symptoms and post-mortem
 appearances of  chronic  enlargement of
 the prostate, iii. 140;  on the characters of
 enlarged prostate, iii.  140; on the treat-
 ment of enlarged  prostate, iii, 142; on the
 treatment of retention of urine from en-
 larged prostate, and  on  catheterism in
 such cases, iii. 143 ; case of haematocele,
 iii. 177 ; case of haematocele of 17 years
 duration, iii. 177 ; on puncturing in spina
 bifida, iii. 189 ;  on tapping in the linea
 alba, iii. 205; case of spontaneous rupture
 of the ovarian cyst, iii. 214 ;  case of ova-
 rian dropsy iri which  the  fluid was dis-
 charged  by ulceration of  the navel, iii.
 215 ; case  of hour-glass hydrocele, iii.
 221 ; on the situation of the testicle in hy-
 drocele,  iii. 221 ; on the characters of the
 serum in hydrocele, iii. 221 ;  on the spon-
 taneous cure of hydrocele, iii. 223; on the
 radical cure  of  hydrocele by exercise
 after tapping, iii. 225;  on the cause of the
 failure of injection to cure the disease, iii.
 228 ; cases of foreign bodies the nuclei
 of stones, iii. 249 ; case of renal calculus,
 iii. 267 ; case of renal calculus communi-
 cating with abscess in  the loins, iii. 268 ;
 case of suppuration of the kidney from
 impaction  of  calculus in  the ureter, iii.
 270; on the treatment of  calculi in the
 ureters, iii. 270; case of large calculus, iii.
 273 ; case of a great number of calculi in
 the bladder, iii. 273;  on the dilatation of
 the female  urethra, iii. 284 ; case of an
 old man  operated on for stone, iii. 297; on
 the section of the prostate, iii. 320 ; on
 opening  the  membranous part of  the
; urethra,  iii. 321; on  the  symptoms of
 stone in  women, iii. 349;  case of ulcera-
 tion of  the bladder  and  vagina  by the
  pressure of a large stone, iii. 349 ; on the
  incontinence of urine consequent on litho-
  tomy in women, iii. 353 ; case of prostatic
  stone, iii. 368 ; case in which lithectasy
  was performed, iii. 375; case of enlarge-
  ment' of the  nymphae, iii. 400; case of
  human horns, iii. 403; case of very large
  fatty tumour, iii. 428 ; opinion that fatty
  tumours sometimes take  on a malignant
  degeneration, iii. 429 ; on cellular  hyda-
  tids of the breast, iii. 432 ; on sebaceous
  tumours, iii.  434 ; on the cause of  seba-
  ceous tumours, iii. 434; case of cellular
  membranous  tumour, iii. 449 ; on medul-
  lary fungus of bone, iii. 457 ; case of tu-
  mour in the popliteal nerve, iii. 506; on
  tumours on  nerves  in  stumps, iii. 506;
  on fungous degeneration of the nipple of
  the breast, iii. 528; on the development
  of the nipple in the foetus, and its subse-
  quent changes, iii. 528; on hydatid swell-
  ings of the breast, iii. 534  ; on the symp-
  toms and treatment of cellulous hydatids
  of the breast, iii. 534 ; on polypoid hyda-
  tids of the breast, iii. 535 ; on globular
  hydatids of  the breast, iii. 535; on the
  question as to the propriety of removing
  a scirrhous breast, iii. 539 ; on the nature
  of the cysts in cystic swelling of  the
  testicle, iii. 553; on the retraction of the
  cord during the extirpation of the testicle,
  iii. 557; cases of chimney-sweep's cancer
  in the cheek, iii. 560; case of excision
  of a portion of the radial nerve, iii. 636 ;
  mode of amputating at the shoulder-joint
  with a single flap, iii. 713; case of am-
  putation  at the shoulder joint, iii. 718 ;
  mode of extirpating the metacarpal bones
  of the  middle and ring fingers, iii. 722;
  case of excision of part of the hand, iii.
  722; opinion in favour of immediate am-
  putation  in severe  injuries of the lower
  extremities, the constitution then having
  only one shock to sustain, iii. 725; case of
  excision  of the lower jaw, iii. 747.
Cooper's, Mr.  Bransry, case of reduction
  of an old dislocation of  the elbow, ii. 231;
  on dislocation of  the upper  end of  the
  radius  forwards, ii. 232; on  the double
  hernial sac, ii. 261 ; case of reduction en
  masse, ii. 275 ; case in which  Gerdy's
  operation for the radical cure  of rupture
  was performed, ii. 284; case  of simple
  serous cysts of the neck, iii. 432; case ot
  entrance of air into a vein, iii. 604.        %
Cooper's,  Mr.  Samuel, case  of orchitis
  simulating strangulated rupture, i. 202 ;
  mentions Mr Ramsden's  case of lumbar
  abscess, i. 209; on the substance which
  fills up the acetabulum in secondary dis-
  location in hip disease, i.  287 ; on secon-
  dary haemorrhage in gun-shot wounds, i. 
812
ANALYTICAL  INDEX.
   377;  case  of chronic  tetanus  of  five
   weeks' duration, i. 417 ; on the causes
 .  of tetanus,  i. 418 ; cases of prolapsed
   womb in virgins, ii. 373; on the effects
   of compression in aneurism, ii. 488.
 Cooper's,  Mr.  William,  case of  radial
   aneurism, ii. 528.
 CoPELANn's, Mr., objection to stuffing the
   rectum in casesof haemorrhage after the
   operation for rectal fistula, ii. 168; Opera*
   tion for recto-vaginal fistula by the divi-
   sion of the sphincter ani, ii. 199; on pro-
   lapse of the internal membrane of  the
   rectum, ii. 398; on the diagnosis between
   prolapsed rectum and haemorrhoids, and
   intus-susception,  ii. 399; operation  for
   prolapse of  the rectum, ii. 403; on  the
   removal of internal piles by ligature, ii.
   584; on the application of the ligature,
   ii. 585; on the incisionof the stricture in
   stricture of  the rectum,  iii. 51; case  of
   very large fatty tumour, iii. 428.
 Copland, Dr., on the asthenic boil, i. 152;
   on anthrax, i. 155 ;  diagnostic sign  for
   vertebral  caries,  i. 312; on  puncturing
   the  brain in chronic hydrocephalus,  iii.
   188;  on the age  at which bronchocele
   most usually occurs, iii. 389.
 Coracoid process, fracture of i. 601.
 CornSjdii. 402.
 Cornuau's, M., mode of amputating at the
   hip-joint, iii. 698;  at the knee with the cir-
   cular cut, iii. 700; at the shoulder-joint
   with the circular cut, iii. 715; mode of
   operating in  exarticulation of the fore-arm
   at the elbow, iii. 719.
 Cortez, M., on the treatment  of haemor-
   rhage consecutive on the extraction of a
   tooth, ii. 143.
 Cotton's, Dr., case  of injurious effects pro-
   duced by inhalation of ether, iii. 769.
 Coulson's, Mr. case of hysterical affection
   of the joints, i. 278; on the symptoms of
   this disorder, i. 278 ; explanation of the
   pain on the inside of  the  knee in hip
   disease, i.-280; on the bursting of ab-
   scesses of the hip-joint, i. 282; on dislo-
  cation into the foramen ovale  in hip dis-
  ease, i. 287; on the diagnosis between hip
  disease in the third stage, and  psoas ab-
  scess, i.  289; on salt water  bathing in
  hip disease, i. 292; case of closure of the
  rectum from  the  presence of  a foreign
  body, iii. 108.
Coxalgia, inflammation of the hip-joint,
  i. 278 ; the  three  stages of the disease,
  i.  278; symptoms  of  acute  inflamma-
  tion of the hip-joint, i. 279 ;  Key on the
  greater frequency  of chronic than   of
  acute inflammation of the hip-joint, i.
  279; symptoms when suppuration  takes
  place, i. 279; symptoms of the first  stage
 of chronic inflammation of the hip-joint,
 i. 279 ; Brodie on ulceration of the carti-
 lage, the primary affection in diseased
 hip, i. 280; Key's opinion  that the ulcera-
 tion  of  the  cartilages is preceded  by
 inflammation  of the ligamentum teres,
 i. 280 ; South on the  pain on the inside
 of the knee in hip disease, i. 280; Bell and
 Coulson's explanation of  that symptom,
 i. 280 ; symptoms of the second stages of
 chronic inflammation of the hip-joint, i.
 280; Astley Cooper on the second stage
 of hip disease, i. 280;  Key on  the symp-
 toms which indicate the special  part of the
joint affected, i. 281;  symptoms of the
 third stage, i.  281; Fricke's method  of
 examining the length of the limb during
 the progress of the disease, i. 281;  Astley
 Cooper and Coulson on the bursting  of
 abscesses of  the hip-joint, i.  282; Dr.
 Mackenzie and Scott's  cases of abseesses
 of the hip joint, i. 282; Brodie  on the
 difference between hip disease from ulcer-
ation of the cartilage, and that  from scro-
fulous deposit in the cancellous structures
of the bones,  i. 283; shortening and
lengthening of the diseased limb, i. 284;
 Hunter on these symptoms,i. 284; Cline
and Lawrence on these symptoms, i. 284;
theshortening only apparent, i. 284; Rust
and Fricke's explanation incorrect, i. 284;
South on  the shortening of the limb, i.
284; the  lengthening of the limb may be
either seeming or real, i. 285; explanation
of the lengthening of the limb by Petit,
Camper,  Valselva, Monro, Van der Haar,
de Haen, Vermandois,  Schwenke,  Calli-
sen,  Plenck, Portal,  Ficker, Duverney,
Clossius, Boyer, Falconer,  Rust, Lan-
genbeck, Richter, Schreger, Larrey, Che-
lius,  Fricke, Brodie,  and Crowther, i.
285 ; Weber's experiments show that the
head of the thigh-bone is retained in the
socket by atmospheric  pressure, i. 285;
these experiments of great importance in
reference to diseases of the hip-joint, i.
286;  South's explanation of the length-
ening of the limb, i. 286; Astley Cooper
on the lengthening of the  limb from ef-
fusion into the joint, i. 286;  Lawrence
on the lengthening of  the limb, i. 286;
dislocation of the head  of the thigh-bone,
i.  287 ; Nester,  Van der  Haar, Berdot,
Schreger, and Textor on the dislocation
of the head of the thigh-bone downwards
and inwards, i. 287; Hoffman's  case  of
separation of the head  of the femur, and
its removal by the surgeon, i. 287;  South
on the appearances  after  death  in hip
disease, i. 287 ; Earle on dislocation into
the ischiatic notch, i. 287; Boyer, Brodie,
and Coulson on dislocation into the fora- 
ANALYTICAL  INDEX.
813
men ovale, i. 287; Ducros, jun. on dislo-
cation forwards on the share-bone, i. 287 ;
the formation of a new  socket, i. 287;
Samuel Cooper on the substance which
fills up the acetabulum i. 287 ; diagnosis
of coxalgia from congenital  luxation of
the thigh,  shortening of the extremity
from recession and twisting  of the hip-
bone, nervous sciatica, and malum coxae
senile, i. 288; coxalgia  cannot  well  be
confounded with phlegmasia alba dolens,
psoas abscess, or primitive dislocation of
the thigh,  i. 288 ; may be  confounded
with fracture of the neck of the thigh-
bone under certain circumstances, i. 2^8;
Bell on the pain  in hip disease, i. 288 ;
South on the sympathetic pain in the hip
from disordered bowels, i. 289 ; South,
Smith, Wemherr,  Astley Cooper,  and
Charles  Bell on the morbus coxae senilis,
i. 289; Coulson on the diagnosis between
hip disease in the third stage, and psoas
abscess, i. 289; post-mortem appearances,
i.  290;   post-mortem   appearances  in
William Adams' case, i. 290;  etiology
of hip-joint disease, i. 291 ; Fricke  on
the distinction between coxalgy and cox-
arthrocacy, i. 291; prognosis always un-
favourable, i. 291; treatment, i. 291; in
the first  stage of acute coxalgia, i. 291 ;
treatment  of chronic coxalgia,  i. 292;
Nicolai  and Klein recommend  the  use
 of the apparatus for fractured neck of the
 femur, i. 292; Physick on the treatment
 of coxalgia, i. 292; Scott's plan oftreat-
ment, i. 293; Lawrence's observations on
the plan of treatment advocated by Scott,
i. 293; has been employed by Fricke with
advantage, i. 294; treatment of the second
 stage, i. 294;  application of the actual
cautery, i. 294;  Rust  objects to the use
of issues, i. 294 ; approved of by South,
i.  294;  the actual cautery or  burning
cylinders  preferable in  all  cases where
the limb is much lengthened, the muscles
relaxed, and where there is great swelling
from collection of fluid, i. 294; Volpi has
not found benefit from the actual cautery,
 when the  first symptoms of disease  oc-
curred in  the knee, and not at  the  hip-
joint, i. 294 ; Brodie on the  influence of
the primary irritation  of the issue, and
on the maintaining it by repeated appli-
 cations of caustic potash or sulphate of
 copper, i.  295; approved of  by  South, i.
 295;  Duval's local steam-bathing appa-
 ratus, i. 295 ; Brodie on the use of a seton
in the groin, i. 295 ; results of the treat-
ment, and  management of convalescence,
i. 296; Rust and Brodie on warm bathing,
i. 296;  Fritz, Rust, and Jaeger on  the
mercurial  treatment, i. 296; Brodie on
    Vol hi.—69
 the importance of rest and position, i. 296;
 general treatment in the first  two stages
 of coxalgy, i. 297 ; Jaeger, Rust, Dieffen-
 bach, and Frank on the general treatment
 of coxalgy, i. 297; Fricke's plan, i. 297;
 treatment of the consecutive dislocation,
 U297; reduction of the dislocation fre-
 quently not successful, i. 297; views of
 Petit, Callisen, and Jaeger on the reduc-
 tion of consecutive dislocation, i. 297 ;
 cases  by Berdot, Hagen,  Ficker, Thile-
 nius, Mozilewsky, Schneider, B.  Heine,
 F.  Humbert, M.  N.  Jacquier, Textor,
 Volpi,  Schreger, von  Winter, Harless,
 Fricke, and J.  Hein, i. 297,  298; treat-
 ment of suppuration, i. 298; the abscesses
 to be freely opened, i. 298 ; Ford, Wend,
 Van der Haar, Rust, Brodie, and Jaeger
 on the treatment of these abscesses, i. 298;
 Sabatier and  Ficker  advise  their being
 opened with caustic, i» 298; Larrey, with
 the red-hot trocar, i. 298 ; Rust, with the
 actual cautery, i. 298 ; Rust advises pass-
 ing a  seton through the joint, i. 298;
 Brodie and Jaeger recommend free inci-
 sions in opening these abscesses, i. 299;
 Brodie and South on the management of
 abscesses at  the hip, i. 299 ;  subsequent
 treatment, i. 299 ; resection of the carious
 head of the thigh-bone, i. 299 ; excision
 of  the  head  of the femur recommended
 by Jaeger, Kirkland,  Richter, and Ver-
 mandois, i. 299 ; performed by White and
  Hewson, i. 299 ; Kerr and Baffos exarti-
 culated  the thigh-bone, i. 299; Charles
  Bell's  proposition, i.  299; Barry's case
  of accidental reduction of the dislocation,
  i. 299.
Coxe, Mr.,  on the  treatment  of  vesico-
  vaginal fistula, by drawing off the urine,
  and by compression, ii. 189.
Coze, M., on twisting round of the patella,
  ii.  246.
Cramer's, M., treatment of fistulous pas-
  sages, i. 108.
Crampton's Sir  Philip, experiments  on
  the ligature of arteries, i. 335; on Com-
  pression in the treatment of aneurism, ii.
  486 ; case of aneurism in which the tem-
  porary ligature was employed, ii. 496;
  operation  for  ligature  oF the common
  iliac, ii. 533; on the application of leeches
  to  mucous surfaces, hi. 613 ; on the exci-
  sion of joints, iii. 728 ; recommends the
  non-division of the ulnar nerve in exci-
  sion of the elbow-joint, iii. 733 ; case of
  excision of the elbow-joint, iii. 734.
Crisp's, Mr.,  case  of  a piece of broken
  catheter in the bladder,  iii.  135; case
  of fracture of a renal calculus by sudden
  exertions, iii. 368. 
814
ANALYTICAL INDEX.
 Croix, M. La, d'Orlean's, case of ampu-
   tion at the hip-joint, iii. 689.
 Croserio's, M.,  modification of the opera-
   tion for salivary fistula, ii. 149.
 Crosse,  Mr., on  the characters of the re-
   spective  varieties of  inversion of  the
   womb, ii. 382 ;  on the successive steps
   of the inventing process, ii.  383;  on the
   concavity formed in all cases  of inversion,
   ii. 383 ; on polypus-of the fundus uteri as
   a cause of inversion, ii. 384 ; on the pre-
   sence of coagulated blood, hydatids, and
   moles in the womb,as causes  of inversion,
   ii. 385; on the spontaneous  breaking up
   of calculi in the bladder,  iii. 275.
 Crowther, Mr., on tapping lumbar or psoas
   abscess with a trocar, i. 212,;  on the
   lengthening  of  the limb in hip disease,
   i. 285.                                 j
 Cruveilhskr, M., on phlebitis, i..92;  dis-
   tinctly  of opinion that  cartilages are de-
   void of vascularity, i. 253 ; case of bony
   anchylosis of  the right condyle of the
   lower jaw, i. 274 ; apparatus for fractured
   clavicle, i.  603; on the production of
   callus, i. 621 ; on the causes of congenital
   dislocation, ii.  208; on the  contents of
   the sac formed  by the prolapsed vagina,
   ii. 371;  on  incontinence  of urine  in
   prolapse of  the womb, ii. 372; on the!
   altered  form  and direction of the os uteri
   in prolapse of that organ,  ii. 372; on the
   elongation of the womb in  prolapse, ii.
   372; on the  formation  of calculi  in the
   displaced bladder  consequent  on pro-
   lapsus uteri,  ii.  372 ;  on displacement of
   the rectum consecutive to prolapse,  ii.
   373; on excision of  the prolapsed scir-
   rhous womb, ii. 381; on the causes of
   club-foot, ii.  446; case  of opening  of the
   rectum  under the glans penis,  iii. 38;
   on encysted swellings,  iii. 180.
 Cuillvier, M., on the solution  of the chlo-
   ride of lime in the treatment of foul, gan-
   grenous, or torpid ulcers, ii. 44.
 Cullen, Dr., on the proximate cause of in-
   flammation, i. 38.
 Cullen, Mr. Peter, on  the treatment  of'
   haemorrhage consecutive on  the extrac-;
   tion of a tooth, ii, 143.                 I
 Cumming's  Dr.,  description of cancrum
   oris, i. 76.
 Cuming's, Mr.,  case of resection of the cla-
   vicle, iii. 763.
 Cunningham's, Dr., case of compound frac-
   ture of  the skull, and lodgment of the
   breech of a pistol within the cranium,
   i. 434.
Cupping, iii. 615.
 Curling, Mr., on the effects of the scorpion
   sting, i. 387; on the  proximate cause of
   tetanus, i. 417;  on  haematocele of the
   spermatic cord, iii. 178.
Curvatures:—definition, ii. 417; causes,
  ii* 417 ; condition of the muscles in curva-
  tures, ii. 418; Guerin on the condition of
  the muscles in curvatures, ii. 419; disease
  of the bones as  causes  of curvature, ii.
  419; prognosis, ii, 419; treatment, ii. 419;
  subcutaneous division of the muscles, or
  their tendons  or aponeuroses, when the
  muscles are contracted  and changed in
  their tissue, ii. 420; wry neck, ii. 421;
  definition and causes, ii. 421; Stromeyer
  and Dieffenbach on the causes of wry
  neck, ii. 422 ; Syme's case, ii. 422; Bro-
  die's case of wry neck  alternating with
  insanity, ii. 422; Syme on  the distorted
  position of the head  caused by caries be-
  tween the occiput and atlas, as liable to
  be mistaken for wry neck from muscular
  contraction, ii. 423; prognosis, ii. 423 ;
  treatment, ii. 423;  Jorg's apparatus  for
  keeping the head straight, ii. 423 ;  divi-
  sion of  the sterno-cleido-mastoideus, ii.
  424; its subcutaneous section, ii. 424;
  mode of performingthe operation, ii. 424;
  section of other muscles sometimes requi-
  site,  ii. 425; after-treatment, ii.  425,;
  Stromeyer on the after-treatment, ii. 425;
  spasm of the sterno-cleido-mastoideus a
  cause of wry neck, ii. 425; Gooch's case
  of spasm of  the platysma  myoides cured
  by  operation,  ii. 426;  treatment of wry
  neck caused by large scars, ii. 426; their
  entire extirpation requisite, ii. 426;  wry
  neck from curvature of the cervical ver-
  tebrae,  unaccompanied  by anchylosis, ii.
  426; curvatures of the spine, ii. 427;  di-
  rections of the spinal curvatures, ii. 427;
  Meckel,  Jorg, and Choulart on the influ-
  ence of spinal curvature on the transverse
  diameter of the pelvis, ii. 427; inclination
  of the spinal column to one side, ii. 428;
  high shoulder, ii. 428;   South  on  the
  causes of high shoulder, ii. 428; general
  symptoms attending  lateral inclination of
  the spine, ii. 429; posterior curvature of
 the  spine, cyphosis, ii. 429; symptoms,
 ii. 429; inclination if the spine forwards,
 ii. 429; occasional causes of spinal cur-
 vature, ii. 429; Stromeyer on palsy of the
 serratus magnus as a  cause of scoliosis or
 lateral  curvature, ii.  430;  Gunther   on
 the  condition of the muscles in snake-like
 scoliosis, ii.  430; Zink on the. situation
 and direction of scoliosis, ii. 430 ; Syme
 on wry neck  as a cause of lateral curva-
 ture, ii. 431; diagnosis, ii. 431; Delpech
 on the swelling of the fibrous inter-carti-
 lage as  a cause of spinal  curvature,  ii.
 431; symptoms and  progress, ii. 432;
 curvature of  the spine from  softening of
 the  bones, ii. 432;  prognosis, ii. 433;
 South condemns the practice of lifting by
 the head, ii. 434; treatment of spinal cur- 
ANALYTICAL INDEX.                         815
  vature, ii. 434 ; application of apparatus
  acting by pressure, ii. 434; apparatus ope-
  rating  by extension, ii. 434 ; apparatus
  acting by extension and pressure, ii. 435;
  the latter only can act efficiently, ii. 435;
  use of gymnastics with the extending ap-
  paratus, ii. 437;  effects of gymnastics,
  ii. 437; treatment  when   the cause  of
  the curvature  is an unequal  contraction
  of the  muscles, ii. 438; Guerin on the
  section of the contracted muscles, ii. 439;
  Robert Hunter and Syme  on the section
  of muscles in spinal  curvature, ii. 439;
  internal treatment in curvatures  depend-
  ent on great muscular weakness, ii. 440;
  treatment of high shoulder,  ii.  440;  of
  curvature of the spine depending on soften-
  ing and thickening of the  fibrous inter-
  cartilage, ii. 440 ;  on rickets, ii. 441; on
  rheumatism, ii. 441;  curvatures of the
  spine from  contraction of one side of the
  chest,  incurable, ii. 441; from shortening
  of one of the lower limbs, ii. 441; curva-
  tures  of the limbs, ii. 441; nature and
  causes, ii.  441; curvatures  of the  lower
  limbs, ii. 442;  more frequent than those
  of the upper, ii. 442; curvatures of ihe hip,
  ii. 442; causes, ii.  442; treatment, ii. 442;
  Stromeyer's case in which the section of
  the pectineus and sartorius was practised,
  ii.  442; curvatures of the knee, ii. 443;
  causes, ii. 443; to  be distinguished from
  the curvature of anchylosis, ii. 443 ; in-
  knee, ii. 443; characters, ii. 443; treatment,
  ii. 443; curvature of the knee outwards, ii.
  443; of rare occurrence, ii. 443;  curva-
 ture of the knee forwards, ii. 443 ;  causes,
 ii. 443;  treatment,  ii. 444; section of the
 hamstring tendons, ii. 444;  objections to
 the operation, ii. 444; performance of the
 operation, ii. 444; Fergusson on disloca-
 tion of the knee after the division of the
 hamstring tendons, requiring amputation,
 ii. 444; Stanley's case of contracted knees,
 cured by the subcutaneous section of the)
 hamstring tendons, ii. 441;  curvature of
 the feet, ii. 445;  varieties of  curvature, ii.
 445; club-foot, ii. 445; characters,  ii. 445;
 various  degrees of  club-foot,  ii.  446;
 causes, ii. 446; condition of the parts en-
 gaged in the club-foot, ii. 446; Pare, Du-
 verney,  Scarpa, Bruchner,  Naumberg,
 Wantzel, Delpech, Rudolphi, Camper,
 Glisson, Cruveilhier, Martin, Scoutetten,
 Duval, and Blasius on the causes of club-
 foot, ii. 446, 447; Little on the diagnosis
 between club-footand the deformity of the
 tarsus caused by rickets ii. 447; South's
case of hysterical club-foot, ii.447;South's
case of club-foot from palsy of the mus-
cles of the leg, ii. 449; prognosis, ii. 450;
treatment,  ii. 450;  indications oftreat-
  ment, ii. 450; South on the treatment of
  club-foot in early infancy,ii.451 ; Scarpa's
  machine for  club-foot, ii. 451; South on
  the application of Scarpa's shoe, ii. 452 ;
  subcutaneous division of the tendons, ii.
  452 ;  division of the tendo Achillis, ii.
  452; Thilenius, Michaelis, Sartorius,Del-
  pech, Stromeyer,Stoess, Bouvier, Guerin,
  Scoutetten, Dieffenbach, and South on the
  section of the tendo Achillis, ii, 453; treat-
  ment of the foot after the division of the
  tendon, ii.  453; application of the extend-
  ing power  after the wound has healed, ii.
  453;  South on the application of the ex-
  tending power,after the performance of the
  operation, and the  healing of the wound,
  ii. 454; division of the plantar fascia, ii.
  455; of the tendons of tibialis anticus and
  extensor proprius pollicis, ii. 455; of the
  tibialis posticus, flexor pollicis  longus,
  flexor pollicis brevis,and adductor pollicis,
  ii. 455;  South  on the division of the
  plantar fascia, ii. 455; South on the divi-
 sion of the  tendon of the tibialis posticus,
 and on the danger of wounding ihe poste-
 rior tibial artery during the operation, ii.
 455;  after-treatment, ii.  455;  Blasius'
 opinion against tenotomy in club-foot, ii.
 456; splay-foot, ii. 456;  characters, ii.
 456; inconveniences of splay-foot, ii. 456;
 distinguished  from broad-foot, ii. 457;
 causes, ii. 457; Liston, Froriep, Rognetta,
 Thune, and Stromeyer on the causes of
 splay-foot, ii. 457; Thune on primitive
 and secondary valgus, ii. 457 ; treatment,
 ii. 458; Held on the division of the peronei
 muscles in  splay-foot, ii. 458; South on
 the cause of mischief in splay-foot, ii. 459;
 horse-foot, ii.  459;  characters, ii. 459;
 causes, ii. 459; treatment, ii. 459; Jflrg's
 apparatus, ii.  460 ;  South on ulceration of
 the calf as a cause of horse-foot, ii. 460;
 South's case of horse-foot  from palsy, ii.
 460; South's apparatus for  horse-foot,
 ii. 461 ; hook-foot, ii. 461;  characters, ii.
 461; treatment, ii. 461; Tyrrell's case of
 hook-foot, arising from  an accident, ii.
 461; curvature of the upper  limbs, ii. 462 ;
 curvatures of the shoulder, ii. 462 ; of rare
 occurrence,  ii. 462 ; symptoms and treat-
 ment, ii. 462 ; curvatures of the elbow, ii.
 463 ; except when depending on anchy-
 losis or inflammatory deposit  in the soft
 parts about the joint, caused by contrac-
 tion of the biceps and brachialis anticus,
ii. 463; treatment, ii. 463; division of  the
tendon of  the  biceps, ii. 463;  curvatures
 of the hand,  ii. 463 ; causes and charac-
ters, ii. 463; permanent bending of the hand,
ii. 463 ; characters, ii. 463; Lode on two
kinds of curvature of  the hand, ii. 463;
causes and treatment, ii. 463 ; permanent 
816                       ANALYTICAL INDEX.
  straightening of the hand, ii. 464 ; of rare
  occurrence, ii. 464;  characters, ii. 464 ;
  permanent bending of the fingers, ii. 464 ;
  causes, ii. 464; diagnosis, ii. 464 ; curva-
  ture caused by contraction of the palmar
  fascia, ii. 464;  characters, ii. 464; Goy-
  raud and Sanson on the retraction of  the
  tendons, ii. 465; signs of the curvature
  when caused by contraction of the flexor
  muscles, ii. 465;  by a cicatrix, ii. 466;
  by palsy, or section of the  extensor ten-
  dons,  ii. 466; by anchylosis, ii. 466; divi-
  sion of the palmar fascia, ii. 466; treatment
  of curvature from a cicatrix, ii, 466; curva-
  tures of bones and their treatment, ii. 466.
Custance's, Mr., case of blacking pot in
  the rectum, iii.  108.
Cusack's, Mr., mode of operating in exci-
  sion of the lower jaiw with the condyles,
  iii. 750; on the nonnecessity for tying the
  carotid artery,  prior  to excision  of  the
  lower-jaw, iii. 752 ;  cases of exarticula-
  tion of the lower-jaw, iii. 752.
Cyphosis, ii. 429.
Cystectasy, iii. 375.
Cysticercus cellulosa, iii. 441.

Dahl's, M., artery-compressor, i.  331.
Dailliez, M., on  strangulation of intestine
  in the concavity formed by the inverted
  womb, ii. 385.
Dallam, Mr., on  the use of raw  cotton in
  the treatment of burns, i. 131.
Dalrymple,   Mr.,  on  the   treatment  of
  branching aneurism, ii. 554;  case  of
  ossified encysted tumour of the eyelid, iii.
  436;  on  the nature and  characters of
  tumours of the nose; iii. 598.
Davat's,  M., operation  for varicocele, ii.
  578.
Davenport's, Mr., case of consecutive he-
  morrhage after  the extraction of a tooth,
  ii. 141.
David's, M., case of excision  of a joint,
  iii. 726.
Davidson, Mr.,  successful operation  for
  lacerated perineum,  ii. 39; case of arti-
  ficial  retention of the faeces for  several
  days after the operation, ii. 40.
Davie's, Mr., operation  for removing  the
  dislocated sternal end of the clavicle, ii
  219 :  case of excision of a joint, iii..726
Davies, Dr., on the operation for empyema,
  iii. 206.
Deadrick's, Dr., case of .excision  of part
  of the side of the lower-jaw without the
  condyle, iii. 748.
Dease,  Mr., refers, tire-principal cause of
  disease in injuriesof the skull,  not to in-
  flammation and suppuration of the dura
  mater, hut to. injury of the pia mater  and
  brain, i. 424; on the cases in which the
  cranium  is  laid  bare, contused, or  its
  tables  simply divided, i. 425; rules  for
  the application of the trephine, i. 426; on
  puncturing the dura mater, when pus is
  not found between it and the bone, i. 426;
  objection to the  use of the trephine in
  simple fraetures, i.  433;  only employs
  the trepan when secondary symptoms of
  irritation and pressure require  it, i. 454;
  casein which the temporary ligature was
  employed, ii. 496.
Decker's, Mr., on tapping lumbar or psoas
  abscess with a trocar, i. 212.
Delpech's, M., cases of malignant pustule,
  i. 79 ; commendation of cubebsin gonor-
  rhoea, i. 196; has shown that cubebs do
  not cause inflammation of the testicles,
  i. 197; treatment of gonorrhoea, i. 197;
  on the after-management of ligatures on
  arteries, i. 338; denies the possibility of
  simple dislocation of the  spine, i. 586;
  apparatus for fractured clavicle, i. 603; on
  the in-locking of the broken ends of the
  bone in fracture of the neck of the femur,
  i, 618 ; on the rotation of  the foot  out-
  wards, i. 618; on inversion of the foot, i.
  619; on frictions  with the ung. hydrarg.
  cin. in primary syphilis, ii. 81; on the dis-
  eased condition of bones in syphilis, not
  caries, but necrosis, ii. 116; enterotome,
  and operation for  artificial anus, ii. 158;
  on urethroplasty, ii. 179; on the swelling
  of the fibrous inter-cartilage as a cause of
  spinal curvature,  ii. 432; on  the causes
  of club-foot, ii. 446; on the section of the
  tendo Achillis in club-foot, ii. 453;  on
  ligature of the external iliac, ii. 538;  on
  the ligature of the  spermatic veins  in
  varicocele, ii. 578; mode  of extirpating
  piles, ii. 583; objections to gastrotomy or
  entorotomy, iii. 105; case of sarcomatous
  enlargement of the scrotum, iii. 449;  on
  extirpation of the womb, iii. 572; modifi-
  cation of the Indian method of rhinoplasty,
  iii. 583;  case of division of the ulnar
  nerve, iii. 636; case of division of the
  posterior tibial nerve, iii.  636; mode of
  amputating at the hip-joint with the flap
  out with a single flap, iii.  691.
Demme's, M., apparatus for ligaturing com-
  plete rectal fistulae, ii. 169.
Denan's, M., practice in wounded intestine,
  i. 509.
Deneux's, M., case of wound of the womb,
  i. 533.
Desault,-M., on the treatment of in-grow-
  ing of a nail, i, 223; artery-compressor,
  i.,331; only employs the trepan in injuries
  of the head when secondary symptoms of
  irritation and pressure require it, i.  454;
  on the stanching the bleeding from a
  wounded intercostal artery, i. 492; band- 
ANALYTICAL INDEX.
817
   age for rupture of the tendo Achillis, 1
   541; case of  simple  dislocation of the
   spine,  i. 586; apparatus for fractured
   clavicle, i. 604; treatment of fractured
   olecranon, i. 614;  on the in-locking of
   the broken ends of the bone in fracture of
   the neck of the femur, i.  618;  on the
   rotation of the  foot outwards, i. 618; ap-
   paratus  for fracture of the neck of the
   femur, i. 623;  on permanent extension in
   fracture of the  femur, i. 628; on the treat-
   ment of salivary fistula, ii. 147;  on the
   treatment of fistula of the parotid duct, ii.
   149; on the treatment of artificial anus,
   ii. 158; apparatus for ligaturing complete
   rectal fistulae, ii. 169; on the treatment of
   recto-urethral and recto-vesical fistula, ii.
   185; on the treatment of vesico-vaginal
   fistula by drawing off the urine and by
   compression, ii.  189;  on the primitive
   direction of dislocation of the  humerus,
   ii. 221;  on the surgical treatment of dis-
   location of the thumb from the metacarpal
   bone, ii. 235; on the spontaneous cure of
   umbilical rupture, ii. 346; fatal operation
   for the radical  cure of umbilical rupture
   by ligature,  ii. 347; case in which he
   performed Anel's operation for aneurism,
   ii. 488; mode of operating in  ovarian
   dropsy, iii. 209 ;  mode of treating con-
   genital hydrocele, iii. 232; mode of am-
   putating by the circular incision, iii. 640;
   mode  of amputating  at  the shoulder-
   joint, iii. 714.
 Deschamps', M,, case  of displacement of
   the heart, ii. 361; case in which Brasdor's
   operation was performed, ii. 504.
 Deuber, M., on the application of sutures
   in vesico-vaginal fistula, ii. 193.
 Dewar's,  Mr.  H.,  treatment  of fistulous
   passages, f. 357.
 Diathesis purulenta, i.  57.
 Dick, Professor, on the nature of the disease
   in hydrophobia, i. 40.5.
 Dickin's,  Mr., case of  foreign body in the
   bronchus, in which tracheotomy was perT
   formed, and the foreign  body extracted
   with the forceps, iii.  118.
Diday, M., on the seat of strangulation in
  rupture ii. 268.
Dieffenbach, M., on the general treatment
  of coxalgy, i. 297; on the torsion of arte-
  ries, i. 341; torsion-forceps, i. 342;  ob-
  jections  to torsion,  i.  344;  thin insect C
  pins, and the twisted suture, i. 361; on
  the sutures in the operation for hare-lip,
  ii. 25; on the removal of the edges of the
  cleft.in  staphyloraphy, ii. 31; mode of
  uniting the cleft, ii. 32; operation when
  the cleft is very large and complicated, ii.
  33; on the after-treatment, ii. 34; mode
  of closing the fissure which sometimes
          s                           69'
 remains after the operation, ii. 35; on the
 operation for the treatment of lacerated
 perineum,  ii. 40;  on the application of
 the sutures, ii. 40;  on the artificial re-
 tention of the faeces for several days after
 the operation, ii.  40; cure  of artificial
 anus from  a lance-wound  by the actual
 cautery, ii. 161; on the treatment of cal-
 lous urinary fistula, ii. 177; on the suture
 of urethral fistula, ii. 178 ; on the intro-
 duction of the running stitch, ii. 178; on
 urethroplasty, ii.. 179; on the operation of
 urethroplasty in fistulas near the scrotum,
 ii. 179; in large fistulas in the middle or
 fore-part of the penis, ii. 179; in fistulas
 elose behind the prepuce, ii. 180; in large
 openings immediately behind the glans,
 with deficient prepuce, ii. 180 ; on cau-
 terization as a means of cure in vesico-
 vaginal fistula, ii. 190; mode of applying
 sutures in vesico-vaginal fistula, ii.  193 ;
 on  the after-treatment,  ii. 194;  treat-
 ment of  large vesico-vaginal fistulae by
 drawing  the mucous membrane together,
 ii. 196;  treatment  of moderately large
 fistula  with a  projecting fold  of the
 bladder, ii. 197; case of old dislocation
 of, the humerus, to reduce which the ten-
 dons of several muscles were divided, ii.
 226; on  the use of the actual cautery in
 prolapsus uteri, ii. 379;  on the causes of
 wry-neck,  ii.  422;  on  section of the
 tendo Achillis  in club-foot, ii. 453 ;  ope-
 ration for considerable narrowing of the
 mouth, iii. 25; operation to remedy the
 opening of the rectum into the  vagina,
 iii. 36; operation of chiloplasty, iii. 517;
 modification or  the  Indian  method of
 rhinoplasty, iii. 584; operation for defects
 of the wings of the nose, iii. 587; modi-
 fication of the operation for sunken nose,
 iii. 587;  operation for raising a  sunken
 nose, iii. 590 ;  operation for dropping in
 of the bridge  of  the nose, from the de-
 struction of part of the septum, iii. 592 ;
 operation  to remedy  the  turning down-
 wards of the tip of the nose, iii. 592; ope-
 ration  for the subcutaneous division of
 the nerves of the  cheek, iii. 634 ; case of
 exarticulation  of metatarsal bones, with
 the diseased bones of the tarsus, iii.. 710;
 mode of  operating in extirpation of  the
 superior maxillary bone, iii. 755.
ietrich, M., on ligature of the common
 carotid, ii. 509;  on  ligature of the ex-
 ternal  carotid,  ii. 512 ;  of the lingual
 artery, ii.  513;  of the external maxillary
 or facial, ii. 514 ; on the operation for the
 ligature of the subclavian on the tracheal
 side of the scalenus, ii. 520; on ligature
of the innominata, ii. 522; of  the verte-
bral artery, ii. 526. 
818                         ANALYTICAL  INDEX.
Dionis' artery-compressor, i.  331; on in-
  cision of the hernial sac and  the intro-
  duction of the lint-tents for its  radical
  cure, ii.  283; on amputation just above
  the ankle, iii. 674.
Dislocations :—definition, ii. 200;  various
  kinds of dislocations, ii. 200 ; various de-
  grees of distortion, ii. 201 ; diagnosis, ii.
  201; South on the diagnosis of disloca-
  tions, ii. 201 ; occasional causes, ii. 201;
  South and Lawrence on dislocations from
  muscular action, ii. 202; Astley Cooper's
  cases of dislocation from a lax condition of
  the ligamentous capsules of the joints, ii.
  202;Travers, jun.'s case of dislocationinto
  the ischiatic notch in a boy five years old ii.
  202 ; Malgaigne on the frequency of dis-
  location  in the different joints, ii. 202 ;
  laceration of  the ligaments,  etc., in com-
  plete dislocations, ii. 202 ; formation of a
  ne w j oi n t in ol d d isl ocations, ii. 203; prog-
  nosis, ii. 203; reduction of the dislocated
  bone more or less difficult according  to
  the circumstances of the case, ii.  203 ;
  Liston's case of speedy reduction of a dis-
  located femur, ii. 203 ; South on the re-
  duction of dislocations, ii. 203;  treatment
  of dislocations, ii. 204; reduction of the
  dislocated bone by extension and counter-
  extension, ii. 204; South on the reduction
  of old dislocations, and on the necessity of
  caution in practising extension, ii. 204 ;
  Cline jun.'s  case of reduction of  an old
  dislocation of the h umerus, ii. 204; obsta-
  cles which render the reduction  difficult
  or impossible, ii. 205 ; treatment of old
  dislocations, ii. 205; obstacles to the re-
  duction of old dislocations, ii. 205; South,
  Smith, Dupuytren, and  Breschet on the
  reduction of old dislocations, ii. 205,206;
  remedies to reduce the muscular power,
   ii. 20G; after-treatment, ii. 206; South  on
  ;the recurrence of dislocation after reduc-
  tion, from exhaustion of the  muscular
   power, ii. 206 ; treatment of  sprains, ii.
   206 ; South  on the auxiliary treatment in
   reducing dislocations, ii. 206,207, i com-
   pound dislocations, ii. 207 ; treatment, ii.
   207; removal of the head of the bone in
   compound dislocation, when it cannot be
   reduced, ii. 207; treatment of dislocation
   attended with fracture,ii. 207;  congenita!
   dislocations, ii.  207;  Hippocrates, Avi-
   cenna, Pare,Palletta,Sandefort, Schreger,
   and Dupuytren on congenital dislocation
   of the hip, ii. 207; Schreger, Dupuytren,
   Breschet, E. Stromeyer,  D'Outrepont,
   Cruveilhier, von Ammon,, and Guerin on
   the causes of congenital dislocations, ii.
   208; post-mortem appearances, ii. 208;
   causes of congenital dislocations, ii. 208 ;
   possibility ofreduction, ii. 209; dislocation
of the lower jaw, ii. 209; symptoms and
direction, ii.210;causes,ii. 210; reduction,
ii. 210; South on the reduction of this dis-
location, ii. 210; after-treatment, ii. 210;
sub-taxation of the  lower jaw,  ii.  210;
Cooper on laxity of the ligaments of the
lower jaw, ii. 211; congenital dislocation
of the lowerjaw,ii. 21 l;Guerin and Smith's
cases, ii. 211;  dislocation of the  vertebra,
ii. 211; dislocation of the first vertebrae
very rare, and absolutely fatal,  ii.  211 ;
causes of dislocation of the first  vertebra
on the second, ii.  211; causes and symp-
toms of dislocation affecting the  last five
cervical vertebrae, ii. 212; Walther on the
simultaneous dislocation of both inferior
oblique processes of one of the  cervical
vertebrae, ii. 212 ; Dupuytren on  the con-
founding cervical dislocation with rheu-
matic affection  of the neck, ii.  212; re-
duction of the dislocation, ii. 213; dislo-
cation of the  dorsal and lumbar  vertebrae
always accompanied with fracture,ii.213;
rupture of the  ligaments, ii. 214 ; treat-
ment, ii. 214; dislocation nflhepelvic bones,
ii. 214; great violence requisite  to cause
dislocation, and the pelvic viscera, etc.,
generally injured, ii.  214; treatment, ii.
214; case of dislocation of the  hip-bone
upwards, unattended by concussion of the
spinal  marrow, of  injury of the pelvic
viscera, ii. 214 ;  dislocation of  the  hip-
bones more readily produced if  the liga-
ments be lax and yielding, ii. 215 ; treat-
ment, ii. 215; dislocation of thecoccyx, ii.
215 ; treatment, ii. 215 ; dislocation of the
ribs and their  cartilages, ii.  215 ;  dis-
location of  the hinder  end of  the ribs,
ii. 215; Webster, Donne, Fimicane, and
Hankel's cases, ii. 216 ; causes, situation,
and symptoms, ii. 216;  treatment, ii. 216;
dislocation  of the costal cartilages,  ii.
216 ; treatment, ii. 216;  Astley Cooper
on dislocation of the  costal cartilages,
ii.  216; dislocation of the'collar-bone,  ii.
2.17 ; is more rare than fracture, ii. 217;
situation, ii.  217; varieties, ii. 217; symp-
toms of dislocation  of the sternal end
forwards, ii. 217  ; of dislocation  upwards,
ii. 217; of dislocation backwards, ii. 217;
 Pellieux, Duverney, and Astley Cooper
 on  the  symptoms of  dislocation  back-
 wards, ii. 217; Tyrrell's case of compound
 dislocation backwards, ii.. 218; Velpeau's
 case of simple dislocation inwards and
 backwards,  ii. 218;  mode of reduction,
 ik218; Melier's apparatus for dislocation
 of  tbe collar-bone  forwards,   ii.  219;
 Davije's operation for removing  the dislo-
 cated sternal end, ii. 219 ; dislocation  of
 the scapular end of the clavicle upwards,
 ii.  219; cause and  symptoms, ii.  219; 
ANALYTICAL  INDEX.                        819
Tournel and Melle's cases of dislocation
of the scapular end of the clavicle down-
wards, ii. 219 ; mode ofreduction,ii. 220;
South  on the difficulty of  keeping the
dislocated scapular end reduced, ii. 220;
dislocation of the upper arm, ii. 220 ; dis-
location of  the humerus more frequent
than of any other bone, ii. 221; varieties
of dislocation, ii. 221 ; Astley Cooper on
a partial dislocation of the humerus, ii.
221; Hippocrates,  Duverney,  Fabricius
ab  Aquapendente, Desault,  Mursinna,
Richerand,  Mothe, Velpeau, and Mal-
gaigne on the primitive direction of dis-
location of the humerus,  ii. 221 ;  symp-
toms of dislocation downwards, ii. 221;
of dislocation inwards, ii. 222; of dislo-
cation outwards, ii.  222 ; of imperfect dis-
location, ii. 222 ; causes, ii. 222; injury to
the soft parts, ii. 222 ; dislocation of the
humerus occasionally attended with frac-
ture of the neck of the bone, ii. 222; re-
duction of the dislocation, ii. 223; points
to be attended to in  effecting reduction, ii.
223; Rust's mode of reducing the dis-
location, ii. 224 ; after-treatment, ii. 224 ;
obstacles to reduction, ii. 224 ; reduction
of the  dislocation by means of the  heel  in
the axilla, ii. 221; Bertrandi and Sauter's
plans of reduction, ii.  225;  reduction of
the dislocation by means  of the  knee  in
the axilla, ii. 225;  use of the pulleys, ii.
225; reduction of old dislocations, ii. 225;
Weinhold's case, in which he divided the
tendon of the pectoralis  major, ii. 226 ;
Gibson's case, in which the axillary artery
was ruptured, ii.  226;  Dieffenbach's
case, in which he divided the tendons  of
several muscles, ii. 226 ; congenital dislo-
cation of the humerus, ii. 226; not of very
rare occurrence, ii. 226 ; two varieties of
this dislocation, ii. 227 ; symptoms of the
congenital subcoracoid   dislocation, ii.
227 ; examination of a case of this dislo-
cation after death, ii.  227; Smith on the
post-mortem appearances in congenital
sub-acromial dislocation, ii.  227 ; Smith
on the resemblance between the congeni-
tal sub-coracoid dislocation, and the par-
tial dislocation, and that caused by rheu-
 matic affection of the shoulder-joint, and
 by unusual atrophy of the arm, ii. 228 ;
evidence in favour of these dislocations
 being congenital, ii. 228 ; Guillard's case
of reduction of a congenital dislocation
after the lapse of sixteen years, ii. 228;
dislocations of the fore-arm, ii. 228; dis-
 locations at the elbow-joint, ii. 228 ; com-
plete dislocations  of the elbow rare, ii.
228 ; dislocation backwards, ii. 228 ; dis-
location of the ulna alone backwards, ii.
229; lateral dislocation,  ii. 229 ;  causes
of dislocation of the fore-arm backwards,
ii. 229 ;  consequences of these disloca-
tions, ii.  230; they soon become irredu-
cible, ii.  230 ; complications of disloca-
tion backwards, ii. 230;  Astley Cooper,
Bransby  Cooper,  Malgaigne, and  Lis-
franc's cases of reduction of old disloca-
tions  of the elbow, ii.  230; reduction of
the dislocation, ii. 230; Astley Cooper's
mode of proceeding,  ii.  230;  treatment
to be adopted  when  the  radius  is also
displaced, and in compound dislocation,
ii. 230;  reduction of  the  lateral disloca-
tion,  ii.  231;  treatment of old disloca-
tions, ii  231 ;  treatment of dislocation
forwards, ii. 231; dislocation of the radius
backwards, ii. 231;  dislocation of the
upper end  of  the  radius forwards,  its
causes and symptoms, ii.  231;  Boyer,
Astley Cooper, Rouyer, Villaume, Gerdy,
and B. Cooper on dislocation of the upper
end of the radius forwards, ii. 232; Bulley
and Vignolo on simultaneous dislocation
of the radius  forwards and of the ulna
backwards, ii. 232; Adams' case of longi-
tudinal dislocation of the radius, ii. 232 ;
reduction  of  this dislocation, ii.  232;
Astley Cooper on the difficulty attending
the reduction of this dislocation, ii. 232;
dislocations  of the wrist,  ii. 232;  three
kinds of dislocation, ii. 232; dislocation of
the hand from the bones of the fore-arm,
ii. 232;  varieties of this dislocation,  ii.
232;  Dupuytren doubts  the occurrence
of dislocation  of the wrist, the presumed
cases of  which  he regards as fracture of
the lower end of the radius, ii. 233;  Voil-
lemier's case of dislocation of the wrist, ii.
233 ;  Voillemier on the diagnostic  signs
of dislocation of the wrist, and fracture of
the lower end of the radius, ii. 233; causes,
ii. 233;  mode of  reduction, and  after-
treatment,   ii.  233;  dislocation of the
radius alone, ii. 233 ; of the ulna alone,
ii. 233;  dislocation of single bones of the
hand, ii. 234;  dislocation of  the  great
bone, and its treatment, ii. 234; Gras' case
of dislocation of the pisiform bone, ii.234;
partial dislocation of the  great and  unci-
form  bones, ii. 234;  dislocation of the
metacarpal bone of the  thumb, ii.  234;
reduction  and  after-treatment, ii.  234;
dislocation of the phalanges of the fingers,
ii. 234 ; mode of reduction, ii. 234 ; Roser
and Fincke on dislocation of the thumb
from the metacarpal bone, ii. 234; Desault,
Dupuytren, Evans, and Vidal on  the sur-
gical  treatment of  this  dislocation,  ii.
235; Astley Cooper, Lisfranc, Dupuytren,
Hey, Vidal, Malgaigne, Pailloux, Lawrie,
Blechy,  and Roser on the cause of the
difficulty experienced in  reducing this 
820                        ANALYTICAL  INDEX.
dislocation, ii. 235; Hey, Charles Bell,
Fincke, Liston, Reinhardt, and Roser on
the mode of reducing  this dislocation,
ii. 235 ; dislocation of the femur, ii. 235 ;
divisions,  ii.  236;  Astley Cooper  on
the relative frequency of dislocations of
the femur, ii. 236;   South  on repeated
dislocations of the  femur in the same
person, ii. 236; symptoms of dislocation
upwards and backwards, ii. 236; of dis-
location inwards and downwards, ii. 237;
Ollivier on dislocation of the femur di-
rectly  downwards, ii. 237;  dislocation
backwards and downwards into the ischi-
atic notch, ii. 237; regarded by Boyer as
secondary, ii.  ^37; dislocation upwards
and inwards, ii. 238 ; prognosis, ii. 238 ;
the reduction of these dislocations, ii. 239;
mode of reduction, ii. 239; Wattmann,
Kluge, and Rust's methods  of replace-
ment,  ii.  239, 40; Colombat's mode of
reduction, ii. 241; reduction of these dis-
locations  by pulleys,  ii. 241;  Astley
Cooper on the reduction of the dislocation
downwards, ii. 242 ; Morgan and Cock on
the reduction of the  dislocated femur by
placing the foot between  the thighs, ex-
tension and rotation  being made at the
same time, ii.  242 ; completion of the  re-
duction, and subsequent treatment, ii. 243;
congenital dislocation, ii. 243 ; described
by Hippocrates, Palletta, and Dupuytren,
ii. 243;  symptoms, ii.  243;  Dupuytren
and Palletta on the post-mortem appear-
ances, ii.  244 ; Dupuytren on the local
treatment  of this dislocation, ii. 2.45 ;
Duval, Jalade Lafond, Humbert, Pravaz,
and Guerin on the reduction of this dislo-
cation, ii.  245; Pravaz and Guerin's cases
of successful reduction, ii. 245; Heine's
apparatus, ii. 245 ; Guerin's mode of pro-
ceeding in effecting the reduction, ii. 245;
dislocation of the knee-cap, ii..246;'varieties,
ii. 246; diagnosis, ii. 246; Coze and Wolf
on twisting round of the patella, ii. 246  ;
causes, ii. 246; mode of reduction, ii. 246;
congenital dislocation of  the  patella, ii.
246 ; Palletta's case,  ii. 247 ;  dislocation
of the knee-joint,  ii.  247;  of rare occur-
rence, ii.  247; is generally incomplete,
ii. 247; mode of reduction, ii. 247; Astley
Cooper on dislocation of the  semi-lunar
cartilages, ii. 247; Wutzer and Kleberg
on congenital dislocation of the knee, ii.
248 ; dislocation of the splint-bone (fibula),
ii, 248; direction of the dislocation, ii. 248;
mode of reduction, ii. 248 ; treatment, ii.
248 ; dislocation of the ankle-joint, ii. 248;
direction of the dislocations^!. 249; symp-
toms of the dislocation inwards, ii. 249 ;
of the dislocation outwards, ii. 249<; dis-
location of the foot forwards, ii. 249; dis-
  location backwards, ii. 249 ; consequences
  of these dislocations, ii. 250 ; mode of re-
  duction, ii. 250 ; Earle's case of disloca-
  tion of the ankle inwards, with laceration
  of the internal  lateral ligament, ii.  250 ;
  compound dislocations  of the ankle, ii.
  251 ; South on the English practice in
  snch cases, ii. 251 ; dislocation of the bones
  of the tarsus, ii. 251 ; of very rare occur-
  rence, and only from great violence, ii.
  251 ; dislocation of the astragalus, ii, 251;
  direction, causes, and symptoms, ii.  251 ;
  twisting  round of the astragalus on its
  axis, ii. 252 ;  Rognetta on dislocation of
  the astragalus inwards, ii. 252; James,
  Guthrie, and  Stanley's cases of disloca-
  tion outwards,  ii. 252; dislocation for-
  wards, ii. 252; dislocation inwards, ii.
  253; dislocation outwards, ii. 253; Du-
  puytren, Boyer, and  South on reduction
  of the  dislocation, ii. 253;  mode of re-
  duction, ii. 253; treatment to be adopted
  if the reduction be impossible, ii.  254 :
  removal of the astragalus, ii. 254; removal
  of the. bone necessary when it is twisted
  on its axis, ii. 254 ; the  operation should
  be performed  early,  ii.  254; dislocation
  of the os calcis, ii. 254 ; South and Han-
  cock's cases, ii. 255; dislocation of the
  navicular  and  cuboid  bones,  ii.   255;
  always  the  result of great violence, ii.
  255; mode  of reduction, ii. 255;  dislo-
  cation of the cuboid, ii. 255 ;  treatment,
  ii. 256 ; dislocation of the great cuneiform
  bone, ii. 256; mode of reduction, ii. 256;
  Astley  Cooper's cases, ii. 256; disloca-
  tion  of the  metatarsal  bones, ii.   256;
  Dupuytren's case, ii.  256 ; mode of reduc-
  tion, ii. 256 ; Green's case of dislocation
  of the two outer metatarsal bones, ii. 256;
  dislocation of the toes, ii.  256; mode of
  reduction, ii. 256 ; Astley Cooper's  case,
  ii, 256.
Dixon's,  Mr., case of resection of a costal
  cartilage, iii. 768.
Dobson's, Sir  R., treatment of erysipelas
  by punctures with a  lancet, i.  125.
Dodard, M., mortification from spurred rye
  first noticed  by, i. 74.
Doelunger, M., on the formation of new
  vessels, i. 324.
Dohlhoff's, M., case  of encysted abscess
  of the abdomen, iii. 216.
Donige's, M., plan of  bringing the edges
  of the cleft  together in staphyloraphy,
  ii. 32; instrument for drawing the knots,
  ii. 33.
Donne, M., on the microscopic characters
  of pus, i. 46;  case of dislocation of the
  ribs, ii. 215.
Dornbluth's, M., artificial  leg, iii. 593.
Douglas, Dr.  James, on Cheselden's ope- 
ANALYTICAL INDEX.                       821
  ration for stone, iii. 314; on the dissection
  of the parts concerned in this operation,
  iii. 315.                      r
Douglas,  Mr. John, originally proposed
  the operation of lithectasy, iii. 375.
Dran, Le, M., on superficial whitlow only
  a disease of the skin, i. 215; considers
  paronychia  tendinosa to  be  caused  by
  erysipelatous inflammation, i. 216;  as-
  serts that Richter's dry whitlow depends
  on disease of the bone, i. 217; on'imme-
  diate amputation in gunshot  wounds, i.
  380 ; on the reduction en masse, ii. 274 ; on,
  ligature of  the hernial sac for its radical
  cure, ii. 283; mode of operating in ovarian
  dropsy, iii.  210; mode of amputating at
  the shoulder-joint,  iii. 712.
Dubled, M., on extirpation of the womb,
  iii. 573; operation for excision of  the
  wrist-joint,  iii. 734.
Dubourg, M., on the  treatment of spina
  bifida by closure of the sac, iii. 190.
Ducamp's,  M.,  mode  of cauterizing  the
  urethra  for stricture, iii.  81; mode of
  dilating the urethra  after cauterization,
  iii.  81; caution respecting the  use of
  caustic, iii. 82.
Ducros, M., jun., on dislocation forwards
  on the share-bone in hip-disease, i. 287.
Duges', M.,  obturator for  vesico-vaginal
  fistula, ii. 189;  on anteversion  of  the
  womb, ii. 415; case of spontaneous  re-
  duction of anteversion, ii. 416.
Duhamel, M., on mortification from spurred
  rye, i. 74.
Duncan's, Dr., condemnation of the treat-
  ment of erysipelas  by moderate compres-
  sion, i. 125.
Duparque, M., on the  fibrous or cartilagi-
  nous resistance of the tissue of the womb,
  i. 529; case of accumulation of blood in
  the womb, i. 530; on rupture of the womb
  during pregnancy,  i.  530;  on the danger
  and immediate treatment of rupture of the
  womb, i. 530;  on  partial rupture of  the
  uterus from a  collection  of fluid in its
  parietes, i.  532; cases of abscess of  the
  womb, i. 532; on puncture or narrow
  lacerations  of the womb, i. 533; on  the
  treatment of lacerations of the perineum,
  ii. 36; on  the  scarring of the edges of
  the torn perineum, ii. 36 ;  case of recto-
  vaginal fistula  cured spontaneously, ii.
  198; on the indications for the treatment
  of recto-vaginal fistula, ii. 198.
Duphoinix, M., on the use of a canula for
  maintaining the patency of the artificial
  duct in the operation for salivary fistula,
  ii. 148, 149.
Dupuy's, M., experiments on the division
  of both pneumogastric nerves, i. 475.
Dupuytren, M., on arteritis, a cause of dry
gangrene, i.  72,  89; on  the  treatment
of senile gangrene in plethoric subjects
by the antiphlogistic plan of treatment,
i. Ill; on incisions in pseudo-erysipelas,
i. 124; treatment of pseudo-erysipelas and
common erysipelas by  blisters,!. 128;
sub-division of burns, i.  126; on inci-
sions in carbuncle, i.  157 ;  on lumbar ab-
scess generally connected with  carious
vertebrae,  i. 210; on the changes that
sometimes take place in the abscess, i.
211; leaves  lumbar  abscess to nature,
i. 213; recommends cauterization, or weak
injections of nitrate  of silver,  or  nitric
acid, in the treatment  of the sinuous cavi-
ties resulting from lumbar abscesses, i.
214;  on ingrowing of the nail, i. 222;
states it to have been mistaken for gout,
i. 222; operation for dividing and re-
moving the* diseased nail  in ingrowing,
i. 223;  on onychia maligna, i. 223; on
the removal of the nail with its secreting
surface  in treating onychia, i. 224; on the
introduction of a  piece of  bougie into an
ossified artery after amputation, i. 336; on
the effects of torsion, i. 344 ; objections to
torsion, i. 344 ; on the effects of gun-shot,
i. 370 ;  case of a person killed by a gun
loaded with powder only,  i.  370; on the
splitting of the ball by the sharp edge of
the bone, i. 375; on secondary hemor-
rhage, i. 377; on amputation in tetanus,
i. 419 ;  case of abscess of the brain suc-
cessfully  opened, i.  439 ; distinguishes
between commotion and contusion  of the
brain, i. 451; objects to  the return  of the.
protruded omentum  into  the  cavity  of
the abdomen in  penetrating wounds  of
the abdominal parietes, i. 507; modifi-
cation of Lembert's  plan  of treating
wounded  intestine, i. 515;  experiments
on the  extravasation of bile and  urine,
i. 525 ;  on the two periods in the forma-
tion of bone, i. 548;  on  the production of
callus,  i. 556;   treatment  of fractured
sternum, i. 598;  treatment  of fractured
clavicle, i. 605;  treatment of fracture  of
the humerus, i. 609; on fracture of the
lower end of the radius, i. 611 ;  on the
treatment of fracture  of  the  radius  or
ulna near the wrist, i. 613 ; on inversion
of the foot in fracture of the  neck of the
femur, i. 618 ; on the treatment of frac-
ture of the neck of the femur, i. 624 ; on
the  advantages   of  the double-inclined
position, i. 625;  on  the duration of the
treatment in  these cases,  i.  625 ; on the
sawing off the ends of the broken bone in
false joint, ii. 18; on  the operation for
the treatment of lacerated perineum, ii.
38;  on  the  appearances  presented on
post-mortem examination some time after 
822
ANALYTICAL INDEX.
the cure of an artificial anus, ii, 156; ap-
plication of the  enterotome for the cure
of artificial anus, ii. 158 ; Seller's modi-
fication of it, ii. 159; on the symptoms of
anal fissure, ii. 172; on the three varieties
of anal fissures, ii. 172; on the treatment,
ii. 172; treatment of recto-urethral  and
recto-vesical fistula, ii. 185; on cauteriza-
tion as a means of cure in vesico-vaginal
fistula,  ii. 190;  on  the reduction of old
dislocations, ii. 206; on congenital dislo-
cations of the hip, ii. 207 ; on the causes
of congenital dislocations, ii. 207;  on
the confounding cervical dislocation with
rheumatic affection of the neck, ii. 212  ;
doubts  the  occurrence of  dislocation of
the wrist, the presumed cases of which he
regards as fracture  of  the  lower  end, of
the radius, ii. 233; on the surgical treat-
ment  of dislocation of thenhumb from
the metacarpal bone, ii. 235 ; on the cause
of the difficulty experienced in reducing
this dislocation, ii, 235 ; on congenital
dislocation of the femur, iL 243 ; on the
post-mortem appearances, ii. 244; on the
local treatment, ii. 245 ;  on reduction of
dislocation of the astragal us, ii. 253; case
of dislocation of the metatarsal bones, ii. I
256;  on the reduction  en masse, ii 274  ;l
modification of the operation for femoral
rupture, ii. 336;  operation for mesenteric!
strangulation, ii. 358; objections to scarifi-
cations or leeches in treating prolapse of,
the rectum, ii. 401; operation for long-
standing prolapse of the rectum, ii. 402;
objections to the actual  cautery in irre-
ducible prolapse, ii. 404; case of aneurism
mistaken  for abscess, ii.  474 ;   on  the
section of the scalenus anticus in ligatdre
of the  subclavian, ii. 518 ; on the treat-
ment of branching aneurism, ii, 554; plan!
to prevent re-union after the operation for
united fingers or toes, iii.  17; case of a
foreign body remaining a  long  time in
the windpipe, iii. 112; mode of operating
for ranula, iii. 124; on the operative treat-;
ment  of encysted swellings, iii. 181;  on
cutting away the tunica vaginalis, iii. 230;
bilateral section for stone, iii. 327; opera-
tion for stone, iii. 347; on encysted cellu-
lar fibrous tumor of the maxillary antrum
and its  treatment, iii. 486; operation  for
the excision of the cancerous neck of the
womb, iii. 640;  mode of amputation by
the circular incision, iii.  610; practice of
leaving the wound of the stump exposed
for several hours after the  operation, iii.
644; mode  of dressing stumps, iii. 654;
mode of amputating at the hip-joint with
two flaps, iii. 692 ;  at the shoulder-joint,
iii. 712, 713, 716; mode of operating in
exarticulation of the fore-arm at the elbow,
  iii. 719; on exarticulation of the middle
  and ring fingers, iii. 723; mode of opera-
  ting in excision of the elbow-joint, iii.733;
  recommends the non-division of the ulnar
  nerve in that operation, iii. 734; case of
  excision of the lower jaw, iii. 747;  cases
  of  extirpation of the upper jaw doubted
  by Gensoul, iii. 754.
Dura mater, fungus of, iii.  419.
  Dussausoy, M., recommends emetics in
  hospital gangrene, i. 114; on the rotation
  of  the foot outwards in  fracture of the
  neck of the femur, i. 618.
Duval's, M., local steam-bathing apparatus
  i.294; on the  reduction  of congenital
  dislocation of the femur, ii. 245 ; on the
  cause of club-foot, ii. 446.
Duverney, M., on the  lengthening of the
  limb in hip disease, i. 286; treatment of
  fractured olecranon, i. 614; apparatus for
  fracture of the neck of the femur, i. 623;
  on the  symptoms  of dislocation of the
  sternal end of the clavicle backwards, ii.
  217 ;  on the  primitive direction of dislo-
  cation of the humerus, ii. 221 ; on the
  causes of club foot, ii. 446,
Dyckman's, M., assertion that a child may
  be  infected by the milk of a diseased
  nurse, ii. 105.
Dzondi's, M., apparatus for fracture of the
  neck of the femur, i. 624;  treatment  of
  syphilis, ii. 100; urinary receptacles for
  vesico-vaginal fistula, ii.  189; plan of in-
  healing a plug  of  skin  for the radical
  cure of rupture, ii. 283; mode of operating
  in ovarian dropsy, iii. 210; on the ligature
  of  the carotid, prior  to  excision of the
  lower jaw writh the condyles, iii. 750.

Earle's,  Mr.,  comments  on  Dr.  John
  Thompson's experiments with respect to
  the state of the vessels in inflammation, i.
  39; on cold moist applications in the
  treatment of burns, i. 129 '} on the  re-
  moval of the  clothes after burns and
  scalds, i. 135 ;  on the contraction of the
  cicatrix in cases of bums, i. 133 ; on the
  effects of this contraction, i. 139; opera-
  tion for the removal of the entire scar, i.
  139 ;  cases in which  this  operation was
  performed, i. 140; on dislocation into the
  ischiatic notch  in hip disease, i. 287; ap-
  paratus  for  fractured  clavicle, i.  603;
  treatment of fractured olecranon, i. 614 ;
  description of apparatus, i. 614; on some
  of  the signs of  fracture of the neck of
  the femur, i. 618; opposed  to Astley
  Cooper's views on bony union in  these
  fractures, i.  620;  fracture-bed, i.  625;
  on urethroplasty, i. 179;  obturator  for
  vesico-vaginal fistula, i. 189; case of dis-
  location of the ankle inwards, with lacer- 
ANALYTICAL INDEX.                        823
  ation of the interna] lateral ligament, ii.
  250; case of hydrocephalocele, ii. 363;
  case of hydrocephalocele treated by punc-
  ture, ii. 368;  case  of secondary haemor-
  rhage after lithotomy, iii. 335; case of
  chimney-sweeper's cancer in the wrist,
  iii. 560; on the extension of the disease
  to the neighbouring parts,  iii. 560;  on
  the age  at which  the disease generally
  occurs, iii. 560; case of  division of the
  ulnar nerve, iii. 636.
Ebel's, M., preparation of the parts for the
  operation of staphyloraphy, ii. 31;  on
  the removal of the edges  of the cleft, ii.
  32; plan for  bringing the edges of the
  cleft together, ii.  32;  instrument for
  drawing the knots, ii. 32.
Eberl's, M., straps for fractured clavicle,
  i. 603.
Ebers, M., on the hydriodate  of potash in
  syphilis, ii. 101.
Eble, M., on the existence of the  acarus
  scabiei, ii. 65; observations on the acarus,
  ii. 65.
Echinoccus hominis, iii. 441.
Eckoldt's, M., method of performing oeso-!
  phagotomy, iii. 160.
Eckstrom's, M., operation for cutting into
  the urethra in the perineum, iii. 146.
Eczema rubrum, or mercuriale, ii. 111.    I
Edmonston's, Mr., plan of treatment  in
  ruptured tendo Achillis, i. 542.
Ehrlich's, M.,  compressor, i. 330.
Ehrmann, M.,  on  the  suture  in vesico-
  vaginal fistula, ii. 193.
Eichheimer's, M., apparatus for fractured
  clavicle, i. 603.
Ekl's, M., opinion on the lymph-swelling,
  i. 61; on some of the signs of fracture of
  the neck of the femur, i. 618 ;  on the in-
  locking of the broken ends of Jhe bone,
  i. 618;  on the solution of the chloride of
  lime in the treatment of foul, gangrenous,
  or torpid ulcers, ii,  44.
Elbow, dislocations of,  ii.  228;, curvature
  of, ii. 462; exarticulation of the fore-arm
  at, iii. 718; excision of the, iii. 732.
Elderton's,  Mr., lithotritie instruments,
  iii. 285.
Elliotson's, Dr., case of gangrene of the
  leg after the use of ergot, the arteries of
  the limb being also ossified, i. 74; on
  glanders in the human subject, i. 78; on
  the period of incubation of hydrophobia,
  i. 404; on the symptoms of hydrophobia,
  i. 405; on thediagnosis between true and
  spurious hydrophobia, and inflammation
  of the pharynx,  i. 406;  on a general
  morbid irritability in hydrophobia,i. 406;
  on the duration of the disease, i, 407; on
  abortive hydrophobia, i. 407; on the post-
  mortem appearances, i. 408; case of pro-
  lapse of the womb in a virgin, ii. 373.
 Elliott's, Mr., case in which he performed
   lithectasy, iii. 376.
 Else, Mr., denies the existence of the so-
   called scirrhus of  the  tonsils, i. 162;
   objection to excision of the tonsils, espe-
   cially in children, on account of the hae-
   morrhage,  i.  165;  prefers Cheselden's
   operation, i. 165; on the  use of sutures
   in wounded intestine, i. 511.
 Elster, M., on the effects of torsion, i. 343.
 Emmert,  M., on the phenomena of inflam-
   mation  under the microscope, i. 41;  ex-
   periments on the injection of bile into the
   cavity of the peritoneum,  i. 526.
 Emery, M-, on the contagion of itch,  de-
   pendent on  the itch-mite,  ii. 65.
 Emphysema, i. 496.
 Empyema, iii. 190.
 Enterotomy, iii. 106.
 Epididymitis. See Inflammation of the Tes-
   ticle.
 Epinychia, or ulceration with great thick-
   ening at the  ends of the fingers, i. 217 ;
   Abernethy on the cure  of epinychia, i.
   221.
 Epulis, ii. 136.
 Erethismus mercurialis, ii. 108.
 Erysipelas ;—nature of the disease, i. 115;
   Rust's division into true and false erysi-
  pelas, i. 115; Hunter's opinion that most
  inflammations which are called erysipe-
  latous are not such,  i. 115;  South on the
  different applications of  the terms erysi-
  pelas and erythema, i. 115; symptoms,
  progress, terminations, and causes of true
  erysipelas, i. 115; vesicular erysipelas, i.
   115; the true erysipelas of Chelius the
j erythema of English practitioners, i. 116;
   Willan's description of erythema, i. 116;
   Bateman's distinction between erythema,
  and erysipelas, i. 116;  Rayer's descrip-
  tion of erythema, i. 116; the vesicular
  erysipelas of Chelius the acute erysipelas
  of Willan  and  Bateman, i. 116;  the
  symptoms and  progress of the disease,
  according to those authors, i. 116; causes
  of spurious  or pseudo-erysipelas, i. 117;
  pseudo-erysipelas divided  into erythema
  idiopathicum and erythema symptoma-
  ticum or consensuale, i. 117; causes of
  erythema idiopathicum, i. 117; SouthoB
  intertrigo a  very frequent form of ery-
   thema idiopathicum,and on its causes,!.
   117; causes of erythema symptoraaticum
   or consensuale, i. 117; Hunter's descrip-
  tion of erythema symptomaticum, i. 118;
  erythema symptomaticum the erratic ery-
  sipelas of Willan and Bateman, i. 118;
  erysipelas from scalp wounds the cedema-
  tous erysipelas of Willanand Bateman,i.
   118; erythema symptomaticum a metas-
  tatic deposit in  the cellular tissue, peri-
  osteum and glands in gastric, rheumatic, 
824                        ANALYTICAL INDEX.
arthritic  and puerperal diseases, i. 118;
symptoms, progress, and terminations of
the disease, i. 118; South's opinion that
this form of erysipelas symptomaticum is
the inflammation of the cellular  tissue,
commonly confounded  with erysipelas
and  erythema, but  decidedly  different
from either, although both  occasionally
run into it, i. 119 ;  Hunter's description
of the disease, under the name of erysipe-
latous inflammation, i. 120 ; South's ac-
count of the disease, i. 120;  South's case
of degeneration  of the cellular tissue  of
the forehead and face, consequent on re-
peated attacks  of this  disease, i. 120;
Gulliver's description of thickening and
induration, and of induration and rigidity
without thickening of the cellular tissue
of the feet and ankles, as occurring  in
soldiers,  i. 121; distinctive characters of
symptomatic and idiopathic pseudo-erysi-
pelas,!. 121; etiology of pseudo-erysipe-
las, i. 122 ; treatment of simple erysipe-
las, i.  122;  the antiphlogistic plan  of
treatment, i, 122; Dr.Williams'stimulant
plan of treatment, i. 123; South  on the
combination of both the antiphlogisticand
the stimulant plans, i. 123; the local treat-
ment of erysipelas, i. 123;  Rust on the
application of moist warmth  in vesicular
erysipelas and its varieties,i. 123; treat-)
ment  of  erysipelas when terminating  in
ulceration or gangrene, i. 123; South on
the local  treatment of erpsipelas, i. 123;
Dobson's plan of relieving the hide-bound
sensation by punctures with a lancet, i.
123; treatment of idiopathic erysipelas,
i. 123; leeches never to be applied, but
punctures made with a lancet, if  neces-
sary, i. 123 ; treatment of erythema con-
sensuale,  i. 123; Rust's stimulant  and
tonic treatment condemned by Chelius, i.
124; South on the treatment, of  erysipe-
las consensuale by incisions varying from
an  inch  and a half to three inches  in
length, i.  124;  Rust,  Dupuytren  and
Lawrence of opinion that incisions should
be made  only in pseudo-erysipelas, and
of the suitable length and  depth, i. 124;
Hutchinson, that they should be made
early,and in considerable numbers, i. 125;
Dobson  employs  numerous punctures
with a lancet in all kinds oferysipelas, and
on all parts of the body,i. 125; Dupuytren's
treatment ofpseudo-erysipelas by blisters,
i. 125; in some cases satisfactory, but the
remedy  doubtful, i.  125;  his opinion
that the suppuration produced by blisters
on the inflamed part is the best mode of
effecting  resolution incommonerysipelas,
i. 125; the extension oferysipelas arrested
by some surgeons hy a blister at the mar-
   gin of the disease, i. 125; this plan of
   treatment  rejected by others,  i.  125;
   Bretonneau and Velpeau's treatment by
   moderate compression, i. 125; condemned
   by Lawrence and Duncan, i. 125 ; South
   on the application of nitrate of silver as a
   means of  arresting the  progress of the
   disease,  i.  125; treatment of  erysipelas
   consequent on wounds must be guided by
   a proper observation of its various causes,
   i.  125.
Erythema of English practitioners, the ery-
   sipelas of Chelius, i. 116 ; Willan's de-
   scription of, i. 116; Bateman's distinction
   between, and erysipelas, i. 116;  Rayer's
   description  of, i,  116;  erythema idio-
   pathicum, i. 116 ; erythema symptomati-
   cum, or  consensuale, i.  117; Hunter's
   description of,  i. 117; erythema symp-
   tomaticum  the erratic erysipelas  of Wil-
   lan and Bateman, i. 118; erythema symp-
   tomaticum, a metastatic deposit in the
   cellular  tissue, periosteum, and  glands,
   in gastric, rheumatic, arthritic, and puer-
   peral disease, i.  118;  South's  opinion
   that this  is the  inflammation of  the cel-
   lular tissue, commonly confounded with
   erysipelas and eTythema, i. 119; Hunter's
   description of this form  of the disease,
   i.  120 ; treatment of, i. 123 ; South on the
   treatment of, by incisions, i. 124.
Ether, inhalation of,  iii. 768 ; Morton and
   Bigelow's application of, as a  safeguard
  against pain in tooth-drawing, iii. 768;
  employed by Warren, Hayward, Bige-
  low, Robinson, and Liston in more im-
  portant surgical operations,iii.768: South,
   Bigelow, Morris, and Cotton's cases of
  injurious effects produced by the inhala-
  tion of ether, iii. 769 ; South on the im-
  propriety of inhaling the  ether,  prior to
   the operation for cataract, iii. 770.
Evans, Mr.  on the surgical treatment of
   dislocation of the thumb from the meta-
   carpal  bone, ii. 235.
Evanson's, Dr. description of noma, i. 75;
   on the suppuration of mumps, i. 169;
   on the communication of syphilis to the
   infant in  the womb, ii. 104; on the symp-
   toms of  syphilis in infants, ii. 104; on
   the treatment of syphilis  in infants, ii.
   106.
Evers', M., apparatus for divided and rup-
   tured tendons of the hand and fingers, i.
   364; bandages for fractured clavicle, i.
   603; objected  to, i. 604; apparatus for
   fracture of the patella, i.  633.
Exudation ;—period of its occurrence, and
   its results, adhesion and  edema, i. 44;
   the term  synonymous with effusion, i. 44;
   Dr. J. H. Bennett on the process of effu-
   sion, i. 44; Travers on  the  effusion of 
ANALYTICAL  INDEX.
825
  serum, 1. 44 ; Wharton Jones on exuda-
  tion, i. 45; Hunter on the cause of the ex-
  travasation of serum, i. 45; Gerberonthe
  varieties of exudation after inflammation,
  i. 45; Gerber on the microscopical resem-
  blance betweenthelymph-corpuscles and
  the exudation corpuscles,i. 45; this resem-
  blance denied by Gulliver, i. 46; Valentin
  on the exudation-corpuscles, i. 46; treat-
  ment after exudation  has taken place, i.
  101.
 Exostosis, iii.  408.

 Fabricius ab Aquapendente on  tearino-
  out the tonsils,i. 164; on  the primitive
  direction of dislocation of  the humerus,
  ii. 221; on ligature of the hernial sac  for
  its radical cure, ii. 283.
 Face, wounds of the, i. 469; important
  in wounds of the face to prevent scars, i.
  469; use of sutures, i. 470;  South on the
  twisted suture or thin pins in suehwourxls,
  i. 470;  wounds of the region of the eye-
  brow, i.  470;  cause of amaurosis  in
  wounds of the eye-brow, i. 470; Thomson
  on amaurosis and inflammation of the eye,
  caused by the passage of a  ball through
  or near the organ, i. 470; Fardeau's case of
  bayonet-wound entering the temple, and
  passing across through the opposite maxil-
  lary sinus, 471; De Limbourg's case of
  wound of the head with a ramrod, i. 47l;
  Hennen on gun-shot wounds in the neigh-
  bourhood of, or penetrating the  orbit, i.
  471;  slight longitudinal and  transverse
  wounds of the eyelids, i. 472; wounds of
  the ear, i. 472; South on wounds of the
  gristly passage of the  ear, i. 472; wounds
  of the nose, i. 472; bandages for the nose,
  i. 473; wounds of the cheek, i. 473;
  wounds of the tongue, i. 473; deep and
  transverse wounds require sutures, i. 473;
  Lawrence on bleeding from  the tongue
  from bites made during a fit, i. 473.
 Facial artery, ligature of, ii. 514.
 Falconer, Mr. on the  lengthening of the
  limb in hip-disease, i. 285.
 Faraday, Mr. on the presence of globules
  in the serumi, i. 56.
 Fardeau's, M., case of bayonet-wound en-
  tering  the  temple, and  passing  across
  through the opposite  maxillary sinus, i.
  471.
Fatio, M., on the use of the suture in vesi-
  co-vaginal fistula, ii. l9l.
Faulquier's,  M.,  artery-compressor,  i.
  331.
Faure,  M.,  on the propriety  of delaying
  amputation in gun-shot wounds, i. 381.
Faye, M., on the operation for the ingrow-
  ing of the nail, i. 224.
Faye's, M. La, apparatus for fracture of the
  Vol. hi.—70
   neck of the femur, i. 624 ;  on the reduc-
   tion en masse, ii. 274.
Featherstone's, Mr., case of fatal bayonet-
   wound of the heart, i. 499.
Feet, curvature of, ii. 445.
Feiler's, M.,  treatment  of fractured ole-
   cranon, i. 614; description of his appa-
   ratus, i. 614.
Femoral rupture, ii. 328.
-------artery, ligature of, ii. 539.
Femoral aneurism,  ii. 535.
Femur, fractures, of, i. 616; dislocation of,
   ii. 236.
Ferne's, M., case of accidental torsion, i.
   344.
Fergusson's, Mr., case of protruded'spleen,
   i. 527; on the treatment of buboes, ii.
   90.
Fergusson's, Mr., new mode of staphylo-
   raphy, ii.  33 ; on dislocation  of the knee
   after  the  divison of the hamstring ten-
   dons, requiring amputation, ii. 444; case
   of opening of the rectum into the bladder,
   ii. 38 ; case in which he performed  the
   operation of lithectasy, iii. 378; operation
   for raising a sunken nose, iii. 591; on the
   relative value  of the  flap  and  circular
   operations for amputation,  iii.  653; on
   amputation through the calf of the leg,
   and at the shoulder-joint, iii. 653; prefers
   Liston's flap  operation for amputation of
   the thigh, iii. 660;  reason why the hind
   flap should be longer than  the front, iii.
   660;  recommendation  to excise  a con-
   siderable portion of the sciatic nerve in
   amputation with a single flap from behind,
   iii. 660; mode of amputating through the
   leg with two flaps, iii. 673; case of exci-
   sion of the head  of the femur, iii. 739;
   mode of operating in resection of the up-
   per jaw, iii. 758;  case of resection of the
   scapula and clavicle together, iii.  765 ;
   mode of operating, iii. 765.
Ferrand's, Mr., case of aneurism mistaken
   for abscess, ii. 474,
Ferrier, Dr., on  an epidemic vaginal ca-
   tarrh, i. 181.
Fest's, M.,  apparatus for fracture of the
   patella, i.  633.
Fibula,  fracture of,  i.  635; dislocation of,
   ii. 248; resection of, iii,  768.
Ficker, M., on the lengtheningof the limb
   in hip disease, i. 285; case of reduction
   of the consecutive dislocation, i.  297;
  advises the opening of  abscesses at the
   hip with caustic, i.  298.
Filkin's, Mr., case  of excision of a joint,
  iii. 726.
Fincke,  M.,  on dislocation of the thumb
  from the metacarpal bone, ii. 234 ; on the
  mode  of reducing  this dislocation, ii.
   235. 
826                        ANALYTICAL INDEX.
Fingers, permanent  bending  of, ii. 464 ;
  supernumerary,  iii. 597; amputation of,
  iii. 686; exarticulation of, iii. 723.
Finucane's, M., case of  dislocation of the
  ribs, ii. 216.
Fischer, M.,  on the chemical composition
  of pus, i. 47; on the distinguishing tests
  for pus and mucus, i. 56; on the applica-
  tion  of smear, black,  or green soap, ii.
  68.
Fisher, Mr., on the  origin of  spina bifida,
  iii. 187.
Fissures, anal, ii. 170.
Fistula:, ii. 144 ; definition, ii. 144 ; John
  Hunter on the inadequacy  of  the  term
  fistula, ii. 144; causes, ii. 144; Hunter on
  the causes of fistula, ii.  144; prognosis, ii.
  145;  indications for the cure of fistula,
  ii. 146; John Hunter on the cure of fistu-
  lae, ii. 146; salivary jistula, ii. 146; signs,
  ii> 146; causes, ii. 146; treatment, ii.
  147 ; treatment of fistula of Steno's duct,
  ii. 147; restoration  of the natural salivary
  duct, ii. 147; modes oftreatment proposed
  for that purpose, ii. 147; Desault, Richter,
  Schreger, and Viborg on the treatment of
  salivary fistula, ii. 147; production of an
  artificial duct, ii. 148; mode of operating,
  ii. 148; De  Roy on  the making an arti-
  ficial opening in  the cheek, ii. 148; Percy
  on the passing a leaden thread into Steno's
  duct after the cheek has been penetrated.
  ii. 148; completion of the operation, i. 148;
  Duphoenix and Atti on the use of a canula
  for maintaining  the  patency of the arti-
  ficial duct,ii. 148; Croserio's modification
  of the operation, ii. 149; treatment of the
  fistula, ii. 149;  Bonafont,  Desault,  Be-
  clard, and South on  the treatment of fis-
  tula  of the parotid duct, ii.  149 ;  subse-
  quent  treatment, ii. 150 ; fluctuating tu-
  mour of Steno's  duct,  ii.  150;  stony
  concretion in the  salivary duct, ii.  150 ;
  Syme, Astley Cooper, and Lawrence on
  salivary calculi, ii.  150; South  on the
  specimens of salivary calculi in the Col-
  lege museum, ii.  150; biliary fistula, ii.
  151; causes and symptoms, ii. 151; South
  on biliary fistulae,  ii. 151 ;  treatment, ii.
  151; J'secularfistula, ii. 152; definition, ii.
  152; signs,  ii. 153; effects of faecular fis-
  tula and of artificial anus on the system, ii.
  153; Begin's case of  closing and wast-
  ing of the portion of intestine below the
  artificial anus, ii.  153; Astley Cooper's
  case of artificial anus in the jejunum ter-
  minating fatally, ii.  153 ; prolapse of the
  intestine at the artificial anus, ii.  153  ;
  symptoms  and  results, ii.  153; causes
  of  faecular  fistula and artificial anus, ii.
   154;  cure  of artificial  anus by nature
  and  by operation, ii.  154;  the process
adopted in the cure by nature, ii.  154;
Lallemand,  Dupuytren,   Scarpa,   and
Lawrence on the appearances presented
on post-mortem  examination, some time
after the cure of artificial  anus, iii. 155,
156 ;  treatment of faecular fistula or arti-
ficial anus, ii. 156; South's case of arti-
ficial anus at the navel, ii. 157;  King on
artificial anus  at  the umbilicus,  con-
nected with the diverticulum ilei, ii. 157;
South's case of  flow of colourless fluid,
from the navel, ii. 157; Lawrence on Du-
puytren's operation for artificial anus, ii.
158; application of Dupuytren's entero-
tome for the cure  of artificial anus, ii. 158;
Seller's modification of Dupuytren's en-
terotome, ii. 158; Liordat'semporte-piece,
ii. 158; Reybard's modification of the ope-
ration, ii. 158 ; Delpech's enterotome, ii.
158; Desault and  Schmalkalder  on  the
treatment  of artificial anus,  ii. 159;
Physick's operation for artificial  anus, ii.
159 ; closure of the fistulous opening, ii.
160 ; Dieffenbach's cure of artificial anus
from a lance-wound by the  actual cautery,
ii. 161;  treatment of artificial anus  con-
nected with thecaecum, ii.  161; Velpeau's
plan of treatment, ii. 161; rectal fistula, ii.
161; definition and sub-divisions, ii. 162
causes and symptoms, ii. 162; abscesses
about the anus, ii. 162; Sabatier, Larrey,
and Ribes on the internal opening of rec-
tal fistula, ii. 162; Astley Cooper's case of
fistula inano, ii.  163 ; examination of rec-
tal fistulae, ii. 163; cure of the rectal fis-
tula with an internal opening, only to be
effected by division of the sphincter, and of
the partition between the fistulous passage
and the gut, ii. 163; contra-indications to
the operation for rectal fistula, ii. 164;
Brodie and Astley Cooper on the impro-
priety of operating for fistula in phthisical
cases, ii. 164; treatment of abscesses in
the neighbourhood of the rectnm, ii. 164;
Brodie on the treatment of large abscesses
high up by the side of the  rectum, ii. 165;
usual modes of operating in rectal fistula,
ii. 165;  the operation by cutting, ii.  165;
South on the operation for rectal fistula, ii.
166 ; operation  for an internal blind fis-
tula, ii.  167; dressing the  wound, ii. 167;
Pouteau, Walther, and Jaeger's objection
to dressing the  wound, ii. 167 ;  Boyer,
Sanson, Textor, and A. Cooper on dress-
ing the wound, ii. 167; accidents which
may occur during and after the operation,
ii. 167;  treatment of hemorrhage, ii. 167;
of inflammation and suppuration, ii. 167;
the hemorrhage occasionally but rarely,
fatal, ii. 168; Copeland's objection to stuff-
ing  the rectum  in cases  of hemorrhage
after the operation, ii. 168; Brodie on in- 
ANALYTICAL INDEX.
827
ternal erysipelas following the operation,
ii. 168; ligature  of the rectal fistula, ii.
168 ; Luke on the advantages of the liga-
ture, and on the mode of operating, ii. 168;
Dr. Nelken's instrument for applying the
ligature, ii. 169 ; South on the ligature of
rectal fistula, ii. 169 ;  application of the
leaden or  silk-worm gut ligature in com-
plete fistula, the  internal opening not
being high up, ii. 169; Desault, Reisinger,
Weidman, Schreger, and Demme's ap-
paratus for ligaturing complete fistula, ii.
169; mode of employing Reisinger's ap-
paratus, ii. 169; treatment of fistula of the
rectal sheath, ii. 169 ;  Mott on the treat-
ment of fistula of  the rectal  sheath, ii.
169; application of the ligature in an in-
wardly blind  fistula, ii.  170; re-application
of  the ligature sometimes  necessary, ii.
170; advantages of the respective opera-
tions by ligature and by cutting, ii. 170 ;
treatment  of rectal  fistulae  by compres-
sion, ii. 170;  treatment of  externally
blind fistulae, ii. 170;  urinary fistula, ii.
174; definition and  sub-division, ii. 174;
situation of  the  external  and  internal
openings,  and direction of the fistulous
passage, ii. 174; false  urinary fistula, ii.
174; causes and appearances,  ii.  174;
incomplete internal urinary fistula, ii.174;
causes and diagnosis, ii. 174; incomplete
internal fistula from ulceration of the mu-
cous membrane of  the urethra, or from
abscesses  in  the lacunae, ii. 175; South
and Brodie on incomplete internal urinary
fistula, ii.  175; complete urinary fistula,
ii. 175; situation of the internal and ex-
ternal openings, ii.  175; causes, ii. 175;
symptoms and progress, ii.176; treatment
of incomplete external  fistula,  ii. 176; of
incomplete internal fistula, ii.  176; pre-
sence of stones in the  sac of a blind fis-
tula, ii. 176;  of complete urinary fistula,
ii. 177;  complete urinary fistula opening
on the penis,  ii. 177; symptoms, ii. 177;
treatment of the accompanying stricture,
ii. 177;  of the fistula, ii. 177;  treatment
of  the  fistula  when  callous, ii. 177;
Cooper and Dieffenbach on the treatment
of callous  fistulae, ii. 177;  Cooper, Dief-
fenbach, Zang, and  Freimann  on the su-
ture of urethral fistula, ii. 178;  Dieffen-
bach on the  introduction of the running
stitch,  ii.  178; Cooper,  Earle, Alliot,
Delpech,  Ricord, and Dieffenbach on
urethroplasty,, ii. 179; the  operation of
urethroplasty in fistulae near the scrotum,
ii. 179;  in large fistulae in the middle or
fore part of the penis,  ii. 179 ; in fistula
close behind the prepuce, ii. 180; in large
openings immediately behind the glands,
with deficient prepuce, ii. 180;  Charles
 Bell's Operation for the restoration of the
 canal  of  the  urethra, ii. 181;  causes,
 situation, and  symptoms  of complete
 urinary fistula in  the hinder part of the
 urethra, ii. 181; Brodie on the causes of
 fistula in perineo, ii. 181; Brodie on the
 causes of perineal abscess, ii. 182; treat-
 ment of urethral fistula, ii. 182;  Hunter,
 B.  Bell, and Richter's  objections to the
 use of the catheter in urethral fistula, ii.
 182;  Brodie on the  treatment of fistula
 in perinaeo, ii. 183;  operation for the cal-
 lous fistula in perineo, ii. 183; Brodie's
 case of malignant disease consecutive on
 neglected perineal fistula,  ii. 184;  ope-
 ration for the division of the stricture in
 great narrowing of  the  urethra,  ii. 184;
 South on the operation for the division of
 the stricture, ii. 184; recto-urethral and
 recio-vesicalfistula, ii. 185; causes, symp-
 toms, and treatment,ii. 185; Dupuytren's
 treatment by the actual cautery or  by
 caustic, ii. 185; Jaeger on the division
 of the sphincter muscle, ii. 185; Desault,.
 Dupuytren, and Zang on the treatment of
 these fistulae,  ii.  185; Astley Cooper's
 operation for recto-urethral fistula, ii. 186;
 South's operation for recto-vesical fistula,
ii.  186;  vesico-vaginal fistula,  ii. 188;
causes, ii. 188; symptoms, ii. 188; diag-
nosis, ii. 189;  prognosis, ii. 189;  the in-
struments of Dzondi, Barnes, Schmitt,
Burchard,  Earle,  and Duges,  ii. 189;
vaginal fistula, ii. 189; Desault,  Baines,
Guthrie, Rognetta, Coxe, and Jaeger on
the  treatment by drawing off the urine
and by compression, ii. 189; Dupuytren,
 Lallemand, and Dieffenbach on cauteri-
zation as a means of cure, ii. 190; Roon-
huysen, Fatio,Voelter, Naegele, Schreger
and Wutzer on the use of the suture, ii.
 190, 191; mode of applying the suture,
ii. 191,192; varieties of sutures, and their
application, by Naegele, Roux, Schreger,
Ehrmann,  Kilian,  Lallemand, Deuber,
and Dieffenbach, ii.  192, 193; puncture
of the bladder above the pubes after the
operation, ii. 194;  Dieffenbach and Wut-
zer  on the after-treatment, ii. 194 ; Jobert
on the treatment of vesico-vaginal fistula
by transplantation, ii. 195 ; Dieffenbach's
treatment of the large fistulae by drawing
the  mucous membrane together,  ii. 196;
 Dieffenbach's  treatment of  moderately
 large fistulae, ii. 197;  Vidal's proposal to
 occlude the vulva, in complete destruction
 of the vagina and wall of the bladder, ii.
 197; Horner's proposal to draw down the
 uterus into the vagina, ii.197; Dr. Keith's
 case  of vesico-vaginal  fistula, ii. 197;
recto-vaginal fistula, ii. 198;  symptoms,
ii.  198; tendency to  spontaneous cure, 
828
ANALYTICAL INDEX.
  ii. 198; Duparcque's case, ii. 198; Du-
  parcque on the indications in the treats
  ment of this fistula, ii. 199;  Copeland's
  operation by the division of the sphincter
  ani, ii. 199.
Flammant's, M., apparatus for fractured
  clavicle, i. 603.
Fleischmann's, M., description of the mu-
  cous bags beneath the tongue, iii. 123.
Fleming's, Mr., case of ligature of the ex-
  ternal carotid for secondary haemorrhage,
  ii. 508.
Fletcher's, Mr., instrument for oesopha-
  geal stricture, iii. 32.
Fleury's, M., case of simple serous cysts
  of the neck, iii. 432.
Fluctuation, occurrence and signsof, i. 44.
Font ana, on the effects of viper  bites, i.
  389.
Foot, fracture of the bones of, i. 639; arti-
  ficial, iii. 595; exarticulation of, at the
  ankle-joint, iii. 700; partial  amputation
  of, iii. 703.
Ford, on the treatment of abscesses at the
  hip, i. 298; cases of spontaneous cure of
  aneurism, ii. 489.
Fore-arm, fracture of the bones of, i. 610;
  dislocations  of,  ii.  228;   amputation
  through, iii. 681; exarticulation of, at the
  elbow, iii. 718.
Foreign  bodies, diseases,  depending  on
  the presence of, in the organism :—
  Definition  and divisions, iii.  93 ; foreign
  bodies introduced into the body from with-
  out, iii. 94 ; foreign bodies in  the nostrils,
  iii. 94 ; causes of retention, iii. 94 ; their
  removal, iii. 94; presence of balls from
  gun-shot wounds in  thenostrils,  iii. 94 ;!
  when the foreign body cannot be removed I
  it should.be pushed  backwards  into the
  mouth, iii. 94;  Astley Cooper's  case of'
  ball  lodged in the frontal sinuses, iii. 94 ; I
  foreign bodies in the mouthy  iii. 94 ; are
  readily removed or got rid of by suppu-
  ration, iii.  94; South's case of a piece of
  tobacco-pipe lodged in the cheek, iii. 94 ;
  foreign bodies in the asophagus,  iii. 95;,
  situation  of  the foreign  body,  iii. 95 ;
  South's cases of, iii. 95 ;  symptoms,  iii.
  96;   diagnosis often difficult,  iii. 96;
  sensation  of soreness in  the throat after)
  the extraction of the foreign body, iii. 96 ;
  South's case of fish-oone  in  the  oesopha-
  gus,  iii. 96 ; Monro's cases of halfpence
  in, iii.  97 ; Monro's case of a  foreign
  body in a  sac behind the oesophagus at
  its origin, iii. 97 ;  removal   of  foreign
  bodies from  the  oesophagus, iii.  97;  re-
  moval upwards, iii.  97;  extraction  of
  foreign bodies from the oesophagus by in-
  struments, iii. 97 ; thrusting them down
  i#lo the stomach, iii. 98 ; should not be
attempted  unless  they be  beyond the
reach  of  the  finger, iii.  98;  Astley
Cooper's case offish-bone at the glottis,
iii. 98;  Brown's  case  of a  piece of
broken delf plate in the  oesophagus, iii.
98;  Tunnaley's case of a bristle in the
oesophagus, iii. 98;  treatment when the
foreign body has caused severe inflamma-
tion and diseased contractions of the oeso-
phagus, iii.  99 ; consequences of foreign
bodies in the oesophagus, iii. 99; passage
of thin and pointed bodies through its
walls and the neighbouring parts, iii. 99 ;
cases requiring cesophagotomy, iii.  99 ;
South's  preference  of tracheotomy to
cesophagotomy, iii. 100; directions for the
operation, iii. 100; Eckoldt's method, iii.
100;  Vacca Berlinghieri and  Begin's
directions for the operation, iii. 100 ; re-
moval of the foreign body, iii. 102; after-
treatment, iii. 102; foreign bodies in the
stomach and intestinal canal, iii. 102; bulky
bodies often pass away by the intestinal
canal, pointed ones are retained, and cause
inflammation and  suppuration, iii.  102;
Dr. Marcet and Dr. Barnes'cases of knife-
swallowing, iii. 103; retention of bulky
bodies and the symptoms they produce,iii.
104 ; obstructions of the ileum by a gall-
stone, iii. 104; intestinal obstruction from
lumps of carbonate of magnesia, and col-
lections of cherry-stones, iii. 104  ; Lang-
staff's case of a madman who swallowed
a silver spoon,  iii. 104 ; consequences of
the presence of pointed bodies in the in-
testines, iii, 105;  general  treatment in
cases of foreign bodies in  the stomach or
intestines, iii. 105; Green's case of foreign
body in the alimentary  canal, iii.  105;
extraction of the foreign body by gastro-
tomy or enterotomy, iii. 105; Delpech's
objections to these  operations, iii.  105 ;
Shoval's  case  of gastrotomy for the re-
moval of a knife  from the stomach, iii.
106; directions for gastrotomy, iii. 106;
for enterotomy, iii. 106; enterotomy also
advised for the  relief of  stricture and
closure of the large intestines, for collec-
tions of faeces, ileus, and volvulus, iii. 107;
foreign bodies in the rectum, iii. 107 ; Phil-
lips' case of a stick in the rectum, iii. 107;
M'Laughlan's  case of a  large  plug of
wood in the rectum, iii.  107 ;  Johnson's
case  of  obstruction of the rectum by a
large collection of peas, iii. 108 ; Brodie's
case of apple-core in the rectum, iii. 108;
Welbank s case of part of a vertebra and
rib in the rectum, iii. 108 ;  symptoms of
obstruction from foreign body in the rec-
tum, iii. 108 ; abscesses by the side of the
rectum, iii. 108; Brodieand Green's cases,
iii. 108; Coulson's case of closure of the 
ANALYTICAL  INDEX.                        829
rectum  from the presence of a foreign
body, iii.  108; extraction of the foreign
body from the rectum, iii. 108; Marchetti's
case of swine's  tail in the rectum, iii.
109; Custance's case of a blacking-pot in
the rectum, iii. 109; Lawrence's case of
neck of a wine-bottle in the rectum, iii.
109;foreignbodies in the larynx andwind-
pipe,ui. 109; symptoms,iii. 109; Porter
on the passage of foreign bodies into the
larynx, iii. 110; De la Martiniere's case of
a foreign body in the windpipe, iii.  110;
symptoms caused by a foreign  body in
the rima glottidis, iii. Ill;  by a foreign
body loose in the windpipe, iii. Ill; Bul-
lock's caseof a quartz pebble in the upper
part of the larynx, iii. III.; symptoms of
a foreign body in one of the bronchi, iiu.
112; Sue,  Dupuytren,  Louis,  Sutton,
Paris, and Travers, jun.'s eases of foreign
bodies  in  the windpipe during a  long;
 fieriod of  time, iii. 112;; the operation of
 aryngotomy or tracheotomy, iii.   113;;
cases requiring the  operation, iii.  113-;
Stokes' cases of foreign  bodies in the
oesophagus inducing laryngeal symptoms,
iii. 114; Cock's case of sixpence in the
larynx, iii. 114 ; circumstances requiring
the performance of laryngotomy, iii. 114;
the operation must not be long delayed in
angina laryngea, iii, 115;  the operation
useless  in angina membranacea, iii.  115;
Nevermann's statistics of tracheotomy in
laryngitis and tracheitis, iii. 115; Breton-
neau, Trousseau, and Kuby on the trache-
otomy in  croup, iii.  115; directions- for
the  operation  of  laryngotomy, iii.  1T5;
South on the practice of inserting a tube
in the larynx after the operation, iii.  116 ;
South's case of fistulous- opening in the
larynx from an attempt at suicide, iii. 116;
division of the cartilage, iiu 116;  removal*
of the foreign body, iii; 117;  directions
for tracheotomy, iii.  117 ; removal of the
foreign  body,  iii.  117;  removal  of  a
foreign body from the bronchus, iii. 117;
Brodie  and  Macrae's  cases, iii.  118;
Liston  and  Dickin's  oases of foreign
bodies in  the bronchus, in which trache-
otomy was performed, and the foreign
body extracted with forceps, iii.  118;
South on the necessity  of examining the
larynx and  the rima with a probe after
these operations for the  extraction of
foreign bodies, iii. 119 ; circumstances to
be borne in mind respecting bronchotomy,
iii. 119 ; dangers of tracheotomy, iii, 120;
the operation of laryngo-tracheotomy pre-
ferable to tracheotomy, iii.  120; impor-
tance of careful observation during  these
operations, on account  of the variety in
the  course  of  the  great blood-vessels,
                                    70:
iii. 120 ; unnatural collections <f natural
products, in their proper cavities and re-
ceptacles, iii. 120; ranula, iii. 120;  defi-
nition  and characters,  iii. 121;  Cline's
case of impending suffocation from ranula,
iii. 121; opinions on the nature of ranula,
iii. 122; Cline's case of stone in one of
the sub-maxillary ducts, iii. 122; chemical
analysis of the fluid contained in ranula,
iii. 122; Gmelin and Posselt's chemical
analysis, iii. 122; Fleischmann's descrip-
tion of  the  mucous  bags beneath  the
tongue, iii. 123 ; symptoms of a  salivary
calculus in  Wharton's  duct, iii.   123;
treatment  of  ranula,  iii.  123;  Richter
cauterizes ranula in children with  lunar
caustic, iii. 123 ; re-opening the duct in
recent ranula, iii. 123 ;  Dupuytren and
South's modes of operating for ranula, iii.
124 ; retention of bile, iii. 124; symptoms,
iii. 124; case  of  exceedingly enlarged
gall-bladder  from retention  of bile, iii.
125; terminations of the disease,  iii. 125 ;
South on adhesion between and ulceration
of the gall-bladder into the duodenum, iii.
125; treatment, iii. 125 ; opening the gall-
bladder, iiii  125; retention  of urine, iii.
126 ; seat of obstruction to the discharge
of the urine, iii. 126; causes, iii.  127;
symptoms of retention of  urine in the
ureters,  iii. 127;  dangers attendant  on
ischuria ureterica, iii. 127 ;  Allan's case
of retention of urine in the ureter, iii. 127;
treatment of ischuria  ureterica, iii.  127;
symptoms of retention of urine in the
bladder, iii. 128 ;  terminations, iii.  128 ;
South on  bursting or gangrene of the
bladder, as rare  terminations of ischuria,
iii; 128; Cheston's case of  gangrene of
the bladder fromTetention, iii. 128; South
on the rare occurrence of opening of the
uraehus, iii. 128 ; symptoms of retention,
when slowly produced, iii. 128; formation
of sacs in the bladder, iii. 128; causes of
retention of urine in the bladder,  iii. 128 ;
symptoms of paralytic retention,  iii. 129 ;
causes, iii. 130; prognosis, iii. 130; treat-
ment,  iii.  130;  use of the  catheter, iii.
130; local and general treatment, iii. 131;
treatment of the quickly-oceurring  para-
lytic retention, iii. 131; contracted and
irritable bladder, and  its treatment, iii.
132 ; symptoms of retention of urine from
inflammation, iii. 132 ; seat and causes of
the inflammation, iii. 132; treatment, iii.
132 ; the catheter  not  to be used  until
antiphlogistic remedies  have been em-
ployed, iii. 132; spasmodic retention of
urine, iii. 133 ; symptoms, iii. 133 ; treat-
ment,  iii.  133; introduction of the ca-
theter, iii. 133; retention  of urine de-
pending on stoppage  of the urethra, iii. 
$30
ANALYTICAL INDEX.
133 ; causes, iii. 133; South on obstruc-
tion to the urine by calculi in the urethra,
iii, 134; Hunter's case, iii.  134; How-
ship's case of distention of the bladder by
blood,  iii. 134 ; occasional obstruction to
the urine,  by  blood flowing  into the
bladder after lithotomy, iii. 134; Law-
rence's cases of worms and larvae dis-
charged from the urethra, iii. 134; foreign
bodies introduced into  the  urethra, and
there  remaining,  or slipping into the
bladder, iii.  134 ; Tyrrell  and  Crisp's
cases,  iii. 135 ; Hunter on the expulsion
of bougies  by the  contractions of the
bladder, iii.  135; treatment of ischuria
from calculi lying against  the neck of
the bladder, iii. 135; from blood, mucus,
or calculi in the urethra, iii. 135 ; reten-
tion  of urine from  small stones in the
orifice  of the urethra, iii. 135; South on
the removal of calculi from the urethra,
iii. 135; treatment of retention from the
pressure of  the  impregnated  womb or
other  viscera, iii.  136; South's case of
retention of urine from the pressure of an
hydatid, iii. 136;  ischuria from growths
in the  bladder, iii. 136 ;  from swellings
of the prostate, iii.  136; symptoms of
inflammation of the prostate, iii. 136 ;
suppuration and abscess of the prostate,
iii. 137; Brodie on abscess  of the pros-
tate, iii. 137; treatment, of  retention of
urine from inflammation of the prostate,
iii. 137 ; introduction of the  catheter, iii.
137;  Lawrence,  Brodie, and South on
catheterism in inflammation  of the pros-
tate, iii, 137 ; Brodie on the  treatment of
abscess of the prostate, iii, 138; swelling
of the  prostate from varieose veins, iii.
138;  treatment, iii.  139; indurationof
tiie prostate, iii. 139  ; the discharge of a
mucous or pusrlike fluid in diseased con-
ditions of the urinary passages, iii. 139 ;
Astley Cooper, Brodie, and Lawrence on
chronic enlargement  of the  prostate, iii.
139;  Astley Cooper on the symptoms
and post-mortem appearances.in chronic
enlargement  of the  prostate, iii.  140;
Brodie and Aslley Cooper on the charac-.
ters of enlarged prostate, iii.  141; Brodie
on the rare occurrence of ruptured bladder,
from retention of  urine in enlarged pros-,
tate, iii. 141 ; prognosis, iii,  141 ; treat-
ment, iii. 142,; Astjey Cooper, Lawrence,
and Brodie on the  treatment of enlarged
prostate, iii. 142;  Brodie, Astley Cooper,
and Lawrence on the treatment of reten-
tion of urine from enlarged prostate, and
on catheterism in such  cases, iii.  143;
South on catheterism in enlarged prostate,
iii. 144 ; treatment of complete retention
in stricture, iii. 144; Amussat, Lallemandj
Begin, and South on the  treatment  of
complete retention in stricture, iii. 145 ;
forcible catheterism, and  its dangers, iii.
145;  Eckstrom's  operation  for cutting
into the urethra in the perineum, iii. 146;
directions for its  performance, iii. 146;
Lallemand, Begin, and  South on  this
operation, iii. 147 ; of the catheter and its
introduction, iii.  147; form, shape, and
consistence of the catheter, iii. 147 ;  va-
rious kinds of catheters, iii. 147;  South
on the shape and thickness  of the cathe-
ter, iii. 148 ; directions for the introduc-
tion of the catheter, iii. 14S; the tour de
maitre, iii. 148;  introduction of   the
straight catheter, iii. 148; Amussat and
Civiale on|the introduction of the straight
catheter, iii. 149 ; great care required in
passing the catheter, iii. 149; obstacles to
its introduction, iii.  149;  signs of the
catheter's having entered the bladder, iii.
150;   retention  of the catheter in the
urethra, iii. 150;  Lallemand  on the  re-
tention of the catheter in the urethra, iii.
150 ; introduction of the female catheter,
iii. 150■■; puncturing the bladder, iii. 150;
causes requiring this operation, iii. 151;
puncturing  the bladder above the pubes,
iii. 151.; directions for the operation, iii.
151;  after-treatment, iii.  151; changing
the tubes  inserted  in the  bladder,  iii.
152; puncturing the bladder through the
rectum, iii. 152; directions for the opera-
tion,  iii.  152;  puncturing  the bladder
through the perineum, iii. 153 ; directions
for the operation,  iii. 153; relative value
of these  operations, iii. 154 ; objections
to these operations, iii. 154; Potter  and
South on puncturing the bladder, iii. 154;
the Caesarean operation, iii. 155; circum-
stances.requiring the  operation, iii. 155;
Rigby, on the  circumstances authorizing
the operation, iii.'  155;  the Caesarean
operation  on a pregnant woman actually
dead, the  child  being viable,  iii.  156;
danger of the operation, iii, 156;  Mi-
chaelis on the doubtful character of the
old cases  in which the Caesarean opera-
tion is reported to have been performed
several times  successfully  on  the same
woman, iii: 156; Kayser on the statistics
of the operation, iii. 157; Michaelis'case,
in which the Caesarean section was per-
formed four times on the same woman,
iii. 157 ; proper time for the performance
of the operation, iii. 158; Rigby on the
propriety  of  not  operating until  after
labour has commenced, iii. 158 ; prepara-
tions for the operation, iii.  158 ; directions
for the performance of the  operation, ii.
159 ; dressing the wound, iii. 160;  Gode-
froy'sease of Caesarean section, in  which 
ANALYTICAL INDEX.
831
 he sewed up the wound in the wombyiii.
 161; Michaelis on the danger attending
 the effusion of the secretions from the
 wound into the belly, iii. 161; the after-
 treatment, iii. 161; Michaelis on the exhi-
 bition of opium,and the necessityof keep-
 ing the bowels open, after the operation,
 iii. 162; proposals to diminish the danger
 of the operation, iii. 162; Rietgen, Baude-
 locque, and Physick on the mode of per-
 forming the Caesarean operation, iii. 162,
 163; Michaelis on the greater probability
 of success attending a repetition of the
 Caesarean   operation  than in the  first
 instance,  iii.  163;  gastrotomy, iii.  164;
 circumstances requiring  the operation,
 iii. 164; circumstances of danger attend-.
 ing  gastrotomy for  extra-uterine  preg-
 nancy, iii. 164; symptoms of escape of
 the foetus  into the  abdomen in  tubular
 or ovarian pregnancy, iii.  164 ;  the per-
 formance of the operation, iii. 164; cut-
 ting through the pubic symphysis, iii.  165 ;
 circumstances requiring  the operation,
 iii. 166; results, iii.  166; directions for
 the  operation, iii.  166; after-treatment,
 iii. 166 ;  collection of natural-fluids ex-
 ternal to their proper cavities  and re-
 ceptacles .- blood-swellings  on the Heads of
 newly-bom children, iii. 167; definition,
 seat, and  characters, iii.  167 ; progress
 and  termination of  the tumour, iii."  168;
 suppuration  of the  blood-swelling, and
 perforation of the skull, iii. 169; causes
 and  origin  of blood-swellings, iii.  169;
 opinions as to the  nature of the  blood-
 swellings, iii. 170;  appearances  of the
 cavity  of  the blood-swellings  when
 opened  during life or after death, iii.
 171; distinguishing characters of blood-
 swellings from other tumours on the head,
 iii. 172 ; prognosis, iii. 173; treatment,
 iii. 173; opening  the tumour, iii.  174;
 the opening not to be crucial, nor the en-
 tire length of the tumour, iii. 174; Hoere's
 case of simultaneous collection of blood
 between the pericranium  and the skull,
 and the dura  mater  and  skull, the latter:
 being fissured, iii.  175; haematocele, iii-!
 175; definition and  divisions, iii.  175;!
 Mayo on haematocele, iii. 175;  causes, |
 iii. 175 ; Pott  and Brodie on effusion of
 blood into the cellular tissue of the scro-
 tum, iii. 175 ; treatment, iii. 175 ; causes
 of haematocele in the vaginal tunic, iii.
 176;  diagnosis,  iii. 176;  Brodie on
haematocele complicated with hydrocele,
iii. 176; South on haematocele following
the operation  for  hydrocele,  iii.  176;
Brodie's case  of haematocele, in  which
the tunica  vaginalis ruptured,  ii. 176 ;
Astley Cooper's case of haematocele, iii.
 176; treatment, iii. 176;  by operation,
 iii. 176; South on dispersing the blood in
 haematocele of the vaginal tunic, iii. 176;
 Astley  Cooper's  case  of haematocele of
 17 years' duration, iii.  177; South on the
 occurrence of suppuration, if the effused
 blood  be  not soon absorbed, iii. 177;
 haematocele of the testicle, and its treat-
 ment, iii. 178; Pott and Curling on haema-
 tocele  of the spermatic cord,  iii.  178;
 outpouring of blood into  the cavities of
joints,  iii". 178; causes, iii.  178;  Hey's
 oase,iii. 178; treatment, iii. 178; collections
 of diseased products.- dropsy of the mucous
 sacs, iii. 178;  characters, iii. 178; Mayo
 on dropsy of the bursae mucosae, iii. 178;
 Mayo  and  South  on the formation of
 bursae from pressure, iii. 178 ; causes of
 dropsy  of the  mucous sacs, iii. 178 ; con-
 dition of the diseased" part, iii. 179; Cru-
 veilhier on encysted swellings, iii. 179;
 South   on partial enlargements  of the
 sheaths  of tendons, iii.  179 ; dropsy of
 the bursae most  frequent  on the knee-
 cap, iii. 179; characters,  iii. 179; de-
 generation of mucous sacs, and  their
 treatment, iii. 180; South on housemaid's
 knee, iii. 180;  treatment, iii. 180;  by ope-
 ration, iii. 180; Dupuytren on the opera-
 tive treatment of encysted swellings, iii.
 181 ;  Lenoir on dropsy of the bursae in
 the sole of the foot, iii.  181; Travers'case
 of suppuration of the bursae on the knee-
 cap, iii.  181;  South on the treatment of
 dropsical bursae, xii. 181 ;  dropsy of the
joints, iii. 181 ; definition and characters,
 iii. 182; causes and progress, iii. 182;
 Brodie on hydrarthrus, iii. 182; prognosis,
 iii. 182; treatment, iii. 182; by operative
 proceeding, iii. 183; South's objections to
 the operation, iii. 183;  after-treatment iii.
 183;  Bonnet, Velpeau, and South  on
 injections of  iodine in hydrarthrus, iii.
 184 ;  water in the head, and cleft-spine,
 iii. 184; definition and  varieties of hydro-
 cephalus, iii.  184 ; seat of the fluid in
 hydrocephalus externus, iii. 185; effusion
 of the fluid between the membranes and
 the skull,  and in the  ventricles of the
 brain, iii. 185 ; condition of  the parts in
 congenital hydrocephalus  internus,  iii.
 185; nature and characters of spina bifida,
 iii. 186; spina bifida may be unconnected
 with hydrocephalus, iii. 186 ; Gall and
 Chesman's cases, iii.  186;  state of the
 cerebral and spinal  functions \n hydro-
 cephalus and spina bifida, iii. 187; Fisher
 on the  origin of spina bifida, iik 187;
 Hewett on the connexion between the
 cord or the nerves and the walls of the
 sac in  spina  bifida, iii. 187; treatment,
 iii. 188; Dr. Copland  on puncturing the 
832                         ANALYTICAL  INDEX.
 brain in chronic hydrocephalus, iii. 188;
 Abernethy,  Astley Cooper, and Hewett
 on puncturing spina bifida, iii.  189 ; Du-
 bourge, Tavignot, and Beynard on the
 treatment of spina bifida by closing the
 sac, iii. 190 ;  the  collection of serous and
purulent fluids in the cavity- of the chest,—
 hydrothorax,and empyema, iii. 190; symp-
 toms, iii. 191; characters by mensuration,
 percussion,  and  auscultation,  iii. 191 ;
 physical phenomena of pleuritic effusion,
 iii. 192;  Hirtz  on the  physical  pheno-
 mena  of  pleuritic  effusion,  iii.  193;
 causes of effusion  into the chest, iii. 194;
 circumstances requiring and  admitting
 of paracentesis thoracis, iii. 1#4; mode of
 operating, iii. 195; mode of operating  by
 opening the chest with a cut, iii. 195;
 place where the incision should be made,
 iii. 195;  South's  objections  to opening
 abscess of the lung, iii.  196;  dressing-
 and  after-treatment, iii. 196 ; puncturing
 the chest  with a trocar, iii. 197 ; various
 plans recommended for preventing the
 entrance of air, iii. 197;  after-treatment,
 iii. 198; relative value of the two  opera-
 tions, iii.  198;  mode of cure  after the
 operation, iii. 198;  Dr. Davies  on the
 operation  for empyema, iii. 200;  dropsy,
 of the pericardium, iii.  200; symptoms
 and characters, iii. 200; Laennec, Piorry,
 and  Gendrin on the physical characters
 of dropsy of the pericardium,  iii. 200;
 condition  of the parts in hydro-pericar^
 diura, iii.  201; South on suppuration of
 the  pericardium, iii. 201 ; treatment by
 operation  very dangerous, iii. 201; mode
 of operating, iii. 202; the accumulation
 of serous  and purulent fluids in the
 mediastina, iii. 203; symptoms, iii. 203 ;
 treatment by operation,  iii.  203; de-
 scription  of the  operation,  iii.   203;
 dressing  and  after-treatment, iii.  204 ;;
 dropsy  of the  belly,  iii.  204;   varie-
 ties,  iii.  204;  treatment by  tapping,
 iii. 204 ; tapping only a palliative  opera-
 tion, iii. 204 ; place where it should  be
 performed, iii.  204;  Astley Cooper  on
 tapping in the linea alba, iii. 205; cases in
 which another place should be selected
 for the operation, iii. 205;  performance of
 the operation, iii. 205; South on the pro-
 priety of passing the catheter before tap-
 ping, iii. 206; South on the propriety of
 ascertaining the condition of the womb
 before tapping, iii. 206; South on the ope-
 ration of  tapping, iii. 206 ; dressing the
 wound, iii.  206;  occurrence of hemor-
 rhage, iii. 207; South's case of  wound of
 the epigastric artery during the  operation
 of tapping, iii. 207; South's case  of venous:
 hemorrhage during the operation  of tap-j
ping, iii. 208 ; Watson's cases of hemor-
rhage during the operation of tapping, iii.
208; after-treatment, iii. 208; remarks on
puncturing in different places, iii. 208;
Buchanan's operation of puncturing the
cavity of the abdomen through the blad-
der, iii. 208; ovarian dropsy, iii. 209;
diagnosis, iii. 209 ; puncturing ovarian
dropsy only palliative, iii. 209; Ollenroth,
Le Dran, Littre,  Chopart, Desault, and
Dzondi's modes  of  operating,  iii.  209;
King, West, Jeaffreson, De la Porte, and
Morand on the extirpation of the ovary,
iii, 210; mode of operating, iii. 210; Re-
eamier's fatal operation, iii. 210; Brown's
treatment  of ovarian dropsy, iii. 210;
Bonfils and Camus' mode of proceeding,
iii. 211; Southam on the effects of para-
centesis in  ovarian dropsy, iii.  211; the
small and the large operations for the ex-
tirpation of ovarian dropsy,  iii. 211; the
small operation first suggested by Dr. W.
Hunter, iii. 211; Jeaffreson, King,  and
West's cases, iii. 211; M'Dowell, Lizars,
and Clay on the large operation, iii. 212;
relative value of  the operations for ova-
riandropsy, iii. 212; South on the relative
value of the small and  large operations
for ovarian  dropsy, iii. 213;  Phillip's
Jeaffreson, and Stafford Lee on the statis-
tics of these operations, iii. 213; Southam
on the nature of ovarian disease, iii. 214;
Bonfils, Camus, Locock, Astley Cooper,
and  SchmuGker's  cases of  spontaneous
rupture of ovarian cyst, iii. 214; Astley
Cooper's case of ovarian dropsy, in which
the fluid was discharged by ulceration of
the navel, iii. 215; Sutton's case of ovarian
dropsy, with discharge of hair by the
wound made in tapping, iii. 215; Ashwell
and  Southam on  the extirpation of ova-
rian cysts, iii. 215; cases  in which tap-
ping was repeatedly performed, iii. 216;
DohlhofPs case of encysted abscess of the
abdomen, iii*. 216; abdominal dropsy com-
plicated with pregnancy, iii. 217; situation
in which tapping should be performed, iii.
217; dropsy of the womb—hydrometra, iii.
217; symptoms, iii. 217; distinctions be-
tween hydrometraand pregnancy, iii. 218;
dropsy of the  pregnant womb, iii. 218 ;
symptoms, iii. 218; causes of dropsy of
the unimpregnated womb, iii. 218; para-
centesis uteri, iii. 218; tympanitis, iii. 218;
treatment by paracentesis, iii*. 219; mode
of operating, iii. 219; hydrocele, iii. 219;
definition,.iii. 220;  varieties,  iii.  220;
causes of collection of water in the cellu-
lar tissue of the scrotum, iii. 220; symp-
toms and characters of  hydrocele of the
tunica vaginalis, iii. 220; South  on the
characters of hydrocele, iii. 220;  Astley 
ANALYTICAL INDEX.
833
Cooper and Brodie's cases of hour-glass
hydrocele, iii. 221 ; Astley Cooper and
South on  the situation of the testicle  in
hydrocele, iii. 221;  Cline and  Brodie's
cases of large hydroeeles, iii. 221; South
and  Astley Cooper on the characters  of
the serum in hydrocele, iii. 221; diagnosis
between  hydrocele and  diseases of the
testis, iii. 221; South on the complications
of hydrocele, iii.  221;  causes, iii. 221;
Rochoux, Velpeau, Blandin, Pigne, and
Gausseil on hydrocele caused by gonor-
rhea, iii. 222; prognosis, iii. 222 ; treat-
ment,  iii,  222;  Brodie,  Astley Cooper,
and  South  on  the spontaneous cure  of
hydrocele, iii.  223 ;  situation in which
the puncture of the hydrocele  is  to  be
performed, iii. 223; the  operation of tap-
ping, iii. 223 ; Travers, Lewis and South
on the treatment of hydrocele  by punc-
tures,  iii.  224;  tapping with  a lancet,
iii. 224; varying consistence  of the fluid
in hydrocele, iii. 224 ;  treatment after
tapping, iii. 224;  Astley Cooper on  the
radical cure of  hydrocele by exercise
after tapping, iii. 225; South on the im-
propriety of any other operation than tap-
ping in old people, iii. 225; radical cure
of hydrocele, iii, 225 ; by external stimu-
lant applications, iii. 225; Kinder Wood's
 operation  of excising a portion of  the
 tunica  vaginalis, iii.  225;  the radical
cure by incision, iii. 225; mode of ope-
 rating, iii. 226; after-treatment, iii. 226;
 if during the  operation the testicle  be
found hardened,  must be  extirpated, iii.
 226; hydatids of the testicle also to  be
 removed, iii. 226 ; the operation by injec-
 tion, iii. 226; mode of operating, iii. 226 ;
 after-treatment, iii. 227; strength of the
 injection  should  vary according to the
 sensibility of the patient, iii. 227; various
 fluids used as injections, iii. 227;  South
 on the iodine injection in  hydrocele,  iii.
 227; occasional failure of the injection to
 cure the disease,iii. 228; Astley Cooperon
 the  cause  of the failure, iii, 228 ;  Brodie
 and Everard Horne's cases of relapse of
 hydrocele after a long time, iii. 228; South
 on  suppuration  of the  tunica vaginalis
 after the operation by injection, iii. 228 ;
 South on the treatment when the cellular
 tissue of the scrotum is injected by mis-
 take, instead of  the tunica vaginalis,  iii.
 228; treatment of hydrocele by the  in-
 troduction of a seton, iii. 228; Holbropk,
 Onsenoort,  Green,  and  South  on   the
 treatment of hydrocele  by the seton, m.
 229;  use of a tent, iii. 229;  treatment
 by caustic, iii. 229 ; Hesselbach on  the
 treatment of hydrocele by caustic,  in.
229 ; cutting away the vaginal tunic, in.
230; Boyer, Dupuytren, Textor, Balling,
and  South  on this  operation, iii,  230;
relative value of these operations, iii.230;
congenital hydrocele, iii. 231; characters
and  natural  cure,  iii. 231 ; congenital
hydrocele of women, iii. 231;  period of its
occurrence,  iii. 231; treatment, iii. 231;
Viguerin and Desault's plans, iii. 232;
treatment by injection dangerous, iii. 23.2;
varieties of" congenital  hydrocele, and
their treatment, iii. 232;  hydrocele com-
plicated with rupture, iii. 233; symptoms,
ii.. 233; diagnosis,  iii. 233; treatment,
iii. 234; when  the rupture is reducible,
iii. 234; when irreducible, iii. 234; South
on the treatment of hydrocele complicated
with rupture, iii. 235; hydrocele of the
general vaginal tunic, iii.  235 ; varieties,
iii. 235; characters and treatment, iii. 235;
encysted hydrocele, iii. 235; characters
and treatment, iii. 235; the operation, iii.
236 ; formation of stony concretions in the
fluids of the body, iii. 236; are formed in
the urine, bile, saliva, and faeces, iii, 236;
urinary calculus.- Magendie, von  Wal-
ther, Austin, Wetzlar, Willis, and  Jones
on the formation of calculi, iii. 237;-ge-
neral  constituents  of calculi, iii. 241;
other and more rare constituents, iii 241;
Taylor on the rarity of carbonate of lime
calculi, iii. 242; uric acid and urate of
ammonia,  iii.  242; the  combination of
uric acid with ammonia,  and its precipi-
tation in the free state on the cooling of
the urine, iii. 244; the  development of
free acids in  the urine, iii. 244; oxalate
 of lime, iii. 244; frequently forms  the
 nucleus of  a calculus, but not uncom-
 bined, iii. 214;  a calculus of almost pure
 oxalate of  lime has been  met with, iii.
 244; Prout and Walther on  the  origin
 of oxalic acid in the urine, iii. 244 ; pre-
 sence of free oxalic acid in the urine, iii.
 244; combinations of oxalic acid, ii. 245;
 cystin, iii.  245; calculi  of cystic oxide
 rare, iii. 245 ;  usually consist entirely of
 this substance, but occasionally met with
 as nuclei  of other calculi, iii. 245;  for-
 mation of cystic oxide calculi, iii. 245;
 chemical composition, iii. ;246; xanthic
 oxide, uric oxide, iii. 246;  of very rare
 occurrence, 246; chemical  composition,
 iii. 216;  never occurs in solution, or as
 a  precipitate from  the  urine, iii. 246;
 phosphate of ammonia and, magnesia, in.
 246; causes of its formation, iii. 246;
 Jones on the phosphatic diathesis, iii.247;
 connecting  material of calculi, iii. 247;
 causes of the production of gravel  and
 calculi, iii. 247 ; remote  causes, iii. 247;
 Taylor on the calculi of children, iii. 248;
 foreign bodies  in the bladder act  as the 
834                       ANALYTICAL  INDEX.
nuclei of calculi, iii. 248; foreign bodies i
rarely coated  with uric acid,  iii.  248 ;|
South on foreign bodies as the nuclei of
stone, iii. 248;  Astley  Cooper, Brodie,
and Everard Home's cases, iii. 249; A,
White and Arnott's cases of foreign bo-
dies in the vagina, the bladder injured,
and formation of calculi, iii. 249;  varie-
ties of calculi,  iii. 250; characters, iii.
250;  characters  of uric acid calculi, iii.
250;  of urate of  ammonia, iii. 250; of
mulberry  stones, iii. 250; of hempseed
calculi, iii. 250;  of the earthy phosphates,
iii. 250; of the phosphate  of lime, iii.
251;  of the fusible stone, iii. 251;  of the
cystic oxide, iii. 251; of xanthic oxide,
iii. 251; of carbonate of lime, iii. 251;
physical characters  of calculi, iii. 251;
division of calculi  according to  their
chemical composition, iii. 252; frequency
of the different kinds of calculi, iii. 252;
amorphous urinary  sediments, iii.  253;
Dr. Prout on lithic or uric acid sediments,
iii. 253; characters of yellow sediments,
iii. 253; of red  or lateritious sediments,
iii. 253;  of pink sediments,  iii.  253;
white lithate or  urate of soda sediment,
iii. 254; characters and accompanying
symptoms  of the phosphatic sediments,
iii. 254; causes  of the  phosphatic sedi-
ments, iii. 255; oxalate of lime sediment,
iii. 255 ; characters of the urine in cystic
oxide calculus, iii. 255; gravel, iii. 255;
definition  and characters, iii. 256; Ma-
gendie on  hairy gravel, iii. 256 ; symp-
toms  of gravel,  iii. 256; Prout on the
characters and symptoms of crystallized
uric acid gravel, iii. 256; Prout on the
crystallized phosphaticsediments,iii,257;
Prout on the rarity of crystallized oxalate
of lime gravel, iii. 257;  symptoms of the
oxalic diathesis,  iii. 258; causes and treat-
ment, iii.258; treatment of gravel, iii.258;
of uric acid  gravel,  iii. 258;  Wetzler,
Jones, Wilson, Philip, and Brodie on the
treatment of uric  acid gravel, iii,  259;
Prout on  the  treatment of  a fit of the
gravel, iii. 260; Jones on the treatment
of uric acid gravel, iii. 260; treatment of
cystic oxide gravel, iii. 261; of oxalate of
lime gravel, iii. 261; of phosphate of lime
gravel, iii. 261;  Prout on the treatment of
cystic oxide gravel, iii. 262;  Prout and
Jones on the treatment of the oxalate of
lime  diathesis, iii. 262; Prout and Jones
on the treatment of the phosphatic dia-
thesis, iii. 264 ;  stones in the kidneys, iii.
265 ; situation, iii. 265; Prout on the for-
mation of uric  acid  calculi  in  the kid-
neys, iii. 265;  Brodie on the connexion
between uric acid calculi and gout, iii.
266;  Prout and Brodie on renal calculi
of oxalate of lime, iii. 266; Prout on renal
calculi of cystic oxide, iii. 267 ; Prout on
the rarity of phosphatic renal calculi, iii.
267;  diagnosis, iii. 267 ;  symptoms, iii.
267;  Brodie on the  symptoms of  renal
calculi, iii. 267 ; Astley Cooper and Bro-
die's cases, iii. 267; progress of stone in
the kidney, iii. 267; Brodie on the pas-
sage of renal calculi  into the bladder, iii.
267;  Hevin, Astley Cooper and Brodie's
cases of renal calculi communicating with
abscess in the loins, iii. 268; Crisp's case
of fracture of a renal calculus by sudden
exertion, iii. 268 ; treatment, iii. 268; re-
moval of the calculus by nephrotomy, iii.
268; directions for the operation, iii. 268;
Brodie  and South  on  the  treatment of
renal  calculi, iii. 268;  Prout on the treat-
ment of nephritis complicating renal cal-
culi, iii. 269 ; Brodie on gouty inflamma-
tion of the kidneys, iii. 269; stone in  the
ureters,  iii. 269; symptoms, iii. 269; treat-
ment, iii. 269; Brodie on the symptoms of
stone in the ureter, iii. 269  ; Brodie and
Travers' cases of impaction of calculi in
the ureters, iii.  270;  Cline and Astley
Cooper's cases of suppuration of the kid-
ney from impaction of calculi in the ure-
ters, iii. 270 ; Astley Cooper on the treat-
ment of calculi in the ureters, iii. 270;
stone  in the bladder, iii. 271;  origin and
varieties, iii. 271 ; Brodie on the preva-
lence of calculi in different classes of so-
ciety, and atdifferent ages, iii. 271; Smith
on the  statistics  of  lithotomy, iii.  271 ;
Copland Hutchinson on the rarity of cal-
culus among seamen, iii. 271; forms of
calculi in the bladder, iii. 272; characters
and situation, iii. 272;  sacculated and  ad-
herent calculi, iii. 272; Taylor on hour-
glass calculi, 272 ;  Cline, Mayo, Astley
Cooper, Smith, and Cheselden's cases of
large calculi, iii. 273; Martineau's cases of
verysmall stones,iii. 273; Astley Cooper's
case  of a  great number of calculi in
the bladder, iii. 273;  Pott's case of fusible
calculus in a vesical  rupture, iii.  273;
Brodie's case of encysted caloulus,iii.274;
Wickhara's case of calculus enclosed in  a
bag of  lymph encrusted with calculous
matter, iii.  274;  Brodie,  Prout,  and
Crosse  on the spontaneous breaking up of
calculi  in the bladder, iii. 275 ; symptoms
of vesical calculus, iii.. 275; Prout on the
symptoms of vesical  calculus, iii. 275;
sounding the bladder, iii.  277;  Klein,
Brodie,and South on sounding, iii. 277;
Brodie and South on the existence of cal-
culous symptoms, without the presence of
a stone in the bladder, iii. 277 ; South on
the  simulation of calculus  by vesical
polypus,  iii. 278;, measuring tha size of 
ANALYTICAL INDEX.
835
the calculus, iii. 278; South on measuring]
the calculus, iii. 278; various modes  of
treatment, iii. 278 ; internal  use of stone-
solvents, iii. 279; empirical  remedies, iii.
279; efficacy of stone-solvents, iii. 279 ;
Liston's case of partial solution of a stone
in the bladder, iii. 280 ; injection of sol-
vents into the bladder, iii. 280; directions
for the use of solvent injections, iii. 280;
difference of opinion as  to the value  of
these modes of treatment,  iii. 280; Pe-
louze's  experiments, iii. 281;  Prout and
Brodie on the use of stone-solvents, iii.
281; dissolving stone by means of the
galvanic pile, iii. 282 ; the apparatus and
its application, iii. 282 ;  extraction of the
stone through the urethra, iii. 283 ; by di-
latation, iii. 283 ; principally applicable to
females, iii. 283; mode of effecting the dila-
tation, iii. 283 ; Brodie on the dilatation of
the urethra, iii. 283 ; Astley Cooper, Lis-
ton and Brodie on  the dilatation of the fe-
male urethra, iii. 283,284; crushing the
stone lithotrity, iii. 285 ; Gruithuisen, El-
derton,  and Sanctorious' lithotritie instru-
ments, iii. 285; case of the Monk of Ci-
teaux, iii. 286; General?Martin's case, iii.
286; improvement of lithotritie instru-
ments, iii. 286; three classes of lithotritie
instruments, iii. 287; relative value  of
these instruments, iii. 287; advantages
and  disadvantages of the  three-limbed
perforating forceps, iii. 288;  of Jacobson's
instrument, iii. 288; of Heurteloup's per-
cuteur, iii. 2c8; treatment prior to  the ope-
ration, iii. 288; position of the patient, iii.
289; mode of operating, iii. 289; with the
three-limbed perforating forceps of Civiale
and  Leroy, iii. 289 ;  with Jacobson's in-
strument, iii. 291; with Heurteloup's per-
cuteur,  iii. 291; duration  of a lithotriptic
sitting, iii. 292; treatment  after the ope-
ration, iii. 292 ; escape of sand and calcu-
lous fragments,iii. 293; arrest of fragments
in the urethra, iii. 293 ;  breaking up the
fragments in the bladder, iii. 293 ; treat-
ment of fragments of calculus fixed in the
urethra, iii. 293; by extraction, iii. 293; re-
moval by incision, iii. 294; examination of
the bladder when the calculous symptoms
have ceased, iii. 294;  lithotrity in women,
iii. 294 ; cutting for the stone,—lithotomy,
iii. 296; definition, iii. 297;  should  be
performed early, iii. 297 ; circumstances
contra-indicating the  operation, iii. 297  ;
Cline, Attenburrow and Astley Cooper's
cases of old men operated on for stone,
iii. 297; Keate, Hunter, and Civiale's ope-
rations on infants, iii. 297; Green's case of
lithotomy in a fat man of 50 years of age,
iii. 298; preparation of the patient for the
operation, iii. 298; cutting for the stone in
man, iii. 298 ; with the little or Celsian
apparatus, iii. 299; mode of operating, iii.
299; objections to the operation, iii. 299;
cutting for the stone with the great appa-
ratus, iii. 300; mode of operating, iii. 300;
advantages of this operation over the little
apparatus, iii. 300 ;  the high  operation,
iii. 301; mode of operating, iii. 302; modi-
fications of the operation,iii. 303; dressing
the wound, iii. 304; the prevention of in-
filtration of urine from this operation, iii.
304; treatment of the wound for some
days, iii. 305; untoward circumstances
during and after the  operation, iii. 305;
advantages and disadvantages of the ope-
ration, and cases in which it is applicable,
iii. 305; Cheselden on the high operation,
iii.  306; the lateral operation, iii. 307;
Rau's mode of operating, iii. 307; Chesel-
den's  operation  for  stone,  iii.  309;
preparations  for the operation, iii. 309;
South  on the binding a patient prior to
the operation, iii. 309; mode of operating,
iii.  310; Brodie's case of encysted calcu-
lus removed  by the lateral operation, iii.
310; South's case of stone undetected by
the sound  during eight years, iii. 310;
Brodie and  South on the  external inci-
sion, iii. 311;  Scarpa on  the division of
the prostate, iii. 312 ;  Key and Liston's
modes of operating for stone, iii. 313; Dr.
James Douglas and Sharp on Cheselden's
operation, iii. 314;  Douglas on the  dis-
section of the parts concerned in this ope-
ration, iii.  315;  Martineau and Brom-
field's operations, iii. 317; Brodie on the
section of the  prostate and bladder, iii.
31*; use of Langenbeck's knife, iii. 318;
Thomas Blizard, Astley  Cooper,  and
Tyrrel on the section of the prostate, iii.
320 ;  extraction of the calculus, iii. 321;
use of the cutting gorget, an improve-
ment on Cheselden's blunt  gorget, iii.
321;  Cline's gorget, iii. 321; Scarpa's
gorget, iii. 321; Astley Cooper on open-
ing the membranous part of the urethra,
iii. 321;  South on the use of the cutting
gorget, iii. 321;  objections to  the  cut-
ting gorgets, iii. 324; South's opinion
that these objections  are groundless, iii.
324;  Le Cat and Pajola's mode of ope-
rating for stone, iii.  324; objections to
the  operation, iii. 325; Frere Come's
operation with the  lithotome cache, iii.
326;  disadvantages  of the instrument,
iii. 326; Boyer's mode of using Frere
Come's  lithotome, iii. 327; Dupuytren's
bilateral section, iii. 327; mode of operat-
ing, iii. 327; Beclard's modification of the
operation, iii. 327; advantages and disad-
vantages of the operation, iii. 328; extent
of the incision in the prostate and neck 
836                         ANALYTICAL INDEX.
of the bladder, iii. 329; extraction of the
stone, iii. 329; obstacles to the extraction
of the stone, iii. 330; taille en deux terns,
iii. 330; Brodie and South on contraction
of the bladder during lithotomy, iii. 331;
extraction of the stone when enclosed by
a contracted bladder, iii. 331 ;  of an  en-
cysted stone, iii. 332; of a stone lodging
in the ureter, and projecting into the blad-
der, iii. 332 ; of a stone lying in a hollow
iii. 332; of a stone covered with fungosi-
ties, iii. 332  ;  of  a brittle  and easily-
breaking stone, iii. 332; dressing  the
wound, iii. 332; haemorrhage during  the
operation, iii.  333; from the branches of
the superficial perineal artery, iii.  333 ;
from the inferior haemorrhoidal, iii.  333 ;
from the internal haemorrhoidal, iii 333 ;
from the internal  pudic,  iii. 333 ;  from
the vesical, iii. 333 ;  treatment of  the
haemorrhage, iii. 333; Erard, Dupuytren,
and von  Graefe's compressors, iii.  333 ;
Shaw's case of fatal haemorrhage in litho-
tomy, from wound of the dorsal artery of
the penis, iii. 334; Brodie on the effects of
haemorrhage in lithotomy, iii. 334; South
on the treatment of  haemorrhage during
and after the operation, iii. 334; Brodie's
case of fatal venous haemorrhage in litho-
tomy, iii. 334; symptoms of haemorrhage
into the bladder after the  operation,  iii.
334;  South on  secondary haemorrhage
after lithotomy, iii. 335;  Brodie, Earle,
Travers, Green, and South's cases,  iii.
335;  wounding the rectum,  iii. 336;
South on wounding the rectum, iii. 337;
convulsions and fainting, iii. 337 ; after-
treatment, iii. 338; South on the treatment
to be adopted after the operation for litho-,
tomy, iii. 338; causes  and treatment of
inflammation after  the operation, iii. 340;
of spasm, iii.  340; Key on suppurative
inflammation of the cellular  tissue sur-
rounding the bladder the most frequent
cause of death after lithotomy, iii. 340 ;
Brodie on the dangerous symptoms which
follow the incision of the prostate extend-
ing into  the loose  cellular texture sur-
rounding the neck of the bladder, iii. 341;
treatment of the consecutive haemorrhage,
iii, 342; -abscesses about the neck of the
bladder,  iii. 342; incontinence of urine
and impotence, iii. 342;  disposition  to
lithogenesis, iii. 342; opening the bladder
from the perineum, iii. 343;  Foubert's
operation, iii. 343 ;  cutting for the stone
through the rectum, iii. 343;  Brodie  on
the recto-vesical operation, iii. 344; Sol-
ly's case of recto-vesical operation,  iii.
344 ;  Sanson's two modes of operating,
iii. 344 ;  description of the operation, iii.
344; modifications of  the operation, iii.
 344; after-treatment, iii. 345; advantages
 and  disadvantages of the  recto-vesical
 operation, iii. 346; results of recto-vesical
 lithotomy, iii. 346;  Vacca Berlinghieri
 and Dupuytren's operations for stone, iii.
 347; cutting for  the stone in women, iii.
 348; various modes of operating, iii. 348;
 Astley Cooper on the symptoms of stone
 in women, iii. 348; Brodie on the expul-
 sion of small calculi from the bladder in
 women,  iii. 349;  Brodie  and Astley
 Cooper's cases of ulceration of the blad-
 der  and vagina by the  pressure of large
 calculi, iii. 349 ; cutting for the stone in
 women by the lateral operation, iii. 349;
 mode of operating, iii. 349; the horizontal
 cut on one or both sides, iii. 349; Liston's
 operation, iii. 350; the vertical cut  up-
 wards, iii. 350;  Brodie's modification of
 the  vertical cut upwards, iii. 350; advan-
 tages of the vertical cut upwards, iii, 350;
 the  vertical cut downwards, iii. 351;  the
 cut  below the pubic symphysis, iii. 351;
 objections to the operation, iii. 351; Lis-
 franc's vestibular  cut,  iii. 351; mode of
 operating, iii. 352; objections to the ope-
 ration, iii. 352; von Kern's operation, iii.
 352; the  vagino-vesical cut, iii. 353; ad-
 vantages of this operation, iii. 353; Astley
 Cooper, Brodie, Liston, Hey, and South
 on the  incontinence of  urine consequent
 on the operation, iii. 353; South on dilata-
 tion  of the female urethra for the extraction
 of calculi, iii. 354; opening the bladder
 above the pubic symphysis, iii. 354; com-
parison of lithotomy and lithotrity,  iii.
 354  ; equality of the possible  evils after
 the two operations, iii. 354; possible evils
 from lithotrity, iii. 355 ; Liston on  the
 breaking or bending of  lithotritie instru-
 ments in the bladder, iii. 356 ; Brodie on
 the  occurrence  of  hemorrhage and  of
 rigors after lithotrity, iii. 356; comparison
 of the results in lithotomy and lithotrity,
 iii. 356 ; cases in which lithotrity is inap-
 plicable,  iii. 357; lithotomy  preferable
 for children, iii. 357; lithotrity preferable
 in advanced age, females, and in very stout
 persons, iii. 357; stones of moderate size,
 and  round  or  oval in  shape, best  for
 crushing, iii. 357 ; cases in which  litho-
 trity is preferable, and cases in which
 lithotomy should be performed, iii. 357;
 stricture of the urethra  only a temporary
 contra-indication  to lithotrity, iii. 357;
 palsy of the bladder not  a contra-indica-
 tion, iii. 357; Key on the advantages and
 applicability of lithotrity, iii.  357; Key
 on lithotrity  with reference to  the size of
 the calculus, iii. 358; Key on the applica-
 bility of lithotrity or lithotomy according
 to the age of the calculous patient, iii. 358; 
ANALYTICAL  INDEX.                        S37
  Key on  the requisite condition of the
  bladder for the operation of lithotrity, iii.
  358; Key on irritability of the bladder, iii.
  358;  Brodie, Liston, and  South on the
  cases in which lithotrity should be per-
  formed, and on those in which lithotomy
  should be preferred, iii. 360 ; stone in the
  urethra, iii. 362; consequences of the im-
  paction of stones or other foreign bodies in
  any part of the urethra, iii. 362;  Travers'
  case of calculus in the urethra,  iii. 362;
  Home's case of retention of urine, and con-
  sequent mortification from  the impaction
  of calculi in the urethra, iii. 363;  Liston's
  case of a small brass ring  encircling the
  penis, iii. 363; symptoms of stone at the
  neck of the bladder, iii. 363 ; treatment
  and removal by operation, iii. 363; South
  on the treatment of stone in the urethra, iii.
  364; symptoms and treatment of stone in
  the membranous part of the urethra, iii.
  364 ; of stone  in the spongy part of the
  urethra, iii. 364; in the fossa navicularis,
  iii. 364; the entire urethra, in rare cases,
  blocked up with calculi, iii. 364; South on
  the extraction of calculi in  the urethra in
  front of the scrotum  without incising the
  canal, iii. 364;  urinary calculi external to
  the urinary passage, iii. 365; are met with
  in the perineum or scrotum from the de-
  struction of the walls of the urethra, iii.
  365;  consequences, iii.  365; may also
  occur in the vagina or rectum by the de-
  struction of their parietes, iii. 365;  Vin-
  cent's case of calculi in the perineum, iii.
  365;  Vincent's case of calculi  between
  the prepuce  and glans penis, iii.  366 ;
  treatment of these calculi, iii. 366:  pros-
  tatal stones, iii. 366; varieties, iii.  366 ;
  Astley Cooper's case, iii. 367 ; treatment
  by operation, iii.  367; Green's  case of
  encysted stone, iii, 367; Travers' case of
  stone broken up under the use of a consti-
  tutional stone-solvent, iii. 367; statistics
  of the  operation of lithotomy at  St. Tho-
  mas' Hospital from 1800 to 1846, iii. 368;
  lithectasy, cystectasy, iii. 3TO; object of the
  operation, iii.  375;  originally proposed
  by John Douglas, iii. 375; Dr. Arnott and
  Astley Cooper's case, iii. 376;  Elliott, Dr.
  Wright, and Fergusson's cases, iii. 376.
Forster on  the  cure  of syphilis by the
  chloride of gold and silver, ii. 102.
Foubert's operation of opening  the bladder
  through the perineum, iii.  343.
Foulliay's plan  of amputating the thigh
  with the  flap from before, iii.  660.
Fournier's  case of foreign  body in the
  heart, i. 500.
Foy's analysis of scirrhus, iii. 504.
Fractures of bones in general :—Defini-
  tion of a fracture, i. 544;  nature  and
     Vol  hi.—71
varieties of fractures,  i. 544; sub-divi-
sion of fractures into  complete  and in-
complete, i. 544; Boyer's  objection to
this sub-division, i. 544; Meding's experi-
ments, i. 545; causes, local and general,
of fractures, i. 545; influence of external
violence, i. 545; the contrecoup, i. 545;
opinions of Bichat, Mercier, and Pigne
on the changes which the substance of
bone undergoes in advanced age, i. 545 ;
diagnosis of fracture, i. 545 ; Lisfranc on
the use of the stethoscope in the diagnosis
of fractures, i.  545;  prognosis, i. 545;
union of the ends of a fractured bone, i.
547 ; formation of callus* i. 547 ; Dupuy-
tren on the two periods in the formation
of bone,  i. 548; John  Hunter on the
period  of union, and the manner in which
it takes place in simple fracture, i. 548;
Breschet and Villerme on there-union of
fractures,  i, 548; Breschet and Villerme
on the double formation of bony substance
in fracture, i.  549;  Miescher,  Weber,
Breschet, Villerme, Meding, Scarpa, and
Dupuytren on the production of callus, i.
550; summary of Miescher's views on
the formation of the primary and secon-
dary callus, i. 550 ; formation of an arti-
ficial unnatural joint, from an imperfect
condition  of the callus, i. 550; fracture of
the neck of the femur within the capsule,
of the olecranon, knee-cap, and heel-bone,
unites generally by a tough cellular inter-
substance, i. 550; South on the causes of
the want of bony union in such cases, i.
551; partial union of  broken bone from
imperfect adaptation, i. 551;  treatment of
fractures,  i. 551; setting  the fracture, i.
551; application of  the fracture-appara-
tus, i.  551; varieties  of splints, i. 552;
rejection of fracture-plasters, i. 552; com-
presses should not be applied on the  seat
of fracture, i.  552; South  on the non-
necessity for  bandages  in  fractures, i
552;  Cheselden,  John  Lawrence,  and
South  on the immoveable apparatus for
fractiires, i. 553; Smee's experiments,
i. 554;   Tavignot on  the  use  of  oil
varnish applied over the starch bandage
in fractures in  young children, i. 554;
the simple contentive apparatus in trans-
verse fractures, and such as are not very
oblique, i. 554 ;  position of the limb
during extension and counter-extension,
i. 555; South on the position of the limb
when stiffness of the joint is anticipated,
i. 555; treatment of the fracture after, it
has been set, i. 555; South  on the after-
treatment of the fracture, i. 556; general
treatment, i.  556; South  on the imprpy
priety  of  setting a fracture before*  the'
lapse of a few days, i. 556; South on the 
838
ANALYTICAL  INDEX.
immediate management of fractured cla-
vicle, and of oblique fractures, i. 557 ; se-
verity of the symptoms in compound frac-
tures, i. 557;  setting a compound frac-
ture, i. 557; enlarging the wound, if the
projecting piece of bone be firmly girt by
it, or  sawing off the protruding portion,
i.  557;  removal  of splinters, i.  557;
treatment during suppuration, i.  558;
wounds  of large vessels in compound
fracture, i. 558 ; causes and treatment of
mortification  in  compound  fracture,  i.
558;  complication of compound fracture
with  delirium tremens—symptoms and
treatment, i. 558; South's definition of a
compound fracture, i. 558; John Hunter
on the consequences of compound frac-
tures, i. 558; Astley Cooper on the effect
of compound fractures on the constitution,
and on the  reduction of a compound to
a simple fracture, i.  559; Miescher's ex-
periments to induce  suppuration in com-
pound fractures, i.  559;  South  on the
antiphlogistic  treatment  in  compound
fracture, i. 559 ; South on the exhibition
of opium in compound  fractures, i.  559;
South on bread and  water poultices in
compound fractures, i. 559 ; South on the
enlargement of the wound, and on sawing
off the projecting portion of bone, i. 559 ;
South on the removal of splinters, i  560;
South on the  formation and treatment of
abscesses duringthe progressof compound
fractures, i. 560; South on the treatment
ofwoundedvessels in compound fractures,
i. 560;  South on mortification in  com-
pound fracture, and its treatment,  local
and general, i. 560; measures proposed
to keep the limb at  rest, i, 561; Larrey
and Seutin on the treatment for compound
fracture,  i. 561;  Amesbury's fracture-
apparatus, i. 562; choice of  position in
compound  fracture, i. 562;  setting the
fracture, i. 563; Astley Cooper on dress-
ing the wound in  compound fracture,
i. 563; local  treatment  of  the injured
limb, i. 563 ; after-treatment, i. 564 ; John
Hunter  on the treatment  of compound
fracture,  i. 565; Astley Cooper  on the
union  of compound fractures, i.  565;
summary  of Miescher's experiments to
ascertain the processes under which sup-
purating fractures are united, i. 566; con-
ditions under which  amputation may be
necessary in  fractures, i. 567;  Astley
Cooper and Abernethy on the question of
immediate amputation,  i. 568; South on
the principal points to be considered in de-
termining on the necessity for immediate
amputation, i. 568; of the nature and
extent of the injury,  i. 568 ; the condition
of the patient, and his capability to bear
the second  severe  shock of the opera-
tion, i.  570; the immediate and remote
consequences of compound  fracture, i.
570;  sympathetic, symptomatic, or irri-
tative fever, i. 571; Abernethy and John
Hunter on symptomatic fever, i. 571; the
fever almost invariably subsides as sup-
puration is established, i. 571; occurrence
of secondary constitutional or nervous
symptoms, i. 572; amputation must  not
be  performed while  the  symptomatic
fever  continues, i. 572; John Hunter on
heetic fever, i. 572; Hunter  on the  re-
moval of the injured limb while the pa-
tient is hectic, i. 572; of the advantages
hoped for by the  immediate removal of
the injured parts, in preference to attempt-
ing to save them, i. 573; John  Hunter
on the slight constitutional irritation after
amputation, when  union  by the first  in-
tention takes place, i. 573;  South on the
objects and  occasional results of imme-
diate amputation, i. 573;  the suspensory
apparatus in the treatment of fractures, i.
573; South on Abernethy's bracket-splint,
and the swing box or slings, in the treat-
ment of fractures, i. 574; description of
Abernethy's  bracket-splint, i. 574; de-
scription of the swing-box, i.  574; treat-
ment  of the  subsequent  stiffness of the
joints, i. 575; re-breaking  of badlyrunited
fractures, i.575; Oesterlen's observations,
i, 575;  Bosch, Oesterlen, and  Wasser-
fuhr's apparatus for re-breaking the bone,
i. 576;  various operations on  the callus,
i. 576;  Briesche's case of softening of
the callus  by the  internal use of the
Carlsbad waters, i. 576; South on the
bending of bones, i. 576; fracture of  the
nasal bones, i. 577; are always consequent
on imme,diate violence, and accompanied
by bruising or wound, i. 577;  symptoms
and diagnosis, i. 577; severe bleeding
and symptoms of pressure or concussion
of the brain  sometimes present, i. 577;
compound fracture of the nasal  bones, i.
577; treatment of simple fracture, i. 577;
treatment when the edges of the fracture
are depressed, i. 577 ; plugging the nos-
trils useless and  injurious, i. 577 ;  treat-
ment of the attendant inflammation, i.
577;  of the  attendant bleeding, i. 577;
of the symptoms  of  brain affection, i.
577 ; fractures of the cheek-bones, i. 578;
of rare occurrence, and mostly accompa-
nied with  crushing and  wound of  the
soft parts, i. 578; fracture of the zygoma,
i. 578;  the brain may be affected by  the
violence, i. 578; diagnosis and treatment,
i. 578;  fracture  of the alveolar process
and its treatment, i. 578; Graefe's case
of fracture of the upperjaw,i.578; South's 
ANALYTICAL INDEX.
839
 case of extensive fracture of the bones of
 the face, i. 578; fracture of the lower jaw,
 i. 579 ; is of rare occurrence, i. 579 ; site
 and direction of  the fracture, i. 579; in-
 juries which  complicate the fracture, i.
 579; displacement  of the broken bone,
 i. 579; South on fracture of the lower
 jaw, i. 579; diagnosis, i. 579; setting the
 fracture, i. 579; application of a bandage
 to keep  the  fracture reduced,  i. 580;
 treatment of fracture of the  neck of the
 jaw-bone, i. 580; compound  fracture of
 the lower jaw, i. 580; Ruetenich, Kluge,
 Bush, Hartwig, and Wallner's apparatus
 for  fracture  of the  lower jaw,  i. 580;
 fracture of the os hyoides or  tongue-bone,
 i. 581; is of rare occurrence, and always
 the result of direct violence, i. 581; symp-
 toms, i. 581;  South on fracture of the os
 hyoides in persons who have  been hung,
 i. 581;  treatment, i. 581; fracture if the
 cartilages of the larynx, i. 581; the result
 of severe violence,  i. 581;   may cause
 speedy death by suffocation, i.581; symp-
 toms, i. 581;  operation for the reduction
 of the fracture, and subsequent treatment,
 i. 581; fractures  and dislocations of ver-
 tebrx, i. 582 ;  situation of the fracture, i.
 582; South  on the signs and rarity of
 occurrence of fracture of the spinous pro-
 cess alone, i.  582; fracture of the body
 of a vertebra rare, and only produced by
 great violence, i. 582; always connected
 with injury of the spinal marrow or its
 nerves, i. 582; occurrence of paraplegia
 at the time of the accident, or some time
 after, i. 583;  formation  of bed-sores, i.
 583 ; fracture and dislocation of the spine
 above the third vertebra soon fatal, i. 583;
 fractures below the origin of the phrenic
 nerves generally fatal in from  three to
 seven days, i. 583; Phillips' case of frac-
 ture of the first vertebra and pivot process
 of the second, i. 583; Jaeger's opinion
 that the  preparations of fractured spine
 united by callus only show that the frac-
 ture may be cured, but not the palsy, i.
 583; case of vertebral fracture with palsy
 of the lower limbs and  bladder, i. 583;
 South on the occurrence of fracture of the
 vertebrae without any great  violence, i.
 583; South's cases of fractured vertebrae
from jumping head-foremost into the wa-
 ter, i. 583; South on the causes of frac-
 tured vertebra, and  on  the  injury the
 spinal cord sustains from the accident, i.
 584; the danger in fractured  vertebra
 depends  on the injury sustained by the
 spinal cord, i. 585;  Cline's sen. case of
 fracture of the spine without displace-
ment, i.  585; post-mortem appearances
in Phillip's case of fracture of the atlas
 and pivot of the axis, i. 585;  case  of
 fracture of the atlas, axis, and fifth ver-
 tebra, without displacement, i. 585 ; dis-
 location of  one  vertebra  from  another,
 either  partially  or  completely,  without
 fracture, extremely rare, i. 586; denied by
 Delpech and Abernethy, i. 586; Astley
 Cooper considers it of very rare occurrence
 i. 586;  Boyer infers the impossibility of
 its occurring, i. 586; the cases mentioned
 by Boyer, Desault, Chopart, and Rust, i.
 586; Lawrence's cases of partial or com-
 plete dislocation, i. 586 ;  South's case of
 separation of the  under surface of  the
 second  cervical  vertebra from the inter-
 vertebral substance without displacement,
 i. 586; Lawrence's case of complete dis-
 location of the fourth  from the fifth cer-
 vical vertebra, i. 587; Schuh's case of par-
 tial dislocation, i. 587; Lawrence on the
 occurrence of dislocation of the vertebrae,
 specially in  the  neck, i. 588; period at
 which death  occurs after fracture  and dis-
 placement of the vertebrae, i. 588; Astley
 Cooper says fracture with displacement
 above the fourth  cervical vertebra imme-
 diately fatal, i. 588; this not always the
 case, i. 588;  formation of a false joint in
 fracture of the spine, i. 588;  instances of
 partial  union  by  ossification in fractured
 spine, i. 588; Astley Cooper and Brodie
 on softening  of  the spinal cord  after a
 severe  blow, i.  588;  diagnosis, i. 589;
 treatment general and local, i. 589 ; South
 on the treatment  of fracture of the spinous
 processes, i. 589; South and Brodie on the
 attempt to  set   a  fracture through the
 body of a vertebra, i. 589 ; Hardwicke's
 case,  i. 589;  South  on  the treatment
 of fractured  spine, i.  590; treatment
 of fractured vertebrae with impression, i.
 590; the operation of trepanning the
 spine  performed by Cline jun.,  Wick-
 ham, Attenburrow, Tyrrell,  Holscher,
 Smith and Rogers, i. 590; Charles Bell,
 Astley  Cooper, and Jaeger's opinions re-
 specting this operation, i. 590;  Cline's
jun. case of trepanning the spine, i. 590;
 Cline's jun. clinical observations on the
 case, i. 591;  Abernethy and  Brodie on
 the  operation of  trepanning the spine, i.
 592, 593 ; objections to  the operation, i.
 593; South's description of the operation,
 i. 594; South  on the after-treatment, i.594;
 Knox's pine-bed, i. 594; fracture of the
pelvic  bones,  i. 595; of rare  occurrence,
 and always  the result  of very great vio-
 lence,  i. 595; fracture  of  the  sacrum
 (rump-bone,) i. 595; diagnosis difficult,
 when the upper part of the bone is broken,
 because no displacement, i. 595; reduc-
 tion of  fracture of the  lower part of the 
840                       ANALYTICAL INDEX.
bone, i. 595; subsequent  treatment, i.
595;  South mentions a preparation  of
vertical fracture of the  sacrum  in  the
College Museum, i. 595; fracture of the
coccyx rare, and generally in old persons,
i.  595;  treatment,  i.  595;  South  on
fracture of the coccyx, i. 595; fracture of
the ilium or hip-bone, i. 595; direction of
the fracture, and attendant injury to the
soft parts, etc., i. 596; South on fractures  .
of  the hip-bone, and their danger from
rupture of the bladder, i. 596; diagnosis
of fracture of the hip, share, or haunch-
bone, i. 596 ;  South on the diagnosis of
fracture of the hip-bone, i. 596; Houston's
case of fracture of the  haunch-bone fol-
lowed by abscess in the perineum and
urinary fistulae, 597;  subsequent treat-
ment,!.  597; fracture  of the breast-bone
(sternum,) i. 597; of rare  occurrence, i.
597; causes and direction, i. 597; conse-
quences of  the displacement of the frac-
tured portions, i. 597; diagnosis, i. 597;
treatment, i. 598; Charles Bell's objection
to laying open the fracture and using the
elevator, or removing  its edge  by the
lenticular, in order to raise the depressed
portion, i. 598; Dupuytren and Gunther's
mode oftreatment, i. 598; general treat-
ment, i.  598; South  on the impropriety
 of the operation to raise the depressed
 portion of the bone, 598 ; fracture of the
ribs, i. 598; causes, direction, and conse-
 quences, i. 598;  case  of  fractured  rib
 caused by severe cough, i. 599;  South's
 case of wound  of the heart caused by a
 broken rib, i.  599;  diagnosis,  i. 599;
 local  and  general   treatment,  i.  599;
 Graefe,  Larrey, Seutin, Malgaigne, and
 Bailie on the local treatment-of fractured I
 ribs, i. 599; South on  the treatment of
 fractured  ribs, i. 600 ; fracture of the
 cartilages  of the ribs, i. 600; diagnosis, i.
 600; setting and treatment,!. 600 ; frac-
 ture of the shoulder-blade (scapula,) i.
 600;  parts liable  to be broken, i. 600;
 South on the causes of fracture  of those
 parts, i. 600; fracture of the acromion, i.
 600; symptorns  and treatment, i. 600;
 South on the symptoms of fracture of the
 acromion, i.  601  ; fracture of the neck of
 the scapula,  i. 601 ; diagnosis, i.  601;
 South doubts the occurrence of this frac-
 ture, i. 601 ; fracture of the coracoid pro-
 cess,!. 601; South's case, i. 601; fracture
 of the body of the scapula, i. 601 ; symp-
 toms and  treatment, i. 601; fracture if
 the  lower  angle  of  the scapula, i.  602;
 treatment, i. 602;  South on fracture of
 the body, spine, and angle of the scapula.
 i. 602; treatment of compound fracture cf
 the scapula, i. 602; fracture of the collar-
bone, (clavicle,)i. 602; situation and causes
of fracture, i. 602; fracture of ihe clavicle
between its sternal  end and the coracoid
process, i. 603 ; diagnosis, i. 603; trans-
verse and oblique fractures, i. 603; setting
the fracture, i.  603; deformity  generally
the result of  this fracture, i. 603; mode
of reducing the fracture, i. 603; the ban-
dages and apparatus of Galon, Pare, Petit,
Kluge, Richter, Heister, Brasdor, Evers,
Brunninghausen, Wilhelm,  Eberl,  De-
sault, Boyer, Brefeld, Eichheimer, Kop-
penstaedter,Keckely,Cruveilhier,Laserre,
Flammant, Delpech,H. Earle, Amesbury,
Richerand,  Wattmann, Mayor,  Huber-
thal, and Renaud,  i.  603; objections to
the apparatus of Heister, Brasdor, Evers,
Brunninghausen, and Wilhelm, i. 604;
the apparatus of Desault and Boyer  pre-
ferable, i. 604; Dupuytren,  Cloquet, Sa-
lamon, and Jaeger's practice, i. 605; the
preference given to Brefeld's apparatus, i.
605; South on the  treatment of fractured
clavicle, i. 605; application of the appa-
ratus, i. 605; fracture of the clavicle be-
tween the coracoid process and the scapular
end, i. 605;  diagnosis  and treatment, i.
 605; fracture of the upper arm (humerus),
i. 606 ; fracture of the neck  of the bone, i.
 606;  diagnosis, i. 606; causes, i. 606;
 South on fracture of the greater tubercle,
 i. 606; Astley Cooper on fracture of the
 anatomical neck of the humerus, i. 606 ;
 South's cases, i. 607; Astley CoopeTand
 South  on fracture of the surgical neck, i.
 607; setting  and treatment  of the  frac-
 ture,  i. 607; Richerand's plan of treat-
 ment, i. 607; condemned by South, i. 608;
fracture of the body  if  the  bone, i.  608;
 situations in which it may occur, i.  608;
 diagnosis, i. 608; occasional  results, i.
 608;  setting the  fracture,  i. 609; treat-
 ment, i. 609 ;  South on the treatment of
 fracture of the humerus, i. 609; Seutin
 and Dupuytren's plan,i. 609; separation
 of  the condyles in fracture of the lower
 end of the bone, i. 609 ; symptoms, diag-
 nosis, and  treatment, i.  609;  Astley
 Cooper on the union of these fractures, i.
 610;  South on fracture of the condyles,
 i.  610; compound fractures  of the hu-
 merus, i.  610; South on the treatment of
 compound fractures of the humerus, i.
 610 ; fracture of ihe  bones if the fore-arm,
 i. 610', fracture of the radius alone, i. 610;
 symptoms and diagnosis,  i. 610;  symp-
 toms  of  displacement of  the fractured
 ends, i. 611;  Dupuytren and  Brodie on
  fracture of the lower  end of  the radius,
  i. 611;  South on fracture  of  the neck of
  the radius, i.  612 ; fracture of tlie ulna, i.
  612;  causes and symptoms, i. 612 ;frac- 
ANALYTICAL INDEX.                         841
 ture of both bones of the fore-arm, i. 612 ;
 situation, causes, and symptoms, i. 612;
 setting the  fracture, i.  612 ; treatment, i.
 613; setting  a fracture of the radius or
 ulna alone, i. 613; Dupuytren  on the
 treatment of fracture of either bone near
 the wrist, i. 613 ;  Blandin's treatment, i.
 613; South on the treatment of fractures
 of the  fore-arm,  i. 613; treatment of
 compound fracture of the fore-arm, i. 613 ;
 fracture of  the  olecranon, i. 613; causes
 and symptoms, i.  613; mode of union of
 the fractured ends, i.  613; treatment of
 the fracture by the apparatus  of Bottcher,
 Wardenburg, Astley Cooper, and Ames-
 bury, i. 614;  plan  of treatment recom-
 mended .by Duverney, Sheldon, Desault,
 Feiler,  and   Earle,  i.  614;  descrip-
 tion of  Feiler and  Earle's apparatus, i.
 614; South on the treatment of fracture
 of the olecranon,  i. 615 ; fracture of ihe
 coronoid process of the ulna,  i. 615; first
 described by Astley Cooper, i. 615; treat-
 ment, i. 615;  union takes place by liga-
 ment, i. 615 ;  Jaeger's case of imperfect
 fracture of  the  coronoid process, i. 615;
 fracture of the bones of the hand, i. 615;
 fracture of  the bones of the wrist, i. 615;
 causes, symptoms, treatment, and results,
 i. 615; fracture of the bones of the meta-
 carpus,  i.  615; causes, symptoms, and
 treatment,  i.  615;  fracture  if the pha-
 langes, i. 616; treatment, i. 616; frac-
 ture of the femur, i. 616 ; of the neck of the
 femur, i. 616; situation and  direction,
 i. 616; causes, i. 617 ; symptoms of frac-
 ture of  the neck  of the  femur, i.  617;
 Astley Cooper on the distinction between
 fracture within and  without the capsular
 ligament, i. 617; Earle, Smith, Ekl, and
 Fricke on some of the signs  of this frac-
 ture, i.  618;.Desault, Delpech, Astley
 Cooper, Ekl, Fricke, Hahn,  Jaeger, and
 South  on  the in-locking of  the broken
 ends of the  bone,  i.  618; Pare, Petit,
 Louis, Desault, Dessaussoy,and Delpech
 on the  rotation of the foot outwards, i.
 .618; Guthrie, Syme, Stanley, Dupuytren,
 Astley Cooper, Mercier, Larrey, and Del-
 pech  on inversion  of the foot, i.  618 ;
 diagnosis, i. 619; separation  of the head
' of the femur from its neck from external
 violence, i. 619; South's case, i. 619;
 fracture of the neck of  the  femur dis-
 tinguished  from severe contusion of the
 hip-joint, i. 619 ;  from dislocation of the
 femur outwards and upwards, and out-
 wards and  downwards, i. 619 ; from dis-
 location upwards and  inwards,  i.  619 ;
 Astley Cooper and  Gulliver on intersti-
 tial absorption in the neck of the femur,
 i. 619 ; opinions of surgeons on the prog:
 nosis in fracture of the neck 9f the femur,
 i. 620; Astley Cooper admits bony union
 in fractures external to, but  not in frac-
 tures internal to  the capsular ligament,
 i. 620; Boyer  and Earle opposed to his
 views, i. 620; bony union may take place
 within  the /capsular ligament, i.  620;
 causes of the non-union by bone in frac-
 ture  of  the  neck  of  the  femur,  620;
 Soemmering and  South's preparations of
 fracture  within  the capsular  ligament
 united by callus,  621;  Cruvielhier  on
 the production of callus, i. 621; Swan
 and Stanley's cases of fracture of the neck
 of the femur within the capsule  united by
 bone, i. 621; setting the fracture, i. 622;
 arrangement of the bed in fractures of
 the  lower extremities, i. 622; various
 apparatus  for fixing the broken ends of
 the  bone, i.  622;  apparatus  of  Pare,
 Sabatier, Guyot,  Hildanus, La Faye, Ar-
 naud,Duverney, Hedenus, Theden, Bott-
 cher, Bernstein,  Larrey, Desault, Van
 Houte,  Volpi, Josse, Meyer,  Physick,
 Houston, Alban, Gressley, Brunninghau-
 sen, Boyer, Heyne, Hagedorn,  Dzondi,
 Nicolai,  Klein,  Gibson, Beck, Schiir-
 mayer, Weckert,  and Sauter, i.  623, 624;
 Mursinna, Dupuytren,  Richerand,  and
 Astley Cooper on the treatment of these
 fractures, i. 624 ;  fracture-beds  of Earle,
 Amesbury, Smith, Koppenstaedter,  and
 Hager, i.  625; the preference  given to
 Hagedorn's apparatus, i. 625; Dupuytren
 on the advantages of the double inclined
 position, i. 625 ; subsequent treatment, i.
 625; Dupuytren on the duration of the
 treatment, i.  6251;  oblique fracture of the
femur through the great trochanter, i. 626;
 symptoms, i. 626  ; Astley Cooper's band-
 age for the treatment of this fracture, i.
 626 ; fracture of the femur below the great
 trochanter, i. 626; seat, causes, and direc-
 tion,  i. 626 ; signs, i. 626; these fractures
 always a severe accident, and  generally
 cured with deformity and  shortening, i.
 627;  South  on  simple and compound
 fractures  of the femur, i. 627;  the con-
, tentive apparatus with  splints  and limb
 in a straight  direction, i. 6J7;  South on
 the treatment of fracture of the femur,
 i. 628; the apparatus with  splints, with
 the limb  bent, and the patient lying on
 the side or back, i. 628; Pott, C. Bell,
 and Astley Cooper on  the bent position,
 i. 628; Desault, Brunninghausen, BoyerT
 Hagedorn, and Sauter  on permanent  ex-
 tension,  i. 628;  Earle's  fracture-bed,
 Granger's apparatus,  and  Mojsisovic's
 equilibrium plan, i. 629; application of
 Seutin's  permanent apparatus, i. 629;
 treatment  of transverse fractures of the
IV 
842                        ANALYTICAL INDEX.
middle of the femur, i. 629; of the upper
and lower thirds, i. 630; of oblique  frac-
ture, i. 630; of compound fracture, i. 630;
of fracture of the femur in children, i.
630; after-treatment, i.  630; fracture of
the condyles, i. 630; symptoms and treat-
ment, i. 630; fracture of the patella, (knee-
cap), i. 630; direction, nature, and causes,
i.  631;  diagnosis, i. 631;  union of the
fractured portions by a fibrous inter-sub-
stance, i. 631; complication of the  frac-
ture  with severe bruising  or  wound of
the joint, i.  631; Gulliver on the union
of fractured patella, i. 632;  treatment of
transverse fracture, i. 632; application of
bandages round the joint, when there is
considerable  separation  of  the broken
pieces, i, 632; Langenbeck and South on
the treatment of fractured patella, i.  633;
bandages  and apparatus   of  Bucking,
Evers, Mohrenheim, B. Bell,  Boyer, A.
Cooper, Baillif, and Fest, i. 633; treat-
ment of the attendant inflammation, i.
633; subsequent treatment, i.  633 ;  eon-
sequences  of the injury, i. 633;  John
Hunter  on  the processes which  follow
after union has taken place, i. 633; South
on the means to be adopted for the adap-
tation of the rectus muscle to the  new
condition of the patella, i. 634; treatment
of longitudinal fracture, i. 634; of splin-
tered and  compound  fracture, i.  634;
South on  compound fracture of the pa-
tella, i.  634; rupture of the ligament of
the patella, i. 634;  treatment, i.  634;
great care required in the application of
the apparatus for transverse fracture, i.
634; fracture of the bones of the leg, i.  635;
causes, i.  635; fracture of the tibia, i.
635; direction, diagnosis and  treatment,
i.  635; fracture  of the fibula, i.  635 ;
causes and seat  of the fracture,!.  635;
symptoms,  i. 635;  frequently accom-
panied with  dislocation inwards of the
tibia, i. 636-; symptoms of the dislocation,
i.  636; treatment of simple fracture, i.
636; fracture of  both bones of ihe leg, i.
636 ; direction and situation of the  frac-
ture, i. 636; diagnosis, i. 636 ; treatment
of simple transverse  fracture, i. 636; of
oblique fracture,  i. 637 ; Posch and  Sau-
ter's apparatus for permanent extension,
i.  637 ;'treatment of ■fracture  of the leg
near the  knee-joint, i.  637;  compound
fracture and its treatment, i. 637; Braun's
apparatus, i.  637; Seutin's  permanent
apparatus for fracture of the leg, i.  638 ;
South on the treatment of fracture of the
bones of the leg, i. 638 ; fracture of the
bones of the foot, i. 639; of rare occurrence,
i. 639;  generally caused  by  immediate
 violence, i. (,39 ; fracture of the os calcis, i.
  639 ; causes and diagnosis, i. 639; signs,
  i. 639 ;  if the periosteum be completely
  torn,great displacement may ensue, i. 639;
  setting the fracture, i. 639; Lawrence's
  case of  fracture of the os calcis, i. 639 ;
  Lisfranc's case, i. 640;  South's case of
  compound fracture of the os calcis, i. 640;
  South on fracture of  the  phalanges and  •
  on the treatment, i.  640.
Franc's operation for  varicocele, ii. 578.
Franco on the application of caustic for the
  radical cure of hernia, ii 282; on ligature
  of the hernial sac for its radical cure, ii.
  282 ; on the operation of dilating the ab-
  dominal ring, the hernial  sac being un-
  opened, ii. 303.
Franz' case of apparent strangulated thy-
  roid rupture, ii. 352.
Frazer, Dr., recommends  the removal of
  the acromion and glenoid cavity in ampu-
  tation at the shoulder-joint, iii.  717.
Freer on  compression in the treatment of
  aneurism, ii. 483 ; case of ligature of the
  external iliac in the  groin, ii. 537 ; case
  of operation for artificial anus at the lower
  end of the colon, iii. 38.
Freitag on  ligature of  the  hernial sac for
  its radical cure, ii. 283.
Fricke's plan for  treating  burns with  a
  solution of lunar caustic, i. 129; on com-
  pression in  orchitis, i. 204; the advan-
  tages of compression, i. 207; method of
  examining the length  of the limb during
  the progress of  hip disease, i.  281; ex-
  planation of the  shortening  of the limb
  incorrect,  i.  284;  explanation  of the
  lengthening of the  limb, i. 285; on the
  distinction  between coxalgy and  coxar-
  throeacy, i. 291; Scott's plan oftreatment
  employed with advantage, i. 294; on the
  treatment of coxalgy, i. 297; case of the
  .reduction of the consecutive dislocation,
  i. 297 ;  on the torsion of arteries, i. 341;
  on the mode of practising torsion, i. 341;
  on the effects  of torsion, i. 343; on the
  torsion  of bony vessels, i. 343; on the
  treatment of severe wounds  of  the  neck,
  i. 476; on some of the signs  of fracture of
  the neck of the femur, i. 618;  on  the in-
  locking of the ends of the broken bone,
  i.  618;  successful  operation for sawing
  off the  ends of  the  broken bone in false
  joints, ii. 20;  on the treatment of buboes,
  ii. 90; on the treatment of caries, ii. 118;
  on the operation of episioraphy, ii. 381;
  operation for varicocele, ii.  578 ;  on ex-
  cision of the head of the metatarsus, iii.
  744.
 Friederich on the proximate cause of teta-
  nus, i. 417.
 Fritz on the mercurial treatment  in hip
  disease, i. 296. 
ANALYTICAL  INDEX.
843
Friemann on suture of the urethral fistula,
  ii. 178.
Froriep, von, on the proximate  cause of
  tetanus, i. 417; on the causes of splay-
  foot, ii.  457; on ligature of the femoral
  below Poupart's ligament, ii.  539;  on
  the application of caustic in varix, ii. 573.
Frost-bite :—definition   of  frost-bite, i.
  143;  South on  the parallelism  of the
  effects of great degrees of heat and cold
  upon the animal body, i.  143 ;  Muller's
  comparison of the effects of heat and cold
  on the body, i. 144; Hunter's experiments
  in freezing rabbits' ears, i. 144  ; case of
  a soldier, whose scrotum was frost-bitten,
  i. 144; cold wet sufficient to induce mor-
  tification, if continued sufficiently long to
  reduce the  natural  heat of the part below
  a certain standard, i.  144 ;  Sir  Joseph
  Banks'  account of his sufferings, and of
  Dr. Solander's  from exposure to cold, i.
  145; Dr. Kellie's case, i. 145 ;  effects of
  frost-bite  on a  limb,  i. 145;  Hunter,
  Astley Cooper, and Larrey on the effects
  of  frost-bite, i. 145;  Green and Solly's
  cases of frost-bite, i. 145; consequences
  of  too suddenly warming a frozen or be-
  numbed part,—chilblains, or gangrene, i.
  148 ;  Astley Cooper and Larrey's obser-
  vations on this point, i. 148 ; directions to
  re-animate a frozen person, i. 148; direc-
  tions for thawing a frozen limb, i.  149;
  treatment of a part in which mortification
  is  threatened, from its having  been  too
  hastily  warmed, i. 149; when mortifica-
  tion has taken place, it must be treated in
  the usual manner, i. 149; chilblains, i.
  149; symptoms  and  results,  i.  149;
  Hunter mentions  another inflammation
  very like chilblains, i. 149 ; seat of chil-
  blains,  i.  149; treatment, i.  149; South
  on the  mustard liniment in their treat-
  ment, i. 150; treatment of ulcerated chil-
  blains,  i. 150; of gangrenous chilblains,
  i. 150;  prevention of chilblains, i. 150.
 Furuncle.   See Boil.

 Gadermann  on the  operation  for strangu-
  lated thyroid rupture, ii, 353.
 Gaetani  Bey's case of  resection of  the
  scapula, and acromial end of the clavicle,
  iii. 766.
 Gairdner, Dr., on  the dangerous symp-
  toms occasionally caused by iodine, iii.
  395.
 Gale on the use of the ligature for wound-
  ed vessels, i. 355; on the  dressing of
  wounds, i. 358; on the application of the
  interrupted suture, i. 362.
 Galen on the removal of the relaxed uvula
  by cutting, i. 166; on the torsion of ar-
  teries, i. 341; on  the  protraction of  the
  period  of  incubation,  of hydrophobia i.
  404; bandage for fractured  clavicle, i.
  603 ; on aneurism, ii. 468 ; on the appli-
  cation of two ligatures in aneurism, and
  the division of the artery between them,
  ii. 497; on aneurismal varix, ii. 547.
Galenzowski's modification of the German
  operation of rhinoplasty, iii. 589.
Gale's   experiment  with the  itch-mite,
  ii. 68.
Gall's case of spina bifida, iii, 186.
Gall-bladder, wounds of, i. 526.
Ganglions, iii. 436.
Gangrene, senile.  See Mortification.  Hos-
  pital Gangrene.  See Mortification.
Garengeot  first  formed four varieties of
  whitlow, i. 215; on agnails as a cause of
  whitlow, i. 218; on the operation of di-
  lating  the  abdominal  ring,  the  hernial
  sac being unopened, ii. 303;  mode of
  amputating at the shoulder-joint, iii. 713.
Gastrotomy, iii. 106, 164.
Gatesden's, John  of, Rosa  Anglicana,  i.
  183.
Gaussil on hydrocele caused by gonorrhea,
  iii. 222.
Gedding's, Dr., cases in which episioraphy
  was performed, ii. 381.
Gendrin's account of the steps by which the
  stagnation of the blood in inflammation is
  produced, i.  40 ; on the nature of the
  cores  of boils, i. 151; never found any
  trace  of inflammation in cartilage, ii.
  262; case of stictured oesophagus commu-
  nicating with the trachea, iii. 28 ; on the
  physical characters of dropsy of the peri-
  cardium, iii.  200; directions for the ex-
  tirpation of the womb, iii. 574.
Gensoul's modification of the operation for
  deficient columna narium, iii. 588; case
  of  chiloplasty, to remedy a  deformity
  caused  by gangrene,  iii.  588; doubts
  Dupuytren's  cases of extirpation of the
  upper jaw, iii. 754; mode of operating in
  extirpation of the upper jaw, iii.  755;
  case of extirpation of the superior maxil-
  lary bone, iii. 750.
Gerard on the stanching the bleeding from
  an interoostal artery, i. 492.
Gerrer on the varieties of exudation after
  inflammation, i. 45 ; on the microscopical
  resemblance  between the lymph-corpus-
  cles and the exudation-corpuscles,  i. 45 ;
  account of the formation of pus, and the
  reproductive organization in suppurative
  wounds, i. 53 ; description of ichor, puri-
  form mucus, and serous exudation, i. 56.
Gerdy on dislocation of the upper end  of
  the radius forwards, ii. 231 ; plan of in-
  healing a plug  of  skin for the radical
  cure of rupture, ii. 283; mode of operating,
  ii. 284. 
844                        ANALYTICAL INDEX.
Gibson, Dr., on the use of raw cotton in the
  treatment of  burns, i.  131 ; his forceps
  for amputating the tonsils, i. 165;  be
  lieves  the divisions of whitlow,  except
  the first, to be arbitrary, i. 216;  on  the
  treatment of  whitlow, i.  219;  Perkins'
  plan tried  without advantage, i. 220;
  performance  of  Barton's  operation  for
  anchylosis, i, 275; on the fatal effects of
  the stings of bees and wasps, i.  387; ap-
  paratus for  fracture of the neck of the
  femur, i. 624; on the formation of a false
  joint with a  fibro-ligamentous  capsule,
  and a  lining  membrane, ii. 14; case of
  old dislocation of the humerus,  in  re-
  ducing  which  the axillary artery was
  ruptured, ii. 226.
Gilbert's case  of resection of the scapula
  and clavicle together, iii. 765.
Gleet.  See Inflammation of the Urethra.
Glisson  on the causes  of  club-foot,   ri.
  446.
Gluge on the microscopic characters of pus,
  i.  47;  on the nature of  the  medullary
  fungus, iii. 459.
Gluteal artery, ligature of, li. 535.
Gmelin's chemical analysis of the fluid  in
  ranula, iii. 122.
Godefrey's cases of anteversion of the
  womb  reduced by position, ii. 416; case
  of Caesarian section in which he  sewed
  up the wound in the womb, iii.  162.
Gonalgia,  Inflammation of the  Knee-
  Joint, i. 301; symptoms  and  progress,
  i. 301 ; difference between rheumatic and
  scrofulous white swelling of the knee-
  joint, i. 301; post mortem appearances,
  i. 302; South and Brodie on the diagnos-
  tic symptoms of the diseases of the knee,
  i. 302; Brodie on ulceration of  the car-
  tilages of the knee, i, 302; Rainey on a
  peculiar degeneration  of the cartilage in
  disease of  the knee, i. 303;  Brodie on
  scrofulous  disease in the  cancellated
  structure of the bones of the knee, i. 304;
  progress of caries, i. 304. White Swell-
  ing, i. 304;  application of the term, i.
  304;  the disease very frequent in Great
  Britain, but  rare in Italy, Vienna, and
  many  other parts  of  Germany, i. 305;
  Russell and  Gotz on the  appearance  of
  white swelling on dissection, i. 305 ; Ni-
  colai  on the  symptoms and progress of
  white  swelling, i. 305; Nicolai  on  the
  anatomy of white swelling, i. 306; prog-
  nosis and treatment, i. 306.
Gonorrhea.  See Inflammation of the Ure-
  thra.
Gonorrheal rheumatism  and: ophthalmia, i.
  342.
Gooch on the arrest  of hemorrhage by  na-
  ture, L 329;  quotes a case of wounded
  gall-bladder, i. 526; bandage for ruptured
  tendo Achillis, i. 541 ;  case of spasm of
  the platysma  myoides  cured by  opera-
  tion, ii. 426 ; mode of amputating by the
  circular incision, iii. 641.
Good, *Dr. Mason, mentions two kinds of
  inflammation of the parotid gland, i. 168;
  the parotid phlegmon, i. 168 ; abscess of
  the parotid gland sometimes of consider-
  able magnitude, i. 168 ; malignant variety
  of parotid phlegmon, i. 168; the malig-
  nant variety of mumps, i. 168 ; on the
  malignant degeneration of parotid phleg-
  mon, i. 169.
Goodlad's  objection  to the term, " hys-
  terical,"  as  applied to certain affections
  of  the joints, i. 278;  on the local appli-
  cations in such affections, i. 278; on liga-
  ture of the carotid prior to the extirpation
  of the parotid, iii. 525.
Goodsir  on the  mucilaginous glands, i.
  237; holds with Key in the  deposit from
  the synovial membrane being the  cause
  of ulceration in cartilage, i. 257 ; on the
  scrofulous disease of the  cancellated tex-
  ture of the heads of bone, i.  266.
Gotter's opinions relative to the formation
  of pus, i. 46.
Gottschalk on the treatment  of varix, ii.
  571.
Gotz on the appearance of white swelling
  on dissection, i. 305
Goulard  on the stanching the bleeding
  from an intercostal artery, i. 492.
Goyraud on retraction  of  the  tendons  of
  the fingers,  ii. 465 ; cases  of subcuta-
  neous section for  cartilaginous bodies in
  joints, iii. 448.
Graefe's  artery-compressor, i. 331;  case
  of fatal gunshot wound of the intercostal
  artery, i. 492; on the application of su-
  tures in wounded intestine, and including
  the peritoneum  in the  suture, i. 504;
  slippers for rupture of the tendo Achillis,
  f. 542 ; case of fracture of the upper jaw,
  i. 578; on the local treatment of fractured
  ribs, i. 599 ; first proposed the operation
  of staphyloraphy, ii. 30 ; preparation of
  the parts for the operation, ii. 30 ; on the
  removal of the edges of the  cleft, ii. 31;
  plan for bringing the edges of the cleft
  together, ii. 31; on  the after-treatment,
  ii.  35;  on  the iodide and  bromide  of
  mercury in  syphilis, ii. 94;  on incision
  of the hernial sac, and the introduction of
  lint tents, for its radical cure, ii. 283; on
  puncturing the distended intestine after
  the operation for  strangulated  hernia, ii.
  299; on the section of the scalenus anticus
  in ligature of the subclavian, ii. 518; ope-
  ration for the ligature of the subclavian,
  ii.  521;  on  the treatment of  branching 
ANALYTICAL INDEX.
845
 aneurism, n. 554; treatment of broncho-
 cele, in. 394; modification of the Talia-
 cotian operation, iii. 577; modification of
 the Indian operation of rhinoplasty, iii.
' 584; on the proper formation of the nos-
 trils, iii. 586 ; modification of the Italian
 operation of  rhinoplasty, iii. 590; artifi-
 cial  leg, iii. 593; mode of amputating by
 the  circular  incision,  iii. 640; mode  of
 amputating at the hip-joint with the cir-
 cular cut, iii. 689; at  the  shoulder-joint
 with the circular cut, iii. 715; case  of
 excision of part of the hand, iii. 722;
 case of excision of a joint, iii. 726;  case
 of excision of the lower jaw, iii. 747;
 mode  of operating in excision of the
 lower jaw with  the condyles, iii. 749;
 on the previous ligature of the carotid
 artery, iii. 750; case of exarticulation of
 one side of the lower jaw, iii. 751.
Graf  on the treatment of itch, ii. 68.
Granger's apparatus for fracture of the fe-
 mur, i. 629.
Grantham's case  of  ruptured muscle, i.
 543.
Gras, Albin, on the existence of the acarus
  scabiei,  ii. 67;  case of dislocation of the
 pisiform bone, ii. 234.
Gras', Le, mode of amputating the thigh
 with the flap from before, iii. 660.
Grashuis' opinions relative  to the forma-
 tion of pus, i. 47.
Grassmeyer on the distinguishing tests for
 pus and mucus, i. 56.
Gratelup's case of rupture of the chest, ii.
 360.
Gravel,  iii. 255.
Gray, Dr., on anteversion of the womb, ii.
  415; on Hall's utero-abdominal supporter
 in antroversion of the womb, ii. 417.
Greatrex on compression in the treatment
 of aneurism, ii.  486.
Green's, J. H., case of frost-bite, i. 145;
 case of secondary haemorrhage after liga-
 ture of  the subclavian,  i. 340; case  of
 ligature of the  external jugular vein, i.
 353; case of indentation of the skull in a
 child, i. 431; case of sympathetic abscess
 of the brain, with irritation and suppura-)
 tion of the dura mater, i. 442; case  of
 cataleptic fits after fracture of the parietal
 bone,  i. 458; case of insanity following
 a blow over the longitudinal sinus, i. 460;:
 case of fatal penetrating wound of the ab-
 domen, i. 507; case of wounded intestine,
 i. 507; operation on an ununited fracture
 of the femur, ii. 19;  commented on by
 South, ii. 19; on the  use of mercury in
 syphilis, and on the forms  in which it
 should be employed, ii.  87; case of dis-
 location of the two outer metatarsal bones,
 ii. 256;  case of  reduction  en masse, ii.
  274 ;  case of carotid aneurism, in which
  pulsation continued for several days, after
  the artery was lied in, ii. 498;  case  of
  secondary haemorrhage  after ligature  of
  the subclavian, ii. 498; on ligature of the
  subclavian, ii. 519;  case of aneurism  of
  the posterior tibial, ii. 543 ;  case of vari-
  cose aneurism, ii. 551; case  of foreign
  body  in  the  alimentary canal, iii. 105;
  case of abscess by the side of the rectum,
  from the irritation of a foreign body, iii.
  108;  on the  treatment  of hydrocele by
  seton, iii. 229; case Of lithotomy in a fat
  man of 50 years of age, iii. 298; case  of
  secondary haemorrhage  after lithotomy,
  iii. 335;  case of encysted stone, iii. 367;
  case of extirpation of bronchocele, iii.398;
  case of fatal haemorrhage from leech bites,
  iii. 614; case of dislocation of the astra-
  galus, iii. 703.
Gregory, Dr., on the prognosis of wounds
  of the chest, i. 488;  on the- origin  of
  vaccination, iii. 622; on the preservation
  of vaccine lymph for transmission, iii.
  652; on the period at which lymph should
  be taken for vaccination, iii. 622; on the
  operation of vaccination, iii. 623; on the
  appearances after successful vaccination,
  iii. 623; on the insusceptibility of some
  constitutions to the vaccine virus, iii. 624;
  on the appearance of vaccine lichen, iii.
  625.
Gressley's apparatus for fracture of the
 •neck of the femur, i. 224.
Grossheim on the stanching the bleeding
  from the intercostal artery, i. 491.
Growths,  diseased  and abnormal, iii.
  378;  definition and characters, jii. 378;
  connexion between  the two classes  of
  disease, iii. 379 ; Lawrence on the tran-
  sition between new or accidental produc-
  tions and changes of structure, and dege-
  nerations of organs, iii. 379;  origin of the
  degeneration  of organic parts, iii. 379;
  special development of the vessels in the
  diseased changes of organic parts, and
  the consequences, iii. 379; after-products
  or new formations, iii. 379; diseased
  growths subject to the same general laws
  as the natural tissues, iii. 379; the cellu-
  lar theory, iii. 379; the corpuscular theory,
  iii. 379; tumours,  iii. 379; Abernethy,
  Laennec,  Meckel,  and Muller on the
  division  of tumours, iii. 381; the more
  minute microscopic elements of tumours,
  iii. 381; difficulty of making an accurate
  and  sufficient  division of tumours de-
  pending on their unnatural structure, iii.
  381;  general  characters of  tumours, iii.
  382;  enlargement of the tongue, iii. 382;
  generally congenital, iii. 382; characters,
  iii. 383; period at which it occurs, and 
846                         ANALYTICAL  INDEX.
cause, iiit384; treatment, iii. 384; Clan-
ny's case, iii. 384; treatment by the knife
or the ligature,iii. 384; mode of operating,
iii. 384; Percy and Harris' operations, iii.
384;  treatment  of  protrusion  of»  the
tongue from paralysis of its muscles, iii.
385; Bronchocele, iii.  385 ; definition and
characters, iii. 385; symptoms when the
bronchocele is large, iii. 385; varieties,
iii. 385; symptoms and treatment of in-
flammation of the thyroid gland, iii. 386;
vascular  or aneurismatic bronchocele,  iii.
386; characters, iii. 386; lymphatic bron-
chocele, iii. 386; characters, iii. 386; seat
of the disease, iii,. 387; South  on lym-
phatic bronchocele, and serous  cysts in
the neck, iii. 387; scirrhous bronchocele,
iii. 388;  characters,  iii. 388; causes of
bronchocele, iii. 388; M'Clellan on  the1
cause of bronchocele, iii. 388; Inglis and
Copland on the age at which bronchocele
is most usual, iii. 389; Dr. Robertson and
M'Clellan on bronchocele as a variety of
scrofula, iii.  389; prognosis, iii.  389;
treatment, iii. 390; in vascular broncho-
cele, iii.  390; ligature of  the  superior
thyroideal artery, iii.  391 ;  mode of ope-
rating, iii. 391;  after-treatment, iii. 392;
relative value of this operation, and other
modes  of treatment formerly  recom-
mended, iii. 392; the tumourmay increase
in size after this operation from  the  en-
largement of the inferior thyroid, and its
communicating with the superior, iii. 393;
Coates and Wickham'scase in which  the
bronchocele ultimately enlarged, after the
ligature of the superior  thyroid, iii. 393 ;
ligatiye of the inferior thyroid artery, iii. |
393; treatment of lymphatic bronchocele,
iii. 393 ; exhibition of burnt sponge and
iodine, iii. 393;  dangerous  symptoms j
caused by large doses of iodine, and their j
treatment, iii. 394; contra-indications to
the use of iodine, iii.  394; Graefe's treat-!
ment  of  bronchocele,  iii.  394 ;  Inglis'
objections to  Coindet's mode of exhibi-
ting iodine, iii. 394; Dr. Gairdner on the
dangerous symptoms  occasionally caused j
by iodine, iii. 395; South on the exhibi-
tion of iodide of potassium, iii. 395;  ex-
ternal remedies  for bronchocele, iii. 395;
South on the employment of iodide of
potassium in the form of ointment, iii.395;
ligature of the superior  thyroid artery for
lymphatic bronchocele, when it presents
a cartilaginous hardness,  iii. 396 ; em-!
ployment of the seton, iii. 396;  mode of
applying it, iii. 396; fatal  results havej
occasionally followed its use, iii. 397; in-
cision of the bronchocele, iii. 397; punc-
turing the bronchocele, iii. 397;  Mau-
noir's treatment by  puncture, and  irri-
tating injections, and  by seton, iii. 397;
extirpation  very dangerous, and to be
almost entirely  forbidden, iii. 398; cases
in which  extirpation  is admissible, and
mode of operating, iii.  398; Green's case,
iii. 398; Mayor and Bach's extirpation of
bronchocele  by ligature, iii. 398 ; Rigal
de Gaillac's extirpation of bronchocele by
subcutaneous ligature, iii. 399; enlarge-
ment of the  clitoris  and  labia, iii. 399 ;
causes of enlargement of the clitoris, iii.
399 ; treatment by  operation, iii  399;
causes of enlargement of the  labia, iii.
399; South  on  the  enlargement of the
nymphae,  iii. 400;  Astley Cooper's case,
iii, 400; treatment of enlarged  labia, iii,
400; by operation, iii.  400; South on the
removal of the enlarged nymphae  by ope-
ration, iii. 400; Warts, iii.  400; defini-
tion and  characters, iii.  400;  South on
venereal and  malignant warts, iii. 401 ;
causes of warts, iii. 401 ; treatment, iii.
401;  by external remedies, iii. 401; by
caustics, ligature,  or the knife, iii. 401;
South on  the treatment of common, vene-
real, and malignant warts, iii. 402; callo-
sities and corns, iii. 402; causes, situation,
and symptoms of callosities aind corns, iii.
402; nature of corns, iii. 402; Breschet,
Pigne, and Brodie on the nature of corns,
iii. 403; treatment by palliatives, iii. 403;
by operation, iii. 403; caution respecting
operating  on corns,  iii. 403 ; Horns, iii.
404;  situation, iii.  404;  Erasmus Wil-
son's statistical account of human horns,
iii. 404;  Astley  Cooper,  Roots,  and
South's cases,iii. 404,5; specimens in the
Museum of  the College of Surgeons, iii.
405; nature and growth,  iii.  405  ; Eras-
mus Wilson on the growth of horns from
a previously obstructed follicle, iii. 405;
proximate and immediate causes, iii. 406;
Mercier on the character of horns,  iii. 406;
nature of these growths,iii.407; treatment,
iii. 407; bony growths, iii. 407; nature and
subdivisions,iii. 408; origin and causes,iii.
409; characters of true exostosis,  iii. 408;
Jaeger and Pigne on the seat of exostosis,
iii. 408; internal condition of exostosisdii.
409; Astley  Cooper's cartilaginous exos-
tosis of the medullary membrane, iii.409;
Scarpa's exostosis maligna, iii. 409; Otto
and von  Walther's osteosteatoma,  iii.
409; Muller on enchondron, iii. 409; si-
tuation of exostosis, iii. 409; proximate
and occasional causes, iii. 409; symptoms,
iii. 410; diagnosis, iii.  410; prognosis, iii.
411;  treatment, iii. 411;  extirpation  of
the  exostosis, iii. 412; osteosteatoma and
osteosarcoma, iii. 412;  nature and causes,
iii.  412; origin  and  seat,  iii. 412;
symptoms,  iii. 413 ; treatment, iii. 413 ; 
ANALYTICAL INDEX.
847
prognosis, iii. 413; spina ventosa, iii. 414;
characters, iii. 414;  symptoms, iii. 414;
Wiseman on spina ventosa, iii. 414; origin
and causes, iii. 415; nature of the disease,
iii. 415; diagnosis, iii. 415; treatment, iii.
416;formation of tubercles in bone, iii. 416;
causes, iii. 416;  varieties, iii.  416; five
stages of encysted  tubercles, iii. 416;
gray granulations,  iii. 417; crude, en-
cysted tubercles, iii. 417; softened  tu-
bercles, iii. 417; eliminatory and repara-
tory processes, iii. 417; tubercular  in-
filtration, iii. 418; gray and purulent in-
filtration, iii. 418;  sequestration of the
affected part, iii. 418 ; diagnosis between
purulent tubercular infiltration and caries,
iii.  418; treatment, iii. 418; fungus of ihe
dura mater and of the skull-bones, iii. 419;
definition of fungus of the dura mater, iii.
419;  symptoms, iii. 419; characters and
progress of the disease when the bone is
destroyed,  iii.  419; appearances after
death, iii. 420; diagnosis, iii. 420; views
as to the origin and course of the disease,
iii.  420 ; Walther on fungus of the dura
mater, iii. 421; varieties  of fungus of the
dura  mater, iii.  422; causes, iii. 423;
treatment, iii. 424; by operation, iii. 424 ;
Walther's objections to the operation, iii.
424;  mode of operating,  iii. 424; Berard
and Orioli's cases treated  by operation, iii.
425;  Fatty  or adipose tumours, iii. 426;
origin, iii. 426; characters, iii. 426; South
on  fatty tumours, iii, 426; seat and cha-
racters of lipoma diffusum, iii.426; Brodie
and South on  lipoma diffusum, iii. 426;
characters of  fatty tumours  arising  be-
tween the two plates of  the  cellular ex-
pansion beneath the skin, iii. 426; Muller
on  the varieties of fatty tumours, iii. 427;
size and seat  of fatty tumours, iii. 428;
Astley Cooper, Copland, Lawrence, and
Portalupe's cases of very large fatty tu-
mours, iii. 428; Brodie's case of fatty tu-
mour connected  with the spermatic cord
within  the abdominal  ring,  iii.  428;
causes and seat, iii. 428; removal by ope-
ration, iii. 428; Brodie on inflammation of
fatty  tumours  running on to  abscess, iii.
429;  Brodie and Astley Cooper's opinion
that fatty tumours sometimes take on the
malignant degeneration,  iii. 429; Brodie's
case of fatty tumour partially removed by
liq. potassae, iii. 429; South on the extir-
pation of  fatty   tumours, iii.  429 ;' re-
moval of lipomata by operation, iii. 429 ;
after-treatment, iii. 429 ; use of the seton
in lipoma uncertain, iii. 429; South on the
removal of  the roots of  the tumour, and
on  the after-dressing, iii. 429; encysted
tumours, iii. 429;   definition, m.  430 ;
Hunter and  South  on   cysts  forming
around  foreign substances,  iii.  430;
varieties of encysted tumours, iii. 431;
Maunoir on simple serous cysts of the
neck, iii. 432; O'Beirne, Bransby Cooper,
Fleury, and T. Blizard's cases, iii. 432;
Brodie on  simple cysts  in the female
breast, iii. 432; Astley Cooper on cellular
hydatids of the breast, iii. 432; Home and
South  on  atheromatous cysts and  their
contents, iii. 433 ;  nature of the cyst, iii.
433; Hunter  on the  internal surface of
the cyst, iii. 433 ;  form,  characters, and
development of encysted tumours, iii.434;
inflammation and ulceration of the cyst,
iii. 434; proximate cause of encysted tu-
mours, iii. 434; sebaceous tumour on the
head,  face, etc.,  described  by Astley
Cooper, iii. 434; characters, causes, and
structure, iii. 434; Erasmus Wilson and
Astley Cooper on sebaceous tumours, iii.
435; Astley  Cooper  and South on the
cause of sebaceous tumours, iii. 435; Dal-
rymple's case of ossified encysted tumour
of the eyelid, iii. 436; ganglia, iii, 436;
characters, iii. 446; treatment of encysted
tumours, 436; by dispersion, iii. 436; re-
moval  with the knife, iii. 436;  by liga-
ture, iii. 436 ; opening the cyst, and re-
moving it by suppuration or with caustic,
iii. 437 ; treatment of encysted  tumours
with roots deeply seated among important
parts, iii. 438; of encysted tumours caused
by closure of a sebaceous follicle, iii. 438;
South  on the removal of sebaceous tu-
mours  by operation, iii. 438; treatment of
ganglions, iii. 438; by operation, iii, 439;
by extirpation, iii, 440 ;  this  operation
condemned by South, iii. 440; hydatids
iii. 440; characters, iii. 440; divisions, iii.
440 ; cysticercus cellulosae, iii. 441; seat
and  characters, iii. 441;  echinoccus ho-
minis, iii.  441; seat and  characters, iii.
441; acephalocyst, iii. 441; seat and cha-
racters, iii. 441; South's cases of acepha-
locysts, iii, 442; causes, iii. 442;  conse-
quences, iii. 442; specimens of acephalo-
cysts in the  humerus  in St. Thomas'
museum,  iii.  442  ;  treatment, iii. 442;
cartilaginoid  bodies  in joints, iii. 443;
characters, iii. 443;  symptoms, iii. 443 ;
diagnosis between these foreign  bodies
and  arthritis  or  rheumatism,  iii. 445;
causes, iii. 445 ;  mode of formation, iii.
445 ; South on the composition of foreign
bodies in joints, iii. 445 ; treatment by
bandages and .by operation, iii. 446  ; treat-
ment  preliminary to  the  operation, iii.
446 ; diagnosis between benignant and
malignant  cases, iii. 446;  mode of ope-
rating  on the knee-joint,iii. 447; South on
the mode of operating, iii. 447; Schreger's
operation on  the shoulder-joint, iii. 447; 
848                        ANALYTICAL  INDEX.
the subcutaneous section, iii. 448; Goy-
raud and Syme's cases, iii. 448; sarco-
matous tumors, iii. 448 ; characters, iii.
448; South on the two kinds of sarco-
matous   tumors, iii.   448;  Lawrence,
M'Murdo, and  Astley  Cooper's cases of
cellular membranous  tumours, iii. 449 ;
South on enlargement of the prepuce and
scrotum,iii. 449; Titley,Delpech, Liston,
and Imbert de Lonnes' cases, iii. 449;
form and growth of sarcomatous tumors,
iii. 449; microscopic characters, iii. 450;
cause, iii. 450 ; treatment, iii. 450; South
on their removal by operation, iii. 450 ;
lardaceous  tumors, iii. 450;  Boyer  on
wens, iii. 450; characters and growth,
451; termination in malignant ulceration,
iii. 451 ; appearances  of the tumor when
the parts are dissected prior to softening
and degeneration, iii.  452;  after degene-
ration has taken place, iii. 452; Heyfelder
on  the varieties founded on microscopic
examination, iii. 452; causes, iii. 452;
treatment by ablation, iii. 452 ; mode of
operating, iii. 453; Boyer on the cancer-
ous  degeneration of steatoma, iii. 453 ;
medullary fungus, iii.  453 ; synonymes,
454; characters, iii. 454; Young, Travers,
Carswell, and Walshe on the genus car-
cinoma, iii. 455 ; symptoms and situation
of medullary fungus, iii. 455;  medullary
fungus of the testicle, iii. 456; symptoms
and  termination, iii, 456;  symptoms of
medullary fungus of bone, iii. 456; Astley
Cooper on  medullary fungus of bone, iii.
457; appearances of the parts on dissec-
tion, iii. 457; chemical examination of the
brain-like  substance,   iii.  457 ;  Hecht,
Maunoir,  and  Muller on the chemical
constituents of the brain-like substance,
iii. 458; Krause on the mic'roscopic cha-
racters  of medullary  fungus, iii. 458;
Gluge on the nature of medullary fungus,
iii. 458; medullary fungus occasionally
encysted, iii. 458; characters of the brain-
like substance in medullary fungus of the
testicle, iii. 459; characters of medullary
fungus, iii. 459 ; Allan Burns and  von
Walther on the difference between fungus
haematodes and sarcoma medullare, iii.
460; Abernethy on fungus haematodes,
iii. 460; Muller on the applicability of
the term " medullary  fungus" to the dif-
ferent forms of soft cancer, iii- 461; Vogel
on the essential element  of  medullary
fungus, iii. 461 ;  Bradley, Jaeger,  and
Vogel on  the  blood  fungus, iii. 461 ;
Meckel's opinion  that melanosis is the
same  as  medullary   fungus, iii.  462;
this opinion only partially correct, iii.
462; diagnosis between medullary fun-
gus and scirrhus, iii. 463; Breschet's
different kinds of carcinoma, merely dif-
ferent degrees of development of medul-
lary fungus, iii.  464; Abernethy's  sar-
coma tuberculatum considered by Meckel
to be medullary  fungus, iii. 464;  this
opinion  incorrect, iii.  464; etiology of
medullary fungus,  iii.  464;  diathesis
fungosa, 464; seat and mode of forma-
tion of medullary fungus, iii. 464; treat-
ment of the disease almost entirely inef-
fective, iii. 464 ; early ablation of the part
or amputation of the  limb  affords the
only chance of cure, iii. 464; the disease
generally returns sooner or later, iii. 465;
polypi, iii. 465; definition and varieties,
iii. 465 ; characters of soft polypi, iii. 465;
of hard  polypi, iii. 465 ; of fleshy polypi,
iii. 465; of fibrous polypi, iii. 465; scir-
rhous degeneration  of  polypus, iii. 465 ;
symptoms of polypus, iii. 466; proximate
cause, iii. 466 ; fleshy polypi self-repro-
ducing  substances, iii. 465 ; occasional
causes, iii. 467 ; prognosis, iii. 467; treat-
ment, iii. 467; by tearing out, iii. 467;
by cutting it off, iii. 468 ; by the ligature,
iii. 468; by the actual cautery, iii. 468 ;
polypus of the nostrils, iii.  46s; origin
and  situation, iii. 469;  symptoms, iii.
469 ; varieties of nasal polypi, iii. 469 ;
malignant nasal polypi, iii.  470 ; benig-
nant nasal polypi, iii.  470;  causes, iii.
470; Schreger on  the complication of
nasal polypus with teleangiectasy, iii.
470; Richerand on the respective origins
of benignant and malignant nasal polypi,
iii. 470; prognosis, iii.  471; treatment
by local astringents, iii.  471; by opera-
tion, iii, 471; tearing away  the polypus,
iii. 471; examination  prior  to the opera-
tion, iii. 471 ;  mode of operating, iii. 472;
the  operation on large polypi, iii.  472;
operation when the polypus is rooted far
back in the  nostrils,  and hangs  down
behind  the soft palate into the throat, iii.
472; treatment  of the  accompanying
bleeding, iii.  473 ;  South  on  plugging
the nostrils, iii. 473 ; after-treatment, iii.
474 ; application of the ligature, iii. 475;
mode of operating, iii. 475; after-treat-
ment, iii. 475 ; cutting off  the  polypus,
iii. 476 ; mode of operating, iii.  476 ; ap-
plication of the actual cautery, iii. 477;
polypus  of the throat,  iii. 477 ;  seat and
symptoms, iii. 478; treatment by liga-
ture, iii. 478; after-symptoms  and  treat-
ment, iii. 478 ; polypi  of the oesophagus,
iii.  478 ; mode  of operating, iii.  478;
polypus in the maxillary sinus, iii. 478 ;
inflammation  of the mucous  membrane  of
the Highmoriancavity,\\i. 479; symptoms,
iii. 480; termination in blenorrhagia, iii.
480; symptoms of polypi, iii. 480; state of 
ANALYTICAL  INDEX.
849
the parts in osteosteatoma and osteosar-
coma, iii. 480; causes of inflammation,
iii. 480; prognosis of the various diseases
of the maxillary sinus, iii. 480; treatment
of the inflammation, iii. 480 ; when chro-
nic, iii. 481; the operation of opening the
sinus, when needed, iii. 481; situational
which it should  be performed, iii. 481;
through the tooth-socket, iii. 482;  cases
in which it should be practised, iii. 482;
South on opening the maxillary sinus, iii.
482; after-treatment, iii.  483 ; South on
the after-treatment, iii. 483 ; boring into
the maxillary cavity in the fossa canina,
iii. 483; cases requiring the operation, iii.
483; mode or operating,  iii. 483;  after-
treatment, iii.  483; cutting  away  the
polypus, iii. 483  ; the-employment of the
ligature  and tearing off the polypus, iii.
483; application of caustic, iii. 483-;  of
the actual cautery, iii. 483; boring into
the maxillary cavity below the molar emi-
nence, and above ihe third or fourth  molar
tooth, iii. 484; through ihe palate,\xi. 484
on the cheek, iii. 484; Weinhold's opera
tions, iii. 485; relative value of these ope-
rations, iii. 485;  operating on the frontal
sinus and after-treatment, iii. 486; Dupuy-
tren on eneysted cellulo-fibrous tumour of
the  antrum, and  its  treatment, iii. 486;
polypus of the womb and vagina, iii. 486;
situation and characters of the polypus of
the womb, hi. 487; symptoms and pro-
gress of the disease, iii. 487 ; of polypus
of the cervix or os uteri, iii. 488;  diag-
nosis of polypus uteri from pregnancy,
iii. 488; of polypus  protruded through
the os uteri, from eversions of the womb,
iii. 489 ; distinction to be made with dif-
ficulty, iii. 489; diagnosis of uterine poly-
pus from fungous growth, iii. 490; causes
of uterine polypus, iii. 490 ; treatment by
operation, iii. 491; by the ligature, iii. 491;
application of Desault's apparatus,iii.491;
of Nissen's instrument, iii.492; of Ribke's
instrument, iii. 492; after-symptoms and
after-treatment, iii. 493;  cutting off the
polypus,  iii. 493;  mode of operating,
iii. 494 ; polypus of the vagina, iii. 494;
causes, symptoms, and treatment, iii. 494;
polypus of the rectum, iii. 496;  situation
and characters,  iii. 496■;  treatment, iii.
496 ; Cancer, iii. 496 ; definition, iii. 496;
origin,  iii. 496;  symptoms of scirrhus,
iii. 496; progress  of the disease,  iii.
496; concealed  cancer,  iii. 496;  ulce-
rated cancer, iii.  496; -condition of the
parts in  scirrhus, iii. 497 ; in concealed
cancer, iii. 497; microscopic  elements
of scirrhus, iii.  497; Muller  on  the
four several  kinds  of   carcinoma,  in.
497; Muller on  carcinoma simplex -and
   Vol. iii.—72
fibrosum, iii. 498;  Muller on carcinoma
reticulare, iii. 498; Muller on carcinoma
alveolare, iii. 498 ;  Muller on carcinoma
fasciculatum,  iii. 498;  Dr.  Hodgkin on
the development and progress of scirrhus,
iii. 499; secondary development  of can-
cerous ulceration, iii. 501; seat of cancer,
iii.  501; difference in the progress of
cancer in different persons, iii. 501; Ali-
bert on the  varieties  of cancer, iii. 502;
diagnosis of scirrhous tumours, iii. 502;
Scarpa on the diagnosis between scrofula
and scirrhus, iii. 503;  Hodgkin on the
diagnosis between scirrhus  and medul-
lary fungus, iii. 503; Foy's analysis of
scirrhus, iii. 504;  cancer in the skin, iii.
504; origin and seat,  504; symptoms,
iii. 504; occurrence of ulceration, iii. 505;
origin of cancer in glands, iii. 505 ; cha-
racters of caneer in mucous membranes,
iii.  5Q5; caneer in the bones, iii. 505;
Characters of cancer in the nerves, iii.505;
other tumours in nerves, and their treat-
ment, iii. 506; Cheselden's cases, iii.506;
Astley Cooper's case of tumour in the
popliteal nerve, iii. 506; Liston  on tu-
mours  of nervesi,  iii.  506;  Langstaff,
South, Astley Cooper,  Cline, and  Mayo
on tumours in nerves of stumps, iii. 507;
cancer  a specific  disease, iii. 508; can-
cerous  dyscrasy, iii. 508;  predisposing
and occasional causes of cancer, iii. 508;
Hunter on the disposing cause of cancer,
iii. 508;  prognosis, iii. 509; Scarpa on
the nature of  scirrhus,  iii. 509; Travers
on the occasional  inertness of scirrhus
during life, iii. 509 ;  Brodie and South's
cases, iii. 509 ; treatment of scirrhus and
cancer, iii. 509 ; Leroy d'Etiolles on the
statistics of operations for cancer, iii 510;
treatment for  effecting  dispersion of the
tumour, iii. 510 ; Young, Recamier, and
South on-compression of scirrhus, iii. 511;
rem oval of the disease, part withthe knife
or by escharotics, iii. 512; contra-indiea-
tions, iii. 512 ; preliminary treatment, iii.
512; necessary to remove all the diseased
parts, iii. 512; destruction of a cancerous
part-by caustic,  iii. 512;  mode of apply-
ing the caustic, and the  resulting symp-
toms, iii. 513 ; Canquoin's  employment
of chloride of zinc as a caustic for cancer,
iii. 513;  Hellmund's mode of applying
Cosme's powder, iii. 514; duration of the
treatment,iii.514; symptoms occasionally
produced by the arsenical  caustic, iii.514;
internal treatment of cancer, iii. 615; ex-
hibition of narcotics  to relieve the pain,
iii. 515 ; cancer of the lips and cheek, iii.
515; seat and  characters of  cancer of
the  lip, iii.  515;' microscopic characters
•of the  disease, iii. &15^  malignant but 
850
ANALYTICAL  INDEX.
non-cancerous ulceration of the  lips, iii.
515; treatment of cancer of the lips by
extirpation, iii.  515;  contra-indications
of  the  operation, iii.  516;  mode of
operating  when  the  cancer  does  not
spread down beyond  the red part of the
lip,  516;  South  on  the  operation  in
such cases, iii. 516; the operation when
the cancer has  spread beyond  the red
edge of the lip, iii. 516;  union of the
divided parts, even when there has been
great loss of substance, iii. 517;  the ope-
ration of chiloplasty, or making a new
lip, iii.  517;  various modes of operating
for chiloplasty, iii. 518; Dieffenbach and
Blasius' operations, iii. 518; treatment of
cancer of the lip connected with the bone,
iii. 518 ; by operation, iii. 518; of cancer
of the cheek, iii. 518; cancer of the tongue,
iii. 51K; characters, iii. 518; prognosis, iii.
518 ; treatment, iii. 518; by operation, iii.
519; mode of operating, iii. 519; after-
treatment,  iii. 520; treatment of fungous
growths, iii. 520; ligature of the lingual
artery,  prior  to the  amputation of the
scirrhous portion of the tongue improper,
iii. 520; removal  of the tongue by liga-
ture, iii. 520; Mirault's operation for liga-
ture of the tongue, iii. 521; Regnoli's
operation for the extirpation of the tongue,
iii.  521 ;  Arnott's  case  of  malignant
tumour of the tongue in which that organ
was removed by ligature, iii, 521; cancer]
ofothe parotid gland~, iii. 522; diseases of
the parotid, iii. 522; characters of swelling
of the parotid, iii. 522; diagnosis between
the several tumours  of the parotid, iii.
523; treatment in scirrhus and medul-
lary fungus of the parotid, iii. 523; ex-
tirpation of the gland a doubtful remedy,
iii.  523;   arteries  in danger  of being
wounded during the operation, iii. 524;
Allan Burns on extirpation of the parotid,
iii. 524;  mode of operating for extir-
pation  of the parotid, iii. 524;  Goodlad j
and Langenbeck on the prior ligature of I
the carotid, iii. 525; after-treatment, iii. i
525 ; cancer of the breast, iii, 525 ; symp-
toms,  character and  progress, iii. 526 ;
Brodie and  South  on  scirrhus  of the
breast,  iii.  527; characters of scirrhus and
cancerous ulceration of the breast, iii. 527;
development  of cancer  of the breast as
skin cancer,  527; characters of  cancer
of the  areola, iii,  528;  of cancer of the
nipple, iii. 528; Astley Cooper on fungous
degeneration of the nipple, iii. 528; Astley
 Cooper on the development of the nipple
 in the foetus and its subsequent changes,
iii. 528; Brodie on scirrhous of the nipple,
iii.  529;  symptoms  of  cancer  of the
breast,  iii.  529; of acute cancer, iii. 529 ;
of chronic cancer, iii. 529 ; Brodie on the
puckering in of  the skin  in  mammary
cancer, and on its cause, iii. 529 ; appear-
ance of scirrhus when cut into, iii. 529;
diagnosis between scirrhus and chronic
inflammation of the lymphatic Vessels, or
of the breast-gland, iii. 530 ;  symptoms
and treatment  of the  inflammation, iii.
531; symptoms and  characters of milk-
knots, iii. 531; malignant  appearance of
rnilk-knots in old women, iii. 532; Scarpa
and South's cases of lacteal swelling, iii.
532;  diagnosis between  scirrhus  and
scrofulous tumours of the breast, iii. 533;
and herpetic and psoric affections, iii. 533;
and encysted tumours, iii. 533; characters
of vesicular scirrhus of the  breast, or car-
cinoma mammae hydatides, iii. 533; this
disease a steatomatous degeneration of the
gland, iii. 533;  Astley Cooper on hydatid
swellings of  the breast, iii. 534;  Astley
Cooper on the symptoms and treatment
of cellulous hydatids  of the breast, iii.
534;  Astley Cooper on polypoid hydatids
of the breast, iii. 535;  Astley  Cooper on
the lobular hydatids of the breast, iii. 535;
Brodie on the serocystic tumours of the
female breast, iii. 535 ; characters of me-
dullary fungus of the breast, iii. 536; of
the blood-swelling of the breast, iii. 536;
ecchymosis of the breast in girls prior to
menstruation, iii. 537;  characters of hy-
pertrophy of  the female breast, iii.  537;
anatomical appearances  of  the  hyper-
trophied breast, iii. 538; causes, iii. 538;
treatment, iii.  538;  causes of scirrhus
of the  breast, iii.  538; prognosis, iii.
539;  the question  as  to propriety of
removing a scirrhous breast, iii. 539 ; opi-
nions of  Cline, Home,  Astley Cooper,
Brodie, and South, iii. 539; Brodie on the
circumstances  permitting the operation,
iii.  539;  extirpation of the  breast, iii.
539;  mode of operating, iii. 541; South
on the position of the  patient during the
operation, iii. 541; South's case of fatal
venous hemorrhage from the extirpation
of the breast, iii. 541; South on the after-
treatment, iii.  541; amputation  of the
breast, iii. 542; South's opinion that ampu-
tation is not preferable to extirpation, iii.
542; relative value of these operations, iii.
542; requisite to  remove all diseased
structures, iii.  542; operation for relapse
of scirrhus after  the removal  of the dis-
ease, iii. 513; cancer of the penis, iii. 544;
origin,  symptoms, causes, and  results,
544; diagnosis, iii. 544; treatment, iii. 544;
by  operation, iii. 544; amputation of the
penis, iii. 544; South on  the recurrence of
cancer after amputation  of the penis, iii.
544; Cline  the younger's  case, 544; 
ANALYTICAL  INDEX.
S51
examination of the organ preliminary to
the operation, iii. 544; amputation of the
penis by the knife, iii. 545; of the glans
alone, m. 545; in the middle of the organ,
in. 545 ; Schreger's mode of amputating
the penis near the pubic bones, iii. 545;
Langenbeck's operation, iii. 545; Barthe-
lemy on the means  of preventing the
retraction of the urethra, iii. 545; occur-
rence of after-haemorrhage, and its treat-
ment, iii. 545 ; after-treatment, iii.  546 ;
amputation of the penis by ligature, iii.
546; relative value of the two operations,
iii. 546; South on the relative value of the
two operations, iii. 546 ;Lisfranc's opera-
tion for the removal of cancer of the cor-
pora  cavernosa, iii.  546 ;  cancer of the
testicle, iii. 547; definition of sarcocele,
iii. 547; symptoms and progress of scir-
rhus of the testicle, iii. 547; characters and
appearances of sarcomatous degeneration
of the testicle, iii. 548 ;  these diseases
occasionally  complicated with  hydro-
cele, iii. 548; diagnosis of scirrhous and
sarcomatous degenerations of the testicle
from other swellings of  that organ, iii.
548; from thickening of thecellular tissue
of the scrotum, iii. 548 ; characters and
causes of that disease, iii. 549; treatment,
iii. 549 ; by operation,  iii. 549 ;  Liston,
Key, O'Ferrall,  and Bennett's cases of
sarcomatous scrotum, iii.  549;  diagnosis
of sarcocele, from simple hydrocele, iii.
553; from cystic swelling of the testicle,
iii. 553; characters  and appearances of
cystic swelling, iii. 553;  Astley Cooper
on the nature of the cyst in cystic swell-
ing, iii. 553 ; removal of  the disease by
operation, iii. 553; hydatids of the  testi-
cle, iii. 553 ; diagnosis  of sarcocele from
thickening of the tunica albuginea, iii.
553;  scirrhus of the tunica  albuginea,
551; diagnosis of sarcocele from fungus
of the testicle  or tunica albuginea, iii.
554; from induration of the testicle, iii.
554; from scrofulous swellings, iii. 554;
from  syphilitic swellings, iii. 554;  from
medullary fungus, iii.  554; extirpation
of the testicle a doubtful  remedy in can-
cerous degeneration, iii. 555; indications
and  contra-indications  of the  operation,
iii. 555 ; Walther and  Maunoir on liga-
ture of the spermatic artery in  sarcocele,
iii. 555; mode  of  operating, iii.  555;
mode of operating for  extirpation of the
testicle,  iii. 556; Aumont's operation, iii.
556; South and Astley Cooper on there-
traction of the cord during the  operation,
iii. 556; degeneration  of the  spermatic
cord, and the  operation, iii. 557;  South
and  Cline  jun. on ligature of the  sper-
matic cord, iii.  557;  dressing the wound,
and subsequent  treatment  after extirpa-
tion, ii. 557; treatment of after-haemor-
rhage, iii. 557; treatment of undescended
testicle, iii. 557; by operation, iii. 557; ex-
tirpation of undescended testicle, iii. 558;
South on the treatment of undescended
testicle, iii. 558;  Paget and Arnott's cases
of diseased undescended testicle, iii. 558;
cancer of the  scrotum, iii. 559;  characters
of chimney-sweep's cancer, iii. 560; Pott
and Paris on cancer of the scrotum, iii.
560; Earle's case of chimney-sweep's can-
cer on the wrist, iii. 560; Astley Cooper
and Keate'scase ofchimney-sweep's can-
cer on the cheek, iii. 560; Earle and South
on  the extension  of the disease  to the
neighbouring parts, iii.  560; Travers on
the resemblance of the  disease to  lupus,
iii. 560; cause  and treatment, iii. 560;
South on the  cause of the disease, iii. 561;
Pott and Earle on the age at  which the
disease generally occurs, iii. 561; South's
case of recurrence of the disease, iii. 561;
cancer of the  womb, iii. 561 ; origin of the
disease, and  primary symptoms, iii. 562;
indications on vaginal  examination, iii.
562;  Montgomery  on the  origin  of the
disease in the ova Nabothi, iii. 562; pro-
gress of the disease, iii. 562; resultsof the
vaginal examination in the advanced state
of the disease, iii. 562;  Ashwell, Bayle,
and Cayol on the pain in cancer uteri, iii.
562; Montgomery and Ashwell's cases of
cancer uteri,  iii.  563; diagnosis, iii. 563;
Simpson on cauliflower excrescence from
the os uteri, iii. 563;  period  of  life  at
which cancer uteri is generally developed
iii 564; causes,  iii. 564; Ashwell  on the
period of life at which cancer uteri  is
developed, iii. 564; treatment, iii. 564; by
internal and  external treatment, iii. 564;
can only be palliative in true scirrhus, iii.
564;  examination of the parts  in  cancer
uteri  by the  speculum,  iii.  565;  mode  of
introducing the speculum, iii. 565;  Simp-
son on the mode of using  the speculum
vaginae, iii 565;  Osiander on the extirpa-
tion of the cancerous neck of the womb,
iii. 566; mode of operating, iii. 566; Du-
puytren's operation, iii.  566; Canella and
Hatin's specula vaginae,iii. 567; von Wal-
ther's case of excision of the cervix uteri,
preceded by  excising the pubic arch, iii.
567; Recamier's operation when the neck
of the womb is softened or destroyed, iii.
567;  Lisfranc's  operation, iii. 567 ; Co-
lombat's hysterotome, iii. 567; destruction
of the degenerated womb by caustic, iii.
567;  Mayor's ligature of the neck of the
womb, iii. 567; mode of applying caustic-
potash to  destroy  the  cancerous  cervix
uteri, iii. 567 ; cases in which this pror- 
852                        ANALYTICAL INDEX.
  ceedingis applicable, iii. 568; extirpation
  of the whole womb, iii. 568; Struve, Gut-
  berlat, and Wenzel on extirpation of the
  womb, iii. 568 ; Langenbeck and Land-
  Wolfs cases  of extirpation of the can-
  cerous womb, iii. 569; Recamier's cases
  of removal of the womb by ligature, iii.
  569;  Sauter's directions for the operation
  of extirpation, iii. 569; dressing and after-
  treatment, iii; 570; von Siebold, Langen-
  beck, Paletta, Holcher,  Blundell, and
  Banner's cases,iii. 570; Delpech, Dubled,
  and  Recamier on  the  extirpation of the
  womb, iii. 572; Roux' cases, iii. 573; the
  difficulty and danger of the operation, iii
  577; Gendrin's directions for the opera-
  tion, iii. 577; Heath's case of excision of
  the uterus by the abdominal section, iii.
  578.
GRUiTHUiSEN'sopinionrelative to the forma-
  tion of pus, i; -46;  microscopic tests for
  pus and  mucus, i.  56; lithotritie instru
  ments, iii. 319.
Guattani's  plan of  treating aneurism by
  compression,  ii; 481.
Guerin on the causes of congenital dislo-
  cation, ii.  207 ; case of congenital dislo-
  cation of  the lower jaw, i. 211 ; on'the
  reduction  of  congenital  dislocation  of
  the femur, i, 245; case's of successful re-
  duction, ii. 245; mode of proceeding in
  effecting the reduction, ii. 245; on local
  anodyne applications in strangulated her-
  nia,  ii.  292;  sub-cutaneous  incision of
  the abdominal ring in strangulated her-
  nia,  ii.  303;  on the condition  of the
  muscles in curvatures, ii.  419;  of the
  contracted muscles in  spinal curvature,
  ii, 439 ; on the section of the tendo Achil-
  lis in club-foot, ii.  453;  on the applica-
  tion of pounded'ice  to  aneurisms, ii.
  480.
Gutberlat on extirpation of the womb, iii.
  567.
Gueterboce on the chemical and micro-
  scopic characters of pus, i. 46; on the
  compositionand chemical analysis of pus,
  i. 52;  discovery of pyine, i. 52; dis-
  covery of  the difference in size of-the
  pus-globules, i. 52.
Guersant,  on  the  furoncle atonique,  i.
  152; cases of gangrene of the tonsils, i.
  159.
Guillard's case of  reduction of a conge-
  nital dislocation of the humerus  after a
  lapse of sixteen years, ii. 228.
Guillebonneau on  the operation  for the
  treatment of lacerated perineum, ii. 38;
  on the application  of the  sutures, ii. 38.
Guillemeau on tying the tonsils, i.  164.
Gulliver on the distinction between the
  lymph-corpuscles and. the exudation-cor-
  puscles, 46; on the putrefaction of pus,
  i. 51; denies the occasional occurrence of
  pus-globules in healthy blood, i. 53 ; on
  thickening and induration of the cellular
  tissue of the ankles and  feet in soldiers,
  i. 120; on indnration and rigidity of the
  cellular tissue of  the ankles and feet in
  soldiers, without  thickening, i. 121; on
  interstitial absorption in the neck of the
  femur from external violence, i. 619; on
  the union of fractured patella, i. 632.
Gunning on immediate amputation in gun-
  shot  wounds, i. 381; case of recurrence
  of the aneurism, after the ligature of the
  artery, iii 499.
Gun-shot-wounds, i. 370; definition, i. 370;
  John Huriteron gun-shot wounds; i. 370;
  Dupuytren on the effects of gun-shot, i.
  370; Dupuytren's case of a person killed
  by a  gun loaded with powder only, i.
  371 ; South's case of severe injury from
  small shot* i. 371; pain and haemorrhage
  attendant on  a gun-shot wound, i. 372;
  form of the wound, i. 372; shock from
  the wound, i. 372;  subsequent symp-
  toms, i. 372; Guthrie on the pain attend-
  ing gun-shot wounds, i. 372 ; Guthrie on
  the attendant haemorrhage, i. 372; Guthrie
  and  Hennen  on  the shock caused by a
  gun-shpt wound, i. 373 ; Hunter on the
  character of gun-shot wounds, i. 373 ; H.
  Larrey7 s casesof regular-shaped gun-shot
  wounds, i. 373; direction of  the shot, i.
  373 ; general kinds of injury from shot
  wounds, i. 373 ; division of shot wounds
  into simple and complicated,!. 373 ; Rust
  and Busch's explanation of wounds from
  the wind of the ball, i. 374;  Hennen on
  severe bruising from shot, i. 374; Guthrie
  on the appearance caused by the passage
  of a  ball, i. 374; Dr. Thompson and Du-
  puytren on the splitting of the ball by the
  sharp edge of a bone, i. 374,375; Guthrie
  on the resistance  offered to the passage of
  the ball by bone  or an elastic body, i.
  375 ; shot wounds generally complicated
  by foreign bodies in their cavity, i. 375';
  prognosis, i. 375; indications oftreatment,
  i. 375; circumstances under which  the
  enlargement of the wound may be neces-
  sary, i. 375; Hennen on the treatment of
  wounds by a bajl in the fleshy part of the
  arm, thigh, or buttock, i.  376; general
  and  local treatment, i. 376; occurrence of
  suppuration, i. 376; of secondary haemor-
  rhage, i. 376; Guthrie, Samuel Cooper,
  and Dupuytren  on  secondary haemor-
  rhage, i. 377; local and general treatment
  during suppuration, i. 377 ; Hennen and
  Dr.  Arthur  on  the  use of the  seton to
  bring away separated pieces of bone, i.
  377; Staff-Surgeon Boggie's cases, i. 377; 
)AL INDEX.                      85$
                            ANALYTIC

 treatment of shot wound complicated with
 fracture, i. 377;  Hennen on the occur-
 rence of necrosis in gun-shot injuries of
 bones, i. 378; bleeding from the whole
 surface of the wound in long-continued
 suppuration, i. 378 ; the circumstances in
 gun-shot wounds requiring amputation on
 the spot, i. 378 ; Hennen on the nature of
 the injuries in gun-shot wounds requiring
 amputation, i. 379 ; amputation, under the
 circumstances mentioned^ should be per-
 formed early, i. 379 ;Wiseman, Le Dran,
 and Ranby on immediate amputation, i.
 380; Faure on the propriety  of  delay-
 ing the operation, i. 381;. Bilguer's ob-
 jections to amputation altogether, i. 381;
 Hunter's  objections to primary amputa-
 tion, i. 381; Hennen, Pitcaim, Gunning,
 and Guthrie on immediate amputation,
 i. 381 ; Guthrie's reasons for an early per-
 formance of theoperation, i. 382 ; symp-
 toms which may require the performance
 of amputation at a time more or less pos-
 terior to the date of the injury, i. 383.
Gunther's treatment of fractured sternum,
 i. 598; on the condition of the muscles
 in snake-like scoliosis, ii. 430.
Guthrie on the after-management of liga-
 tures on arteries, i. 338; case in which a
 ligature remained on  the brachial artery
 for four months after amputation, i. 339 ;
 on the pain attending gun-shot wounds,
 i. 372 ; on the attendant  haemorrhage, i.
 373 ; on the shock caused by a gun-shot
 wOund, i. 373; on the appearances caused
 by the passage of a ball, i. 374;  on the
 resistance offered to the  passage  of  the
 ball by bone, or an elastic body, i. 375;
 on secondary'haemorrhage, i. 376;  on
 immediate amputation, i. 381; reasons
 for an early performance of the operation,
 i. 382; on bruising or destruction of the
 periosteum, not necessarily followed by
 exfoliation or death of the  bone, i. 425;
 on the difference  between the primary
 and secondary swellings, i. 425; on cold
 lotions in bruises of the scalp, i. 426 ; on
 the  existence of  pus  beneath the dura
 mater, i. 426;  on  fracture of the inner
 table of the  skull from  the  blow of a
 sword, axe, or otheT clean-cutting instru-
 ment,  i. 430; cases of fatal  perforation
 of the orbitar plate of the frontal bone, i.
 436; on stertor an uncertain sign of com-
 pression, i. 444; on a peculiar whiff or
 puff from the corner of the  mouth a sign
 of compression, i.  444; on inversion of
 the  foot in fracture of the neck  of  the
 femur, i. 619; on the duration of syphilis
 under  the  non-mercurial treatment, and
 on the subsequent occurrence of  secon-
 dary symptoms, ii. 103; on the treatment
  of vesico-vaginal fistula by compression
  with a sponge, ii. 189; cases of disloca-
  tion of the astragalus outwards, ii. 252;
  on the predisposing causes of aneurism,
  it. 475;  on  the  relative  frequency  of
  aneurism' in the sexes,  ii.  475; on the
  return of the  pulsation in  the  aneurism
  for a short time, after the ligature of the
  artery, ii. 498 ;  on ligature of  the aorta,
  ii. 532; mode of amputating at the hip-
  joint,  iii.  698;  on gun-shot wounds,
  causing fracture of the humerus beneath
  and external to the capsular ligament, iii.
  718; case-of excision of part of the hand,
  iii. 722;  on the excision  of joints, iii.
  726.
Guyot's apparatus for fracture of the neck
  of the femur,  i.  623.
Haar, van der, on the lengthening of the
  limb-in hip disease, i. 285;  on the dis-
  location of  the head of  the thigh-bone
  downwards, and inwards in hip disease,
  i. 287; on the treatment of abscesses at
  the hip, i. 298.
Hachmann on spontaneous inversion of the
  womb from  spasm, ii* 383;
Hacker  on the hydriodate of potash in
  syphilis, ii.  101.
Haen's, De, opinions relative to the  for-
  mation of pus, i. 46; On the lengthening
  of the limb in hip disease, i. 285.
Hagedorn's apparatus for fracture of the
  neck of the  femur,  i. 623; preferred by
  Chelius, i. 625 ;  on permanent extension
  in  fracture of the femur, i. 628.
Hagen's case of reduction of the consecu-
  tive dislocation in hip disease, i. 297.
Hager's fracture-bed,  i. 625 ; on the upper
  and  lower ischiatic ruptures, ii. 351 ;
  mode of operating  in exarticulations of
  the fore-arm at the elbow, iii. 719.
Hahn on the in-locking of the broken ends
  of the bone in fracture of the neck of the
  femur,  i. 618.
Haighton's experiments on the simulta-
  neous division of  both  pneumo-gastric
  nerves, i. 365.
Hai're on the after-management of ligatures
  on arteries, i. 338.
Hall's, Dr. Marshall, operation for pro-
  lapsus  uteri, ii. 379.
Halpin, Dr., on the reduction of the retro-
  verted womb, ii. 412.
Hammond's  case of  exarticulation of  the
  astragalus, iii. 703.
Hancock's case of dislocation of the  os
  calcis, ii. 255.
Hand, fracture of the bones of, i. 615; dis-
  location of, ii. 233;  curvature of, ii. 463;
  permanent bending of, ii. 464; permanent
  straightening of, ii. 464; artificial, iii. 
854
ANALYTICAL INDEX.
  595;  exarticulation of, at the wrist, iii.
  720.
Handyside's, Dr., mode of amputating at
  the ankle-joint, iii. 702.
Hankel's case of dislocation of the ribs,
  ii, 216.
Hanney on the treatment of fissured nip-
  ples, i. 419. !.
Hard on tying the tonsils, i. 164.
Hardening.   See Induration.
Harder on the action of the poison of hy-r
  drophobia on the  system,, i. 409; on the
  stanching the bleeding from a wounded
  intercostal artery, i.. 492.
HArdwicke's case of fracture through the
  body  of a vertebra, i. 589.
Hare-lip* ii.  21;  nature,  situation, and
  complications, ii. 21; South on hare-lip
  not a  complete  impediment to sucking,
  ii/22; causes, ii. 22;  occasional absence
  of the olfactory nerves, ii, 22; Pigne on
  the direction and position of natural and
  acquired  hare-lip,  ii.  22; cure of hare-
  lip by operation, ii.22;. occasional closure
  of the cleft palate after the operation for
  hare-lip,  ii. 22;  period  at  which, the
  operation  should be performed, ii. 22;
  removal of projecting  bone or teeth prior
  to the operation, ii. 22 ; Lawrence, Mut-
  ter, and South on the  period  at which
  tbe operation should be performed, ii. 23;
  South  on  the removal of the projecting
  teeth  prior to the  operation, ii. 23 ; de-
  scription of the Operation, ii. 23;  South
  an the positionof the child's head during
  the operation, ii. 23; Lawrence on the
  use of scissors with knife edges in the
  operation, ii. 23;  South prefers the bis-
  toury, ii. 24; stanching the bleeding, and
  application of the sutures or hare-lip pins,
  ii. 24; Dieffenbach, Mayor, Lawrence,
  and South on the sutures in the operation
  for, hare-lip,,ii. 25;  treatment after, the
  operation, ii.. 25; South on the rarity,of
  Weeding after the operation, ii. 25 ; South
  on the time  the pins should be left, and
  on their removal, ii. 26 ; subsequent treat-
  ment, ii. 26; tearing out of the needles,
  ii. 26 ; Van Onsenoort's plan to prevent
  the needles tearing out, ii. 26; South on
  the tearing  out of the needles, ii. 26;
  treatment  of double  hare-lip,  ii,..26;
  treatment  of cleft in, the  hard  palate,
  ii. 26 ; Mutter on. the advantages of ope-
  rating early in hare-lip and  cleft palate,
  ii. 26; Mutter on  the treatmentof cleft
  palate after  the operation for hare-lip, U
  27; South and Mutter on the use  of.ob-
  turators in cleft, palate, ii. 27 ; operation
  for cleft in the  hard palate, ii. 27;  Met-
  tauer's and Mutter's operation of staphy-
  loplasty by granulation, ii. 27;  descrip-
  tion  of the operation, ii.  27; Mutter's
  successful operation in a case of loss of
  substance in the hard palate from chronic
  mercurial disease, ii. 28; cleft in  the soft
  palate, ii. 29;  not unfrequently  an ori-
  ginal malformation, ii. 29;  often con-
  nected with cleft in the hard palate, and
  with hare-lip, ii.  29 ;  consequences of
  cleft in the soft palate, ii. 30; inutility of
  artificial palates,  ii. 30; use of elastic
  obturatorswhen the cleft cannot be united,
  ii.: 30 ; cure of cleft in the soft palate by
  staphyloraphy, ii. 30; the operation first
  proposed by Graefe, ii. 30; the operation
  applicable in  other diseased states of the
  soft  palate, ii. 30;  Ebel and Graefe's
  preparation of the parts for the operation,
  ii. 30; description  of  the  operation,  ii.
  30;  Le  Monnier's operation of staphy-
  loraphy, ii. 31;  Colombe's experiments
  on the  dead body, ii. 31; artificial means
  not necessary to keep the mouth open and
  press down the  tongue, ii. 31;  Graefe,
  Roux, Ebel,Krimer, Dieffenbach, Berard,
  and Alcock on the removal of the edges
  of the cleft,  ii. 31; application  of the
  sutures,  ii. 31 ;  Graefe,  Roux,  Ebel,
  Doniges, Warren, Wernecke,  Lesenberg,
  and  Krimer's plans, for   bringing the
  edges of the  cleft together, ii. 32; Wer-
  necke* Ebel,  and  Doniges' instruments
  for drawing the knots, ii.  32; Dieffen-
  bach's  mode of uniting the cleft, ii. 32;
  Htuby's palate-holder, ii. 33;  Schwerdt's
  cleft needle for the introduction of the
  thread, ii. 33; Berard's mode of passing
  the needle, ii, 33;  Smith's lance-shaped
  notched needle, ii. 33; objected to  by
  Matter, ii. 33;  Alcock,  Hartig, and
  Liston's mode of operating, ii. 33 ; Fer-
  gusson's new mode of staphyloraphy, ii.
  33; when the cleft is very  large,  inci-
  sions on  each side of it necessary to re-
  lieve the tension, when the operation has
  been performed, ii.  34;  Bonfils, Roux,
  Krimer, Dieffenbach, and Warren's ope-
  rations, ii. 34; treatment after operation,
  ii, 34; Graefe-and  Dieffenbach  on the
  after-treatment, ii. 34; Roux and Berard's
  fatal cases from  pneumonia, ii. 34; treat-
  ment of  the  cleft if union do not take
  place, or is only partial, ii. 35; Dieffen-
  bach's mode of closing the  fissure which
  sometimes remains after the operation, ii.
  35;  the alleged  disadvantages  of the
  lead wire introduced by Dieffenbach, not
  real, ii. 35;. subsequent education of the
  voice,  ii. 35.
Harless' case of reduction of the consecu-
  tive dislocation in hip-disease, i.  298.
Harris'  operation for enlargement of the
  tongue, iii. 384.... 
ANALYTICAL INDEX.
855
Hartig's  mode of operating in staphylo-
  raphy, ii. 33.
Hartwig's apparatus  for  fracture of  the
  lower jaw,  i. 580.
Hasse on the  formation of new vessels, i.
  324.
Hasselberg  on hydriodale  of, pptash,.in
  syphilis, ii. 101.
Hatin's speculum vaginae, iii. 567.
Havers, Clopton, on  the mucilaginous
  glands, i. 237.
Haymann's operation for resection of the
  scapula, iii. 762.
Hayward's, Dr., employment of ether by
  inhalation  prior to the  performance of
  important surgical operations, iii. 786.
 EIead, Wounds of the :—should  be con-
  sidered in a double point of view,  as re-
  gards the direct and  consecutive  affec-
  tions, i. 421; general treatment of simple
  injuries, i.  422; wounds of the  aponeu-
  rosis of the skull and pericranium, com-
  plicated with an elastic* reddish swelling,
  and followed by erysipelas, i. 422;Jreat-
  ment, i. 422; flap-wounds of the coverings
  of the skull, i. 422; South on the non-
  necessity for sutures in wounds.of the
  scalp, i. 423; bruises of the coverings of
  the skull, i. 423; South on bruises of the
  coverings of the skull, followed by collec-
  tions of fluid blood, i. 423; symptoms of
  bruises of the skull, i. 423;,post-mortem
  appearances, i. 423; Pott  on the  puffy,
  circumscribed, indolent  tumour of the
  scalp, indicative of suppuration between
  the dura  mater and the  skull, i. 424;
  Dease refers the principal cause of disease
  in these injuries, not to inflammation and
  suppuration of the dura mater, but to
  injury of the pia mater and brain, i. 424;
  Dease on the cases in which the cranium
  is laid bare, contused, or its tables simply
  divided, i.  425; Guthrie on bruising or
  destruction of the periosteum, not neces-
   sarily followed by exfoliation or death of
   the bone, i. 425 ;  Guthrie  on  the  differ-
  ence between the primary and secondary
  swellings,!. 425 ; treatment of bruises of
   the skull, i. 426;, treatment of the subse-
   quent inflammation, :and compression of
  the brain from suppuration on its surface,
  &e., i. 426 ; South on poultices in bruises
   of the scalp, i. 426 ; Guthrie and Hennen
   on  cold lotions  in  that injury,, i. 426;
   South on the treatment when inflamma-
   tion of the  dura mater has set in, i. 426;
  Dease's rules for the  application  of the
   trephine, i. 426; Guthrie on the existence
   of pus beneath the dura  mater, u 426;
   Dease  on  puncturing  the dura  mater,
   when pus is not found between it and the
   skull, i. 426;  cuts of the skull, i. 426;
Hennen and Thomson on  sabre-wounds
of the  head, i. 427; superficial wounds
caused by a sharp instrument penetrating
to the diploe, or  through the inner table
of the skull, i. 427; similar wounds made
with a blunt instrument, and accompanied
with splintering  of the bone, i.  427;
Hennen's cases of sabre-cuts  of the head,
i. 427; Thomson  on sabre-cuts  of the
head and neck, and  the in-frequency of
hernia  cerebri, i. 428 ; Fractures  of the
Skull,  i. 428;  clefts or fissures,  429;
counter-clefts  and  counter-fractures,  i.
429;  Pott  on the  symptoms  accompa-
nying fracture of the skull, not depending
on the  injury to the bone, but from injury
to the  brain, or  some of the parts con-
tained  in the cranium, i.  429; indications
of fracture of the skull, i. 429; South on
bleeding, at the ears a sign  of fracture
at the base of the cranium, i.  429 ;  imme-
diate results  of fracture of the skull, i.
429;  Guthrie on  fracture of  the inner
table of the skull from the blow,of a sword,
axe, or other clean cutting instrument, i.
430; the danger of clefts and  fractures
of the skull  much exaggerated, i. 430;
South on the non-necessity for the trephine
in general, i. 430 ; fracture  of the skull
with impression, i. 430;  indentation  of
the skull, i. 431; effects  of indentation of
the skull, i.-. 431;  Green's case of inden-
tation  of the skull  in a child,  i. 431;
Astley Cooper and South on fracture of
the frontal sinuses, i. 431; Astley Cooper
and South  on apparent  fracture and de-
pression of the  skull, i.  431;  fractures
with impression of the skull require im-
mediate trepanning, i. 431; South, Astley
Cooper, and Abernethy on the treatment
of simple fracture with  depression with-
out the trephine, i. 432; Dease's objec-
tion to the use of  the trepan in  simple
fractures, i. 433;  in simple depressed
fracture, with decided symptoms of pres-
sure on the brain, trepanning should  be
performed^ i. 433; Astley Cooper on the
necessity, for raising or removing the de-
pressed  bone in compound  fracture,  i.
433;  Hennen does not coincide  in this
opinion, and  gives  cases of  musket-shot
wound of the skull in illustration, i. 433;
separation.of the sutures of  the skull  by
violence, i. 434; the severity of the vio-
lence  causing injury of the  skull an im-
portant, point in determining the danger,
i. 434 ; Hennen, on gun-shot wounds of
the  skull, and their effects, i. 434 ; Dr.
 Cunningham's case of compound fracture
 of the skull, and lodgment of the breech
of a pistol within the  cranium,  i. 434;
 Astley Cooper's case of the lodgment of a 
856
ANALYTICAL INDEX.
 ball in the  frontal  sinuses, i. 435; Dr.
 O'Callaghan's case of the lodgment of a.
 foreign body in  the  frontal  sinuses, L
 435 ;  injuries of the brain and its mem-
 branes, i. 436; Hennen  on perforations
 of the skull by bayonet-thrusts, i. 436 ;
 Astley Cooper's case of fatal  perforation
 of the orbitar plate of the frontal bone, i.
 436;  Guthrie's cases of fatal  perforation
 of the orbitar plate of the frontal bone, i.
 436; South  on the importance of caution
 in the prognosis of  wounds of the orbit,
 i. 437;  Dr.  Congreve Selwyn's  case of
 recovery from wound of the brain, i. 437;
 the first indication in injuries of the brain
 and its  membranes, is to search  for and
 withdraw all  foreign  bodies, i. 438;
 Astley Cooper, Brodie, Hennen, Larrey,
 and Percy  on  the removal  of  foreign
 bodies in injuries of the brain, i. 438 ;
 Lawrence's  case-of  pistol-shot wound of
 the brain, i.  439 ; Cline jun. and Astley
 Cooper on puncturing the brain in wounds
 of  the  dura mater, i, 439;   treatment
 during suppuration, i. 439 ; treatment of
 abscess of the brain, i. 439 ;  South on the
 propriety of  openingabscess of the brain,
 i. 439 ; La Peyronie's case  of abscess of
 the dura mater,  i.  439; Dupuytren's case
 of abscess of the brain, successfully open-
 ed, i. 439; consequences of foreign bodies
 remaining in the brain, i.  440  ; South on
 the consequencesof foreigubodies remain-
 ing in the brain, i. 440; Langlet'scase of
 a ball remaining in the brain for eighteen
 months, i. 440 ;  inflammation of the brain
 and its membranes, i. 440 ; causes, i. 440;
 symptoms and post-mortem appearances
 of acute inflammation of the dura mater,
 i.440 ; symptoms of chronic inflammation
 of the dura mater, i 440 ; AstleyCooper's
 case of chronic-inflammation of the dura
 mater, i. 441; South on chronic inflam-
 mation of the dura mater, i. 441; symp-
 toms  and post-mortem  appearances of
acute  and chronic inflammation  of the
brain,i. 441 ; abscess of thebraih, i. 442;
 Green's case of sympathetic abscess of the
brain, with irritation and  suppuration of
the dura mater, i.,442; Prochaska's case,
i. 442;  prognosis and  treatment  of in-
 flammation of the  brain, i. 443; South on
 mercury in the treatment of inflammation
 of the brain, i. 443;  if  the  symptoms
continue, trepanning must be had recourse
 to, i. 444; if symptoms of suppuration
 occur, prognosis very unsatisfactory,  i.
 444;  trepanning  advisable under such
circumstances, i.  444; great  care and
 watchfulness requisite in every injury of
 the head, to  guard against the insidious
 inflammation of the brain which occurs at
 a later period, i.  444; inflammation of
 the brain  sometimes  simulated by the
 effects  of impurities in the  bowels, i.
 444.—Pressure  on the Brain,  i. 445;
 causes,  i.  445;   symptoms,  i. 445;
 Guthrie on* stertor an uncertain sign of
 compression, i. 445; Guthrie  on a pecu-
 liar whiff or puff from the corner of  the
 mouth  a  sign  of compression, i. 445;
 prognosis  i.  446;  treatment,  i. 446;
 South on mercury in compression, i. 446;
 removal of  extravasated blood either by
 absorption or trepanning, i. 446; signs
 indicative of the propriety of trepanning,
 i. 447; removal of the extravasation after
 the performance of the operation, i. 447 ;
 South on the removal of the extravasated
 blood after the operation, i. 447 ;  South,
 Pott, and  Brodie on puncturing the dura
 mater, when the extravasation lies beneath
 it, i. 447;  Pott on the  extravasation  be-
 tween the meninges  or on the  surface of
 the brain, L 447;  Chevalier and Ogle's
 cases, i. 447;  Hunter,  Astley  Cooper,
 Abernethy, and Lawrence on puncturing
 the dura mater to evacuate the effused
 blood, i. 448;  South on the operation of
 trepanning to remove  effused blood, i.
 448;  Concussion of the Brain, i. 449 ;
 symptoms, i. 449  ; Astley Cooper and
 South on the state of the pulse in concus-
 sion, i. 449 ; Astley Cooper and Larrey's
 cases of loss of memory, &c,  after con-
 cussion, i. 450; Hennen on the loss of
 certain faculties from concussion, i. 450;
 Astley  Cooper  on the  condition  of  the
 alimentary canal and bladder during con-
 cussion, i. 450 ; the diagnosis of concus-
 sion from compression,!. 451; concussion
 and compression may occur together, i.
 451;  difficult  to  distinguish  between
 drunkenness and concussion or compres-
 sion, i. 451; in drunkards  delirium tre-
 mens may succeed concussion,  i. 451;
 inflammation of the brain  may be con-
 nected with concussion, i. 451  ; primary
 and consecutive changes in the brain from
 concussion,  i.  451; Dupuytren distin-
 guishesbetween commotion and contusion
 of the brain, i. 451; Walther and Astley
 Cooper on the symptoms of laceration of
 the brain, i.  451; Astley Cooper on  the
 condition of the brain in moderate con-
 cussion, i. 451; causes of concussion, i.
 451; Astley Cooper on the causes of con-
 cussion, i. 452; Schmucker's case of con-
 cussion, i. 452 ; prognosis,  i. 452 ; treat-
 ment, i. 452; South on the treatment of
 concussion, i. 453; Astley Cooper's case
 of enormous blood-letting in concussion,
 i. 453;  after-treatment, i.  454; Tre-
panning in Injuries of the Head, i. 454; 
ANALYTICAL INDEX.
857
opinions of surgeons differ as to the ap-
plication and necessity of  the trepan, i.
454; Dease, Desault, Richter, Abernethy *
Astley Cooper, Brodie, Langenbeck, and
Walther only employ it when  secondary
symptoms  of irritation  and pressure re-
quire it, i.  454;  Petit, Quesnay, Pott,
Sabatier, Louvrier, Mursinna,  Zang, and
Schindler employ the trepan more gene-
rally, i. 454; reasonsby Dease  and others
for the infrequent use of the trepan, i.
454; South on the inftequency of fungus
of the  brain after  trephining, i.  454;
reasons by Petit andJ others for a more
general use of the  trephine, i.  454;
non-necessity for the use of the trephine
in the  majority of cases, i. 455 ; the tre-
pan  should only be employed for  the re-
moval of decidedly dangerous  conditions
in injuries of the skull, i. 456; indications
for trepanning,  i.  456 ;  South  on trepan-
ning in caries and necrosis, iv 457 ; Dr.
Wells' case of epilepsy consequent on
fissure of the skull, relieved by the tre-
phine, i. 457; Green's case of cataleptic
fits after fracture of  the parietal bone, i.
458; Green's case of insanity following
a blow over the longitudinal sinus, i.
460; Astley Cooper's case of  suspended
intellect, the consequences of an injury to
the  head> curedoy^the application of the
trephine, i.> 460-; parts of the skull where
the  trepan  maybe applied, i. 460; the
operation of trepanning, i. 461; directions
for using the arch-trepan, i. 462;  South
on the distinction between the trepan and
the  trephine, i. 462;  operating with the
trephine, i. 463 ; South on the operation:
of trephining, i. 463; trepanning on the I
frontal sinuses, i. 464;  South on trepan-
ning on the frontal  sinuses, i. 464 ; re-
moval Of the piece of bone, i. 464; South I
on the removal of the depressed and de-
tachedhone, and of any points from the
edge of the fracture, i. 464;  application
of several crowns, u464 ; South on the in-
ftequency of the necessity to apply the
trephine more  than  once,  i.  464; com-
pletion of the operation after the employ-
ment  of the trepan, i. 465; South on
bleeding from  the middle meningeal ar-
tery or from a  sinus, i. 465;  after-treat-
ment, i. 465; South on the after-treatment,
i. 466; general treatment, i. 466; dressing
the wound, i. 466 ; the process adopted by
nature in filling up the opening  in the
skull, i. 466;  unhealthy suppuration, i.
467; fungus of the dura mater, i. 467;
fungus of the brain, i. 467; treatment, l.
467;  protection of  the part operated on
by pads of leather, or of metal lined with
wood, i. 467 ;  Larrey on the  subsequent
  effects of  the closure of the opening in
  the skull, i. 467;  various bandages for
  injuries of the head, i. 467 ; abscesses in
  the liver consequent on injuries of the
  head, i. 468;  Hennen  on sympathetic
  affections  of  the liver,  stomach,  lungs,
  and heart in injuries of the head, i, 468 ;
  Hennen on priapism in injuries  of the
  head, i. 468; Hennen on loss of the gene-
  rative faculty from injuries of the back
  of the head, i. 468; causes of abscesses
  of the liver after injuries of  the head, i.
  468 ; Hennen on the sympathy between
  the brain and the liver, i. 469 ; signs and
  termination of abscesses of  the liver, i.
  469 ; treatment, i. 469.
Heart, wounds of, i. 499 ; displacement of,
  ii. 361; actual protrusion of, ii. 361.
Heath^s case of excision of the uterus by
  the abdominal section, iii. 578.
Hecht on the chemical constituents of the
  brain-like substance in medullary fungus,
  iii. 458.
Hedenus' apparatus for fracture of the neck
  of the femur, i,  623.
Heine's case of reduction of the consecutive
  dislocation in hip-disease, i.  298; artifi-
  cial leg, iii. 593.
Heister's artery-compressor, i. 331; band-
  age  for fractured  clavicle, i. 603;  ob-
  jected to, i. 603.
Held on the division of the peronei mus-
  cles in splay-foot, ii. 458.
Hellmund's mode  of applying  Cosme's
  powder, as a  caustic in the treatment of
  cancer, iii. 514.
Henle's opinion that the exciting cause of
  inflammation operates through the  ner-
  vous system, i. 37;  discovery of  fatty
  vesicles in the  serum  of  pus, i. 52; on
  the continuity of synovial membrane over
  the  cartilage of joints, i. 236;  on the
  fibrous structure of articular  cartilage,  i.
  249 ; on the non-vascularity of cartilage,
  i. 249; explains the absorption of carti-
  lage from want of nutriment, i. 261; on
  the formation of new vessels, i. 324.
Hennen,  Dr., on the after-management of
  the  ligature  on arteries, i. 339;  on the
  shock caused by a gun-shot wound, i.372;
  on severe bruising by shot, i. 374; on the
  treatment of wounds  by a ball  in the
  fleshy part of the arm, thigh, or buttock,
  i. 376; on the  use of the seton to bring
  away separated pieces of bone, i. 377; on
  the  occurrence of  necrosis  in gun-shot
  injuries of bones, i. 377; on the nature of
  the injuries in gun-shot wounds requiring
  amputation, i. 379; on immediate ampu-
  tation, i. 381;  on  the fatal  character of
  tetanus, i. 419; on cold lotions in bruises
  of the scalp, i.  426; on sabre wounds of 
858
ANALYTICAL  INDEX.
 the head, i. 427; cases of sabre cuts of
 the head, i. 427;  does not agree with
 Astley Cooper that the trephine  should
 be used in all cases of compound fracture
 of the skull, and gives cases of musket-
 shot  fracture in  illustration, i. 433; on
 gun-shot wounds of the skull, and their
 effects, i. 434;  on perforation of the skull
 by bayonet-thrusts, i. 436; on  the  re-
 moval of foreign bodies in injuries of the
 brain, i. 4,38; on the loss of certain facul-
 ties from concussion,!. 450; on sympa-
 thetic affections of the liver,  stomach,
 lungs, and heart in injuries of the  head,
 i.  468; on priapism in injuries of  the
 head, i. 468; on the loss of the generative
 faculty in injuries of the back of the head,
 i.  468; on the  sympathy between  the
 brain and the  liver, i. 468 ; on gun-shot
 wounds in the neighbourhood of,  pene-
 trating the orbit, i. 471;  on emphysema
 in wounds of the wind-pipe, i. 474;  case
 of wound of the larynx and oesophagus,
 i. 480; case of severe nervous symptoms
 following gun-shot wound of the throat,
 i.  480; on the course taken by balls in
 woundsof the chest, i. 483; on the prog-
 nosis of wounds of the chest, i. 488; on
 the occurrence of primary and secondary
 haemorrhage  in  incised  or punctured
 wounds of the chest, i. 490; on the im-
 mediate treatment of penetrating wounds
 of the lungs,  i. 494; on emphysema, i.
 495; case of secondary emphysema,!.495;
 on the healing of wounded lung, i. 496;
 on the protrusion of a portion of lung, i.
 497; case of foreign body in the  heart,
 i. 499; case of wound of the pericardium,
 i. 500; on the  escape of the intestines
 from injury in penetrating wounds of the
 abdomen, i. 501;  on the treatment- of
 penetrating wounds of the abdomen, i.
 505 ; on the use of the suture in wounded
 intestine, i. 513 ; on  effusion into  the
 cavity of the abdomen in cases of pene-
 trating wounds, i. 518; ease of musket-
 shot wound of the abdomen, the  ball
 passing afterwardsper anum, i. 520; case
 of ball wound  of the pelvis, involving
  the  bladder, i. 528 ; on the duration of
  syphilis  under  the  non-mercurial  treat-
  ment, and on  the subsequent occurrence
  of secondary symptoms, ii. 103.
Hernandez'  experiments  on  the  iden-
  tity of syphilis and gonorrhoea,  i. 183,
  185.
Hernia :—definition, ii. 258; divisions, ii.
  259 ;  ruptures of the belly, ii. 259 ; situa«
  tion, ii.  259 ;  varieties  of ruptures, ii.
  259 ; South on  certain forms of ruptures,
  ii. 259 ;  parts  forming the rupture, ii.
  259; presence of the hernial sac, ii. 259;
cases in which it is absent,  ii. 259;
South on the presence of the sac in vesi-
cal and ccecal hernia, ii. 259 ; Taramelli's
case of hernia of the vermiform appendix,
ii. 260; sub-divisions  of the sac, ii. 260;
its  coverings, ii. 260;  changes which
take place  in the hernial  sac, and their
causes, ii. 260; case of ossification of the
sac, ii. 260; South  on the causes  of
stricture in the  body of the sac, ii. 260;
South  on the hour-glass contraction of
the hernial sac, ii. 261; size of ruptures,
ii. 261; several ruptures often occur in
the same person, ii. 261 ; double hernial
sac very rare, ii. 261; Bransby Cooper,
Lawrence, and  Astley Cooper on  the
double  hernial sac, ii.  261 ;  Morgan's
case of a pouch formed at  the  mouth of
the tunica vaginalis, ii. 262; vertical di-
vision of a hernial sac into two, ii. 262;
South  on the occasional rupture of  one
side of the sac in femoral hernia, ii. 262;
reducible  and  irreducible ruptures,  ii.
263; congenital or acquired ruptures, ii.
263 ; causes of ruptures, ii. 263; ruptures
more frequent  in men  than women, ii.
263 ; Lawrence and Cloquet on the  sta-
tistics of ruptures, ii. 263,264; symp-
toms of a  reducible abdominal rupture,
ii. 266; diagnosis, ii. 266; South on the
difficulty  of distinguishing between  in-
testinal and omental rupture, ii. 266;
symptoms of intestinal rupture, ii. 266;
South on the gurgling  noise in the rup-
ture, ii. 266; symptoms of omental rup-
ture, ii. 266; of vesical rupture, ii. 266;
of  other ruptures,  ii. 266 ; ruptures al-
ways important diseases, ii. 267;  forma-
tion of adhesions in the sac, ii. 267; con-
dition of the intestine in the sac, ii. 267;
 of  the omentum,  ii.  267; South  on the
thickening of the intestine in the sac, ii.
 267; causes of strangulation, ii. 267; seat
 of strangulation, ii.267; signs determining
 the seat of the strangulation, ii. 267; Mal-
 gaigne and Didayon the seat of strangu-
 lation, ii. 268 ; distinction between incar-
 ceration and strangulation, ii.269; Scarpa,
 Lawrence, Travers, Boyer, von Walther,
 Jaeger, Langenbeck, Wilhelm, Blasius,
 A. Cooper, Rust, Sinogovitz, and Seiler
 on  the nature of strangulation, ii. 269;
 South on incarceration and strangulation,
 ii. 270; symptoms of acute strangulation,
 ii. 270; South on costiveness as a symp-
 tom of strangulation, ii. 270; South and
 Luke on  the dilatation  of strangulated
 rupture on coughing,  ii. 270;  Astley
 Cooper on  the complication of strangu-
 lated  hernia by the  presence  of an irre-
 ducible  rupture, ii. 271; symptoms of
 strangulation with a less degree of in- 
ANALYTICAL INDEX.
859
flammation, ii.271; causesand symptoms
of incarceration, ii. 271;  spasmodic in-
carceration, ii. 271;  symptoms of gan-
grene of the hernia, ii. 272; strangulation
of the omentum, ii. 272;  may terminate
in suppuration or gangrene, ii. 272; Key
on the  propriety of active  general and
local depletion in strangulated  omental
hernia,  prior to the  operation,  ii. 272;
treatment of ruptures, ii. 272 ; of reduci-
ble ruptures, ii. 272; reduction of the
rupture, ii. 272; South on  the application
of the taxis, ii. 273; South on the danger
attending violence  in the application of
the taxis, ii. 273; South, LeDran, De la
Faye, Arnaud, Louis,  Richter, Scarpa,
Sabatier, Dupuytren,  Sanson, Lawrence,
Key, and  Sir Charles Bell on the reduc-
tion en masse,  ii. 274 ; Green and Calla-
way's case of reduction en masse, ii. 274;
Bransby Cooper's case, ii. 275; Luke on
reduction en masse, ii. 275; Cloquet's ex-
planation  of the manner  in  which this
accident takes place, ii. 275; Luke on the
signs indicative of the reduction eh masse,
ii. 276; Dupuytren and Luke on the ope-
ration required  after the reduction  en
masse has occurred, ii. 277; re-descent of
a  reduced  rupture  prevented by appro-
priate bandages, ii. 279; trusses, ii. 279;
application  of the truss, ii. 280; a truss
with  a hollow pad  required  in adherent
rupture, ii. 280 ; a suspender to be used
for large, irreducible ruptures,  ii. 280;
effects from wearing the truss, ii. 281;
Cloquet on the spontaneous return of the
hernial  sac into the abdomen, ii. 281; ra-
dical cure of reducible ruptures, ii. 281;
five modes of attempting it, ii. 282 ; Hil-
danus, Blegny, Winslow, Richter, Lan-
genbeck, Boyer,Ravin, and Beaumont on
the use of  increased pressure,  and the
supine posture for that  purpose, ii. 282;
Jalade Lafond's pad with a reservoir for
caustic, ii. 282;  Paulus  yEgineta, Avi-
cenna,  Kern, Franco, and Monro, on the
application of the actual cautery or caus-
tic for the purpose, ii. 282; ligature and
stitching  of hernial sac,  ii.  283; prac-
tised with various  modifications by Be-
rard,  Franco,  Pare, Nuck, Fabricius ab
Aquapendente,  Guy  de  Chauliac, Le
Dran, Freitag, Senff,Schmucker,Theden,
Langenbeck, Kern, Petit, Lieutaud, Le-
blanc, Mauchart, Richter, Dionis, Mery,
Arnaud, Schreger, von  Graefe,  and vonj
Walther,  ii. 283; the  inhealing a plug of
skin, ii.  283;  Dzondi,  Jameson, and
Gerdy's plans, ii. 283;  Gerdy's mode of
operating,ii.283; modified by Signoromi
and Wiitzer, ii. 284 ;  Bransby  Cooper s
case, in which he performed Gerdy s ope-
ration, ii. 284; Bonnet, Mayor, and Bel-
mas' operations for the radical  cure  of
hernia, ii. 285; circumstances guiding the
decision as to the performance of an ope-
ration for the radical  cure of  hernia,  ii.
286; the several operations for the radical
cure more or less dangerous, ii. 286; opi-
nions differ as to  the value of these ope-
rations, ii.  287;   Schreger's  indications
when the operation is admissible, ii. 287;
Astley Cooper's case,  in  which he  in-
effectually removed the entire hernial sac,
ii. 288; Astley Cooper's objections to the
ligature of the sac, ii. 288; Petit'scase of
approaching peritonitis caused by ligature
of the sac, ii. 288; Lawrence's objections
to operations for radical cure of hernia,
ii. 289; treatment of strangulated rup-
ture, ii. 289; employment of tobacco ene-
mata, ii. 289;  South's objections to the
use of tobacco enemata, ii. 289; treatment
of chronic strangulation, ii. 290; employ-
ment of the taxis, ii. 290; symptoms fol-
lowing the reduction, ii. 290;  symptoms
followingfailure of the taxis, ii.291;Ribes
and Hey on the application of the taxisj
ii. 291; O'Beirne on the introduction of
a thick elastic tube through  the rectum
into the sigmoid flexure of the colon,  ii.
291; Ribieri and Guerin on local anodyne
applications, ii.-292; Nember, Rennerth,
and  Preiss on the exhibition of purga-
tives,  &c, ii.  292;  Church  on the
use of tartar emetic, ii. 292 ; Bell on the
muriate of morphia, ii. 292; South's case
of mortified intestine from strangulation,
ii. 292; the proper time for operating,  ii.
293 ;  South on the proper time at which
the operation  for  strangulated  hernia
should be performed, ii. 294 ; steps of the
operation, ii. 294 ; preliminary measures,
ii. 295; description of the operation,  ii.
295; South's objection to lifting up a fold
of the skin, and incising it, ii. 295; South
on the length of the first incision in scro-
tal and femoral ruptures, ii. 295; exposure
of the sac,  ii. 295; South on the  division
of the coverings, and opening the hernial
sac, ii. 296; South on several cases of in-
ternal  strangulation by bands from  the
mesentery  or diverticula of the ilium,  ii.
296; dilatation of the seat of strangulation
by cutting, ii. 297; instruments for divid-
ing the. strangulating part, ii. 297 ; South
on the division of the stricture,  ii. 297;
dilatation without cutting, ii. 297;  re-
commended by Thevenin,  Leblanc, Le-
cat, Arnaud, Richter, and Scarpa, ii. 298;
South's objections to dilatation without
cutting, ii. 298; return  of the intestines
after the division of the stricture, ii. 298;
South  on the return of the intestines after 
860
ANALYTICAL INDEX.
 the  division  of the stricture,  ii. 298;
 South on the effusion  of fluid after the
 intestine  have  been returned, ii. 298;
 causes  which  impede  the reduction of
 the intestine,  ii. 298 ; treatment of adhe-
 sions, ii. 298 ; treatment of intestine dis-
 tended with faeces or air, ii. 298 ;  Lowe,
 Loeffler,  Richerand,  Jonas,  and  von
 Graefe  on puncturing the distended in-
 testine, ii. 298; South  on the treatment
 of adhesion between the omentum or in-
 testine and  the sac,  ii, 298 ; South's ob-
 jections to puncturing or incising  the in-
 testine, unless distended with solid mat-
 ter,  ii.  299;  treatment of degenerated
 omentum, ii.  300;  its  removal by liga-
 ture or incision, ii. 300 ; Sonth and Cal-
 loway's cases, ii. 300;  Key's advice to
 unfold the omentum before cutting it off,
 ii. 300 ; South's mode of treating the pro-
 truded  omentum, ii. 301  ; sloughing  of
 the omentum, ii. 301;  Astley Cooper's
 case, ii.  301 ; Hewett on  the  formation
 by the omentum of a sac  enclosing the
 intestine, ii. 301 ;  South  on secondary
 haemorrhage from the omentum,ii. 301;
 Key on abscess in the  sac, occasionally
 reproducing the symptoms of strangula-
 tion,  ii.  302 ; the   dark violet or even
 dusky colour of  the  intestine  should
 not   prevent  its  reduction,  ii.   302;
 South on  this  colour,  as  caused  by
 venous  congestion,  ii.  302;  gangrene
 of the intestine, and its  treatment, ii.
 302; treatment of  wounded and nar-
 rowed intestine, ii,  302;  treatment  df
 old irreducible  ruptures when strangu-
 lated, ii. 303 ;  the operation of dilating
 the abdominal ring, the  hernial sac ndt
being opened,'to be rejected in the ma-
jority of cases, ii. 303; cases in which it
 may be adopted, ii. 303 ; this proceeding
adopted by  Franco,  Pare,  Petit, Garen-
 geot, Monro, A. Cooper, Key, and Preiss,
ii. 303 ; advantages of this operation, ii.
303 ; Guerin's subcutaneous incision of
the abdominal ring, ii. 303; Astley Coop-
er's reasons for recommending the opera-
tion  of  dividing the stricture without
 opening the  sac in large and old ruptures,
ii. 303;  mode of operating, ii. 304; Law-
rence's modification of this operation, ii.
 304; Key's views with regard toi.his ope-
ration, ii. 305; Lawrence ascribes the fatal
results after the operation, not to the ex-
posure of the parts to the air and  light,
but to the effects of protracted constric-
 tion, ii. 305; South on the consequences of
 the constriction, and  on violence in the
 application of the taxis, ii. 305 ; Key and
 South on the signs indicative of gan-
 grene of the intestine, ii. 306;  Key and
  South's cases of gangrenous intestine, in
  which  a fetid smell was perceptible be-
  fore the sac was opened, ii. 306; absence
  of the fetid  smell not  a certain sign of
  healthy intestine, ii. 307; Lawrence re-
  commends opening the sac, and dividing
  the stricture from within, ii. 307; South
  on the division of the stricture external
  to the sac, ii. 307; South on the treatment
  after the operation, ii.  307;  Luke's  de-
  scription of the operation for dividing the
  stricture external to the sac, ii. 307; Luke
  on the diagnosis of the seat of stricture,
  ii. 308 ; Luke on the incision of the sac,
  or on partial division of its neck in seve-
 ral places, when the stricture is  caused
  by it, ii. 308; treatment after the opera-
  tion, ii. 308; treatment when the symp-
  toms of • strangulation persist after the
  operation, ii. 309;  Key and South  on
  suppuration of the sac, ii. 309 ; Soutii's
  case of extensive sloughing of the abdo-
  minal and lumbar cellular tissue after the
  operation, ii. 309 ; treatment of sloughy
  intestine, ii.  310; formation of an arti-
  ficial anus, ii. 310; adhesion of the gut
  to the mouth of  the sac when sloughing
  takes place,  ii. 310; Astley Cooper and
  Key's cases of sloughing of the intestine,
 after it had been returned into the abdo-
 men,  ii.  310; Ramsden's case of  fatal
-contraction and ulceration of the intestine
 after strangulation,  ii.  310;  Key and
 South on the occurrence of gangrene in
 the intestine  some days after the  opera-
 tion in persons of enfeebled constitution,
 ii. 310, 311;  Key on the fatal termina-
 tion of  cases after the  operation, when
 preceded by great depression of powers,
 ii. 311;  Astley Cooper's case of tetanus
 after the operation, ii. 311; tabular view
 of operations for strangulated rupture, ii.
 316; inguinal rupture, ii. 316 ; situation
 and varieties, ii. 316;  anatomy  of  the
 parts concerned,  ii. 316; South's descrip-
 tion of the fascia transversalis, ii. 318;
 external or oblique inguinal rupture,  ii.
 319; situation and direction, ii. 319 ; in-
 ternal or direct inguinal rupture, ii. 319 ;
-situation and direction, ii. 319; diagnosis
 between these only possible when small
 and recent, ii. 319;  coverings of the ex-
 ternal or oblique  inguinal rupture, ii. 319;
 imperfect inguinal rupture, or rupture in
 the inguinal canal, ii. 319; situation and
 coverings, ii. 319; South on the coverings
of this variety of rupture, ii. 320; cover-
ings of  the   internal or direct  inguinal
-rupture, ii. 320; comparative frequency
 of protrusion  of the respective viscera, ii.
;320 ; congenital inguinal rupture, ii. 320;
■•causes, ii. 320; distinguished from exter- 
ANALYTICAL INDEX.
861
nal inguinal rupture, ii. 321; coverings of
congenital inguinal rupture, ii. 321; nar-
rowing  of the  hernial sac, ii. 321; con-
genital inguinal hernia called by Astley
Cooper  encysted hernia of the tunica va-
ginalis,  ii. 321; diagnosis of rupture from
hydrocele,  ii. 321 ;  South on the  diffi-
culty of diagnosis between rupture and
hydrocele of the cord, ii. 322;  South's
cases of hydrocele of the cord mistaken
for rupture,  ii. 322; complication of rup-
ture with hydrocele, i. 322; Mr. T. Bli-
zard and Cline's jun. cases of hydrocele
in front of an inguinal rupture, ii. 323 ;
diagnosis between rupture and varicocele,
ii. 323; and inflammatory swelling  of
the spermatic cord, ii. 324; and the  ar-
rest and inflammation of. the testicle in
 the inguinal canal, ii. 324; Key's case of
 strangulated inguinal rupture, the testi-
 cle being at the external ring, ii. 324;
 diagnosis between inguinal ruptures and
 fat-ruptures, ii. 324;  collections of fat on
 the  surface of the peritoneum, ii; 324;
 Pelletan on the mechanism of  the  fat-
 rupture, when  it descends through  the
 inguinal canal, ii. 325; diagnosis between
 inguinal rupture, and collections of pus
 passing through the inguinal canal out at
 the abdominal ring, ii. 325; return of the
 inguinal rupture, ii. 325; application of
 the truss, ii. 326; seat of strangulation, ii.
 326; the operation for  strangulated  in-
 guinal  rupture, ii. 326;  important in old
 scrotal rupture  on  the  right side, to as-
 certain whether the secum or commence-
 ment of the colon  be the protruded vis-
 cus, ii. 326; direction of the cut in divid-
 ing the stricture, ii. 326;  South  on the
 direction of the cut in dividing the stric-
 ture, ii. 327 ; congenital inguinal rupture,
 ii. 327; process  of the radical cure, ii.
 327; operation for strangulated congeni-
 tal inguinal rupture, ii.  327; the  opera-
 tion for inguinal rupture, without open-
 ing  the sac, ii. 328;  external  inguinal
 rupture in women,  ii.  328;  Nuck  and
 Cloquet on the diverticulum of the perito-
 neum,  ii. 328; Allan Burns on the fre-
 quency of  congenital rupture  in the fe-
 male, ii. 328;  femoral rupture, ii, 328;
 situation and sub-divisions, ii.329; Logier
 on  oblique femoral rupture, ii.  329 ^ana-
 tomy of femoral rupture, ii. 329 ; South
 on  the anatomy of femoral rupture, ii.
 330; femoral rupture occurs more rarely
 than inguinal,  and more  frequently in
 women than in men, ii. 33-2 ; symptoms
 of femoral rupture, ii. 332; Astley Cooper
 and Callaway on the seat of femoral rup-
 ture, ii. 333; South on the diagnosis of
 femoral from inguinal rujpture m women,
     Vol hi.—73
ii. 333; Astley Cooper and South on the
presence of  other tumors in the  femoral
region likely to be mistaken for  femoral
rupture,  ii.  333; coverings of  femoral
rupture, ii. 333; parts protruded in femo-
ral fupture, ii. 333 ; South on the cover-
ings of femoral rapture, ii. 333 ; Berard's
case  of  femoral  rupture, in  which the
Fallopian tube was  protruded,  ii.  334;
situation of the epigastric and  obturator
arteries with respect to femoral rupture,
ii. 334;  of  the  spermatic cord, ii.  334;
application of the taxis, ii. 334; situation
and severity of the  strangulation in  fe-
moral rupture, ii. 335; Key on the seat
of strangulation  in  femoral rupture, ii.
335; the operation for strangulated femo-
ral rupture, ii. 335;  direction of the  in-
cision, ii.  335; precautions  to avoid
wounding the epigastric or obturator ar-
tery, ii. 336; Hesselbach's modification
of the operation, ii. 336; Scarpa and Du-
puytren's modification, ii. 336;  Key on
the operation for the femoral rupture, ii.
 337;  after-treatment, ii. 337;  external
femoral rupture, ii. 337 ; situation, signs,
and  coverings,  ii.  337; predisposing
causes, ii. 337; application of the taxis,
ii. 338; Astley Cooper on the Varieties
 of femoral rupture, ii. 338; South's cases
 of femoral  rupture, with two sacs, ii.
 339; wounds of the epigastric  of obtura-
 tor artery, ii. 341;  Lawrence on the sta-
 tistics  of these wounds, ii. 342;  Law-
 rence's case of fatal  haemorrhage from a
 wounded  branch of the  epigastric, ii.
 342;  Everard Home's case of  suppura-
 tion  of the testicle consecutive to  the
 operation for strangulated scrotal rupture,
 followed by severe haemorrhage, ii. 342;
 umbilical rupture, ii. 343;  situation and
 sub-divisions, ii. 343;  congenital um-
 bilical rupture, ii.  343; symptoms, ii.
 -343; South on the ligature of the umbili-
 cal cord, ii. 343;  causes  of  umbilical
 fupture, ii. 343; in  adults, ii.  343; co-
 verings, ii. 844 ; strangulation of rare oc-
 currence, ii. 344 ; Astley Cooper's case;
 in which the sac was  either absorbed or
 burst, ii. 344;  Cline and South's cases
 of double umbilical ruptures, ii. 344;
  Astley Cooper on  the enormous size
  of umbilical ruptures  in  women,  ii.
  344;  treatment of congenital  umbilical
  rupture, ii. 344; treatment of  umbilical
  fupture occurring  after birth,  ii. 345;
  Rothmund's plan  of treatment^ ii. 345;
  Desault, Soemmering,  and   Briinning-
  hausen's case  of  spontaneous cure of
  umbilical rupture, ii. 346 ; the operation
  for  strangulated umbilical rupture, ii.
  346;  Astley Cooper  on  the   danger of 
862
ANALYTICAL INDEX.
 sloughing of the integuments in strangu-
 lated umbilical  rupture, ii. 346 ; Astley
 Cooper on suppuration of the omentum
 in strangulated umbilical rupture, ii. 346;
 strangulation of umbilical rupture rarely
 occurs during pregnancy, ii. 346 ; Astley
 Cooper, Lawrence, and Clement's cases,
 ii. 346; radical cure of reducible umbili-
 cal rupture by ligature objectionable, ii.
 346 ; opposed by Scarpa, Astley Cooper,
 Benedict  and South, ii. 347;  Desault's
 fatal  case, ii.  347; ventral rupture, ii.
 348; definition and  situation, ii.  348;
 causes, ii. 348; Oloquet's case of lumbar
 rupture, ii. 348; South's cases of rupture
 of the linea alba, ii. 348;  Lawrence's
 case of rupture of the recti abdominis, ii.
 348;  case of a boy wounded by a  boar's
 tusk, with protrusion of the omentum,
 colon, and some small intestines, ii. 349;
 Richter and Siebold's cases of yielding
of the abdominal parietes, ii. 349; situa-
 tion,  contents, and  coverings of  these
 ruptures, ii. 349 ; signs and treatment, ii.
 349 ;  diagnosis betweep ventral ruptures
 and fat-ruptures, ii.  349 ;  stomach rup-
 tures, their symptoms and treatment, ii.
 350;  treatment of the other ventral rup-
 tures, ii. 350 ;  ischiatic rupture, ii. 350;
 seat and contents, ii. 350; diagnosis, ii.
 350;  congenital  ischiatic , rupture,  ii.
 350;  diagnosis from a fatty or encysted
 swelling,  ii. 350;  from spina bifida,  ii.
 351;  coverings,  ii. 351 ;  reduction, ii.
 351 ;  Astley Cooper  and Seiler on the
 operations for strangulated ischiatic rup-
 ture, ii. 351 ; Hager  on the upper and
 lower ischiatic ruptures, ii. 351 ; Scarpa
 treats ischiatic rupture as enlarged  pudic
 rupture in women, and enlarged perineal
 rupture in men, ii. 351; thyroid rupture,
 ii.  351;  situation and  boundaries,  ii.
 352;  contents, ii. 352;  Cloquet and
 Lawrence on thyroid rupture, ii.  352;
 Franz' case of apparent strangulated thy-
 roid rupture, ii. 352; diagnosis, ii. 353;
 treatment, ii. 353;  Astley Cooper and
 Gadermann on  the operation for strangu-
 lated thyroid rupture, -ii. 353 ; vaginal
 rupture, ii. 353 ;  situation and contents,
 ii. 353;  symptoms, ii. 353;  predispos-
 ing causes, ii.  354;  treatment, ii.  354;
 perineal rupture, ii. 354;  situation and
 contents,  ii. 355;  of rare occurrence, ii.
 355 ; characters of the rupture, ii. 355 ;
 reduction, ii. 355; Astley Cooper's pu-
 dendal hernia, the  posterior labial rup-
 ture of Seiler, ii. 355 ;  rectal rupture, ii.
 356; causes, signs, and diagnosis, ii.
 356 ; treatment, ii. 356; phrenic rupture,
 ii. 356 ; different ways in which this oc-
 curs,  ii.  356;  Macaulay and  Astley
   Cooper's cases, depending on malforma-
   tion of the diaphragm, ii. 357; Leacock's
   case  of fatal phrenic rupture,  ii.  358;
   mesenteric and mesocolic ruptures, ii. 358;
   nature of the injury, ii. 358; disease ne-
   cessarily  fatal,  ii.  358;   Dupuytren's
   operation,  ii. 358;  strangulation of in-
   testine  within   the  peritoneal  cavity
   (internal   hernia,)  ii.   359;   Astley
   Cooper  on  internal  strangulation,  ii.
   359;  Lawrence on the  symptoms  of
  internal strangulation, ii. 359; Rokitansky
   on internal strangulation, ii. 359;  ruptures
   of the chest, ii. 360; very rare, ii.  360; na-
  ture and causes, ii.  360; Gratelup and
   Sabatier's cases, ii. 360; symptoms and
   treatment, ii. 360;  displacement of the
  heart, ii. 361; Breschet, O'Bryen, Ramel,
  and Deschamps' cases, ii.  361;  Stokes'
  case of displacement of the heart from ex-
  ternal violence, ii. 361; actual protrusion
  of ihe heart, ii. 361; Chaussier's cases, ii.
  361; ruptures of the brain, ii. 362; nature
  of the disease, ii. 362; South on  cerebral
  rupture, ii. 362 ; congenital cerebral rup-
  ture,ii. 363; causes, situation, symptoms,
  and results, ii. 363 ; post-mortem appear-
  ances in congenital cerebral rupture, ii.
  363 ;  Otto on hydrocephalocele, ii. 363 ;
  Penada, Earle, and Baron's cases, ii. 364;
  the  fluid sometimes  contained between
  the  brain  and its  membranes,  ii. 364;
  Meckel and Otto on the causes of cerebral
  rupture, ii. 364;  double  congenital cere-
  bral rupture, ii. 365; Billard and Meckel's
  cases  of cure, ii. 365; accidental cerebral
  rupture, ii. 365 ;  Beck and South  on acci-
  dental cerebral rupture, ii. 365 ; Jamie-
  son's case, ii. 366; diagnosis of accidental
  cerebral rupture from the so-called fungus
  of the dura mater, ii. 366; between con-
  genital cerebral  rupture and the blood-
  swellings of newly-born children,ii. 366;
  from watery cysts, ii. 366 ; treatment, ii.
  367;  by puncture, ii. 367; operations
  generally fatal, ii. 367; Earle and Adams'
  cases of  hydrocephalocele  treated by
  puncture, ii. 367; danger of the puncture,
  ii. 367;  Pitschaft's cases of suppurating
  protrusions in children, ii. 368.
Hernia humoralis.   See Inflammation of the
  Testicle.
Herpes  and its varieties, ii. 57.
Hertwig's observations on  canine mad-
  ness, i.  397; experiments show  that the
   saliva is the vehicle of the poison in hy-
   drophobia, i. 397; also  show the conta-
   gion to  be in the blood of the mad beast,
   i. 397.
Hesselbach's  artery-compressor,  i.  331;
   modification of the operation for femoral
   rupture, ii. 336; on the  treatment of hy- 
ANALYTIC
  drocele by caustic, iii. 229; mode of am-
  putating at the shoulder-joint, iii. 714.
 Hbtling's  case  of osteo-sarcoma of the
  jaws, in  which he.removed part of the
  upper,  and part of the lower jaw, iii.
  760.
 Heurteloup's percuteur,  advantages and
  disadvantages of, iii. 288.
 Hevin's case of renal calculus communi-
  cating with abscess in the  loins, iii. 268.
 Hewett on the formation, by the omentum,
  of a sac inclosing the intestine, ii. 301; on
  the connexion  between  the cord or the
  nerves, and the walls of the sac in spina
  bifida, iii.  188 ; on puncturing spina bi-
  fida, iii. 189.
 Hewson's opinion relative  to the formation
  of pus, i. 46; operation  for the excision
  of the carious head of the  femur in hip-
  disease, i. 300; on the use of caustic to
  destroy the ends of broken bones in false
  joints, ii. 17; case of cure  of false  joint
  by caustic potash, ii. 17;  case of excision
  of the head  of the femur, iii. 737.
 Hey  on the possibility  of infection  from
  secondary syphilis, ii.  106; on the cause
  of the difficulty experienced in reducing
  dislocations of the thumb from the  meta-
  carpal bone, ii. 234 ; on  the mode of re-
  ducing  this dislocation,  ii. 235; on the
  application of the  taxis  in  strangulated
  hernia, ii. 291; on the  cause of the diffi-
  culty in reducing  the  bowel in old pro-
  lapses of the rectum, ii.  402; operation
  for prolapse of the rectum, ii. 402 ; case
  of effusion of blood into the knee-joint, iii.
  178; on the incontinence of urine conse-
  quent on  lithotomy in women, iii. 353 ;
  case of immense tumour  of the nose, iii.
  598; mode of amputating the thigh with
  the flap from behind, iii. 660; on amputa-
  tion just above  the ankle, iii. 674 ; mode
  of operating in exarticulation of the meta-
  tarsal bones, iii. 706.
 Heyfelder on the varieties  of lardaceous
  tumours founded on microscopic exami-
  nation, iii. 452; operation for the resec-
  tion of both upper jaws, iii. 758.
 Heyne's apparatus for fracture of the neck
  of the femur, i. 624.
 Higginbotham's  treatment of burns by the
  nitrate of silver, i.  136; on  the treatment
  of whitlow  with nitrate of  silver, i. 219.
 Hildanus' apparatus for  fracture of the
  neck of the femur, i. 623; on increased
  pressure and  the  supine posture in the
  radical cure for hernia, ii. 282.
Hill on the duration of syphilis under the
  non-mercurial treatment, and on the sub-
  sequent occurrence of secondary symp-
  toms, ii. 103.                      .
Hip, abscess of, i.282 ; curvature of, n. 443,
AL INDEX.                       863

   amputation of the thigh at, iii. 688; ex-
   cision of, iii. 735.
 Hippocrates on congenital dislocation of
   the  hip, ii. 207, 2l3; on  the primitive
   direction of dislocation of  the humerus,
   ii. 221.
 Hirtz on the physical phenomena of pleu-
   ritic effusion, iii. 193.
 Hodgkin,  Dr., on the  development and
   progress of  scirrhus,  iii.  499;  on  the
   diagnosis  between scirrhus and medul-
   lary fungus,  iii. 503.
 Hodgson's cases of arteritis, i. 89; on severe
   phlebitis, i. 92 ; on the bursting of aneu-
   risms, ii. 470;  on the relative frequency
   of aneurism in the sexes, ii. 475; on the
   relative  frequency  of' aneurism  in  the
   arteries, ii. 476; on the application of
   pounded ice to aneurisms, ii.  480;  on
   compression in the. treatment of aneurism,
   ii. 483;  on the  effects produced by the
   ligature  on the arterial coats, ii. 492;
   ease of aneurism of the posterior cerebral,
   ii. 513;  on the section of the  scalenus
   anticus in  the ligature of the subclavian,
   ii. 518 ;  proposal to tie the innominata,
   ii. 521; on ligature of the innominata, ii.
   522; on  spontaneous aneurism  of  the
   brachial, ii. 528; on the coagula in vari-
   cose veins, ii. 568.
 Haematocele, iii. 175.
 Haemorrhoids, ii. 581.
 Hoere's case of simultaneous collection of
   blood between the pericranium and skull,
   and  between the dura mater and skull,
   the latter being fissured, iii. 175.
 Hcering's  experiments on  the injection of
   bile  into the cavity of the peritoneum, i.
   526.
 Hoffmann's opinion relative to the forma-
   tion  of pus, i. 46;  cases of separation of
   the head of the femur, and its removal by
   the surgeon in hip disease,  i. 287.
 Holbrook on the treatment of hydrocele by
   seton, iii. 229.
 Holscher's case of trepanning the spine, i.
   590; cases of extirpation of the womb, iii.
   570.
 Home's, Sir  E., opinion relative to the for-
   mation of pus, i. 47;  on the internal use of
   arsenic and ginger as a cause of gonorrhoea,
   i. 182; cases of gonorrhoea in the female,
   in which the use of stimulating injections
   caused the sides of the vagina to unite to-
   gether by adhesive inflammation, i. 193;
   on the application of a ligature  above a
   viper's bite, i. 390;  case of the bite of a
   rattlesnake, i. 392;  on the appearances
   in the lungs  32  years after their having
   been wounded by a  ball, i. 487; case of
   suppuration of the testicle consecutive to
   the  operation  for  strangulated scrotal 
864
ANALYTICAL INDEX,
  hernia, followed by severe haemorrhage,
  ii. 342; on the Hunterian operation, ii.
  490 ;  on the non-necessity for  the exist-
  ence of large collateral branches to ensure
  the success of  the Hunterian operation,
  ii.  491; on  acupuncture of aneurism,
  ii. 503; on the ligature of* the saphena
  vein or varix, ii. 5.72; on the use of the
  armed bougie in stricture of  the urethra,
  iii. 79;  case of relapse  of  hydrocele a
  long while after the operation, iii. 228 ;
  case of  foreign  body the nucleus  of a
  stone, iii. 249; case of retention of urine,
  and consequent mortification,  from the
  impaction of calculi in the  urethra, iii.
  363;  on atheromatous  cysts and  their
  contents, iii. 433 ;  on the question as to
  the propriety of removing  a  scirrhous
  breast, iii. 539.
Hook-foot, ii. 460.
Horner's Dr., recommendation  to  divide
  the sphincter ani in lacerated perineum,
  after union has taken place,  ii. 40 ; pro-
  posal  to  draw down the  uterus into the
  vagina in cases of  vesico-vaginal fistula,
  to act as a plug, ii. 197.
Horns, iii. 402..
Horse-foot, ii. 460.
Houston's case of fracture of  the haunch-
  bone, followed by abscess  in the peri-
  neum, and urinary fistula,i..597; apparatus
  for fracture of  the neck of the femur, i.
  623.
Houte's apparatus for fracture of the neck
  of the femur, i. 623.
Howship's case of distension of the bladder
  by blood, iii. 134.
Hrury's palate-holder, ii. 33r
Huberthal's apparatus for fractured  clavi-
  cle, i. 603.            i
Huguier  on the  period at which syphilis
  shows itself after birth, ii. 104.
Hulse's treatment of false joints, ii. 17.
Humbert's case of reduction of the conse-
  cutive dislocation in hip disease, i. 297;
  on the reduction of congenital dislocation
  of the femur, ii. 245,
Humerus, fracture of, i. 606; dislocation of,
  ii. 220.
Hummel on the  arrest of  haemorrhage by
  nature,  i. 330.
Hunczorsky's  mode of amputating  at the
  hip-joint with the  flap-cut with a single
  flap, iii. 691.
Hunter,  John, on inflammation, i. 33; on
  the susceptibility  for inflammation, and
  the influence  of  the  constitution  with
  respect to its local effects, i. 34; on the
  cause of pain in inflammation, i. 36 ; on
  the causes of inflammation, i. 37, 38; on
  the  attendant  redress,  i.  37;  experi-
  ments on the increase of heat  in inflam-
mation, i. 37; opinion on the enlarge-
ment of the vessels in inflammation, i. 38;
on the cause of the extravasation of serum",
i. 45;  opinions relative to the formation
of pus, i. 46; on the  cause and results of
suppuration,  i. 47;  on suppurative in-
flammation, i.  49;  on the circumstances
which  determine an abscess to the sur-
face,!.  50; on the qualities of pus, and the
pus-globules, i. 51;  on the putrefaction
of pus, i. 51; on ulcerative inflammation,
i. 62; ulcerative absorption, or absorption
with suppuration, i. 62, 63 ;  progressive
absorption, i. 63; on  inflammation of the
mucous membranes,  i.  87; of the  serous
membranes, i. 87; on the occasional ter-
mination of inflammation of serous mem-
branes  in  suppuration, i.  88; on  the
coagulation  of the blood in phlebitis, i.
93; on severe phlebitis, i. 93; on the red
streaks accompanying  inflammation  of
the absorbents, i. 96 ; on inducing resolu-
tion by constitutional means, i. 97; direc-
tions respecting the employment of blood-
letting, i. 97;  on the local means of in-
ducing resolution, i.  98 ; on fomentations
or steams, washes, and poultices, i. 100;
on derivation,i. 101; first pointed outthe
membrane of the fistula, i. 108; descrip-
tion of it, i. 108; opinion that most in-
flammations which  are called erysipe-
latous, are not such, i. 115; description of
erythema symptomaticum, i.  118;  de-
scription of metastatic erythema symp-
tomaticum, under the name  of erysipe-
latous inflammation, i. 120; on cold in the
treatment of burns,  i. 129; on the  pri-
mary treatment of burns, i. 133;  on the
contraction of the  granulations  during
cicatrization,  i.  138;  experiments  in
freezing rabbits' ears,  i. 144; on the ef-
fects of frost-bite, i. 145; mentions another
inflammation very like  chilblains,  i. 149 ;
on  the inflammation that produces  car-
buncle, i. 154; his observation that there
are generally more carbuncles than  one
not confirmed  by South, i. 154;  his opi-
nion that carbuncle  has some affinity to
boils, i. 155 ;  on the period when gonor-
rhoea first makes  its appearance after in-
fection,!. 176; on the primary symptoms
of  gonorrhoea, i.  176; on  the  specific
extent of the inflammation, i. 176 ; on the
actual seat of the discharge, i. 177; on
the small  swellings which are noticed
externally  near the  urethra,  i. 177; on
the size and form of the stream of urine,
i. 177; on the occurrence of haemorrhage
in severe gonorrhoea, i. 177; on inflam-
matory and spasmodic chordee, i. 178;
on the extent  of  local irritation, i. 178 ;
on the extension of the inflammation to 
ANALYTICAL  INDEX.
865
the bladder, and the consequent inability
of that viscus to retain its contents, i. 178;
case of fever preceding gonorrhoea, i. 178;
on the extension of  the inflammation in
the female to the bladder, i. 180 ; doubts
its  extension  to  the ovaries, i. 180;  on
abscesses complicating gonorrhoea in the
female, i. 181; on gonorrhoea from simple
causes, i. 182; case of gonorrhoea caused
by leucorrhcea in the female, i. 182;  on
the identity of syphilis and gonorrhoea, i.
182; accounts for the two different effects
of  the same  poison,  by the gonorrhoea
proceeding from a secreting surface, and
the chancre being formed  in  a non-se-
creting surface, i. 182; on the sympathetic
swellings  in  gonorrhoea,  188; on the
duration  and spontaneous cure of gonor-
rhoea,  i.  190;  on the treatment of the
disease,  i. 190; on  the  remedies for
chordee,  i. 192 ; on the arrest of haemor-
rhage  from the  urethra,  i. 192;  on the
infectious  nature of  gleet, i.  194; on
balanitis, i. 198; on  the  period when
swelled testicle supervenes, i. 198; swell-
ing of the testicle arises from sympathy,
and not from syphilis,!. 198 ; on gout, as
a cause of orchitis, i. 198; on the fungus
which projects when a whitlow bursts, i.
215; reasons for the severity of the pain,
and the length of time before a whitlow
bursts, i. 216;  regards  whitlow as an
example  of the ulcerative process having
no power over the cuticle, i. 218 ; on the
treatment of  whitlow, and its  free and
early incision, i. 219;  on inflammation of
the joints, i. 230; on the ulcerative ab-
sorption  of cartilage, i. 254 ;  on anchy-
losis,  i.  268;  on the inflammatory and
scrofulous diseases of joints, causing an-
chylosis, i. 269 ;  on soft anchylosis  from
granulations,   i.  269;  on  bony  anchy-
losis, i. 269 ; case of soft anchylosis from
the extension  of  inflammation  from the
surrounding parts to the joints, i. 272 ; on
the shortening and lengthening  of the
diseased  limb  in hip disease, i. 284; on
the three kinds of union of divided  parts
—quick union, by adhesion, and  by granu-
lation,!. 319 ;  description of quick union,
i. 319; objected to by Dr. John Thomson,
i. 319; on the adhesive inflammation, in
connection with wounds, i. 321;  on the
formation of new vessels, i. 323 ; on sup-
puration  and  granulation  as leading to
cicatrization, i. 324; on the suppression
of haemorrhage, i. 341; on the means for
keeping the lips of a wound in apposition,
i. 357; on the use of sticking plaster or the
dry suture for wounds, i. 359 ; on the use
of sutures, i. 360; on gun-shot wounds, l.
370; on the character of gun-shot wounds,
                                    73
i. 374; objections to primary amputation,
i. 381; on the cause of death in tetanus,
i. 418; on the causes of tetanus, i. 418 ;
on  puncturing  the  dura  mater,  when
the extravasation lies beneath it, i, 448;
on   the   suppurative  inflammation  of
wounded joints, i. 537; on rupture of the
tendo Achillis, i. 540; on  the treatment
of  the ruptured tendon, i. 540; on  the
period of union, and the manner in which
it takes place in simple fracture, i. 548;
on the consequences of compound frac-
tures, i. 558;  Qn the treatment of com-
pound  fracture, i. 565;  on symptomatic
fever, i. 571; on hectic fever, i. 571; on
the removal of the injured limb during
the continuance  of  hectic  fever,  572;
on  the  slight constitutional  irritation
after amputation, when union by the first
intention takes place, i. 573;  on the pro-
cesses  which  follow after  union  has
taken place in fractured patella, i. 633; on
the formation  of false joints, ii. 14;  on
the treatment  of  false joints, ii. 15;  on
the two  modes in which  the  venereal
poison affects the system, ii. 71; on the
period at which chancres appear after in-
fection,  ii.  71;  on  the  symptoms of
chancre,  ii.  72; experiments by inocu-
lating with the matter of gonorrhoea and
chancre,  ii. 72;  on the  true  venereal
bubo, ii. 75; on the  existence of syphi-
litic buboes without primary sore, ii. 76;
on the continuance of the constitutional
irritation from lues, independent of con-
tinued  absorption, ii. 77;  on the non-
infectious character  of the  pus from a
secondary syphilitic  sore, ii, 79; on the
relative  rapidity of cure of gonorrhoea,
chancre,  and  lues venerea, ii. 85;  on
the relapse of ulcers after chancres have
cicatrized), ii. 85; case of diseased  child
infecting the nurse, ii. 105; on the pos-
sibility of infection from.secondary syphi-
lis, ii. 106;  on the  ossific  inflammation
preceding necrosis, ii. 121; on the process
of exfoliation,  ii. 124;  on the  signs of
exfoliation, ii. 125»; on the species of ex-
foliation,  ii. 128; on the inadequacy of
the term fistula, ii. 144 ;  on the causes of
fistula, ii. 144; on the cure of fistula, ii..
146; objections to the use of the catheter
in urethral fistula, ii. 182; definition of
aneurism, ii. 469 ; on the coagulation<of
blood in  an  aneurism,  ii.  470; on the-
bursting of aneurism, ii. 470; on the re-
lative frequency of aneurism in the sexes,
ii. 475;  on  the  relative frequency  of
aneurism in the arteries, ii. 475; admits
a diseased state of an artery as the cause
of aneurism, ii. 477;  on the spontaneous
cure of aneurism, ii. 479; on compression 
AL INDEX.
866*                       ANALYTIC

  in the treatment of aneurism, ii. 485;
  claims to originality in reference to the
  Hunterian operation, ii. 489;  on the size
  of the aneurism best fitted for operation,
  ii. 491; operation for tying the femoral
  artery in  popliteal aneurism,  ii. 493;
  cases of secondary haemorrhage after the
  operation, ii.  498;  on ligature of the
  femoral artery, ii. 542; description  of
  three forms of stricture of the  urethra, iii..
  67;  on the use of the armed bougie  in
  stricture,  iii.  79; case of retention  of
  urine from  calculus in the urethra, iii.
  133 ; on the expulsion of bougies by the-
  contractibns of the bladder, iii. 135; ope-
  ration for stone on infants, iii, 297; on
  cysts forming around foreign substances,
  iii. 430;  on the internal surface of cysts,
  iii. 433;  on the disposing causes of can-
  cer,  iii. 508; preference of secondary  to
  primary amputation in severe injuries  of
  the lower extremities, iii. 725; objections
  to primary  amputations  in such cases,
  iii. 725.
Hunter, Dr.  William, on the' structure
  of synovial  membrane, i, 236;  on the
  structure of cartilage, i. 249; Miescher
  differs in opinion with, respecting the-
  fibrous structure of articular cartilage, i.
  229;  views  on the structure of Cartilage
  generally correct, i. 253; on aneurismal
  varix, ii. 547;  on the distinction between
  aneurismal varix  and false aneurism, ii.
  550;  on varicose  aneurism, ii. 551;  first
  suggests the small operation  for ovarian
  dropsy, iii, 212,
Hunter, Robert, on the section  of muscles
  in spinal curvature, ii. 439.
Hutchinson on incisions in pseudo-erysi-
  pelas, i. 125; on the rarity of  calculus,
  among seamen, iii. 271.
Hutton, Dr.,  on compression in the treat-
  ment of aneurism, ii. 486.
Hydatids, iii, 440.
Hydrarthrus, or hydrops articuli, i.„ 341;
  iii. 181.
Hydrocele, iii. 219.
Hydrocephalocele, ii. 364.,
Hydrocephalus, iii.. 184.
Hydro-mediastina, iii. 203.
Hydrometra,.iii. 217..
Hydro-pericardium, iii, 200,
Hydrophobia :^bite of a rabid beast,  i.
  396;  the bite of beasts much  excited, or
  when disturbed.' during copulation, may
  produce canine madness, i. 396; causes
  of dog-madness, i. 396;  spontaneous de-
  velopment of hydrophobia in man, i. 397;
  signs of incipient madness in  the dog,  i.
  397;  Hertwig's observations  on canine
  madness, i. 397; progress of the disease,
  i.  398; signs, of  dumb  madness in the
dog, i. 398 ; Youatt on rabies in the dog,
i. 398; Youatt on the peculiar bark of the
mad dog, i. 399;  Youatt on the saliva of
the mad dog, i. 400 ;  Youatt on the con-
dition of the lumbar portion of the spinal
cord in rabies and dumb madness in the
dog,i.400; Youatt on a peculiar paralysis
of the muscles of the tongue and jaws
occasionally  occurring  in  mad dogs, i.
400;  Youatt on the insensibility to pain
in mad dogs, i. 400;  Youatt on the diag-
nosis between pain in the ear in canker
and in  hydrophobia  in  the dog, i. 401;
Y'ouatt on the period of incubation  of
rabies in the  dog, i. 401; Hertwig's ex-
periments show  that the saliva is the
vehicle of the mad poison, i. 401;  Trol-
liet considers the mucus  from  the in-
flamed raucous membrane of the bronchi
to be the vehicle of the poison, i. 401;
Hertwig's experiments also  show the
contagion to be in the blood of the mad
beast, i. 401; Youatt on the appearances
on dissection in the dog, i. 401; Youatt's
caution against suffering dogs to lick the
face or hands, or  any other part of the
body, i. 403 ^ Lawrence's details  of the
Hon.  Mrs. Duff's case, i.403;  Lawrence
on the  communication of  hydrophobia
from  one human being to  another, or
from man to beasts, i. 403; Magendie and
Breschet's experiment, i. 403; period of
incubation of hydrophobia in man, i. 403;
Galen, Mead, and Hale  Thomson on the
protraction of the  period of incubation, i.
404;  Dr.. Bardsley's case of the disease
twelve years after the bite  had been in-
flicted, i.. 404; his opinion that the case
was not. one of hydrophobia, i. 404; sup-
ports his opinion by the views of Darwin,
Haygarth, andR. Pearson, i. 404; Eliiot-
son on the period  of  incubation of the
disease, i. 404; Professor  Dick on the
nature of the disease in hydrophobia, i.
405; symptoms of incipient hydrophobia,
i. 405;  Urban's opinion that there is a
circlet of small vesicles round the wound
or scar, i. 405; general symptoms of hy-
drophobia, u 406 ; Elliotson on the symp-
toms of hydrophobia, i. 406; Elliotson on
the diagnosis between true and spurious
hydrophobia, and- inflammation of the
pharynx, L 406 ; the disposition of hy-
drophobic patients to bite,  doubted  by
South, i. 406 ;  Powell  and Magendie's
cases, i. 407;  Cline jun.  on the dispo-
sition of hydrophobic animals to'use their
weapons of offence, i. 407;  Elliotson on
a general morbid  irritability  in hydro-
phobia, i. 407; Youatt on the peculiar
delirium in  hydrophobia, i. 407; Bards-
ley and Babington's cases illustrative of 
ANALYTICAL  INDEX.
867
 this delirium, i. 407;  Lawrence  on the
 peculiar delirium of hydrophobia, i. 407;
 Youatt on the tenacity of the  human
 saliva in  hydrophobia, i. 407; Elliotson
 on  the duration of the disease, i. 408;
 Mead on the increase of muscular strength
 in hydrophobia, i. 408;  Elliotson on abor-
 tive hydrophobia, i. 408; Dr. Bardsley
 on  the stages  of hydrophobia, i. 408;
 Marcet, Babington, and Callisen on the
 premonitory  pains  of hydrophobia,  i.
 408; post-mortem appearances in hydro-
 phobia, i. 409;  Locker on vesicles on
 the spleen in hydrophobia in dogs, i. 409;
 the  post-mortem appearances in Elliot-
 son's case, i. 409; the proximate cause of
 hydrqphobia, i. 409; Harder on the action
 of the poison on the system, i. 409;  Lan-
 genbeck on hydrophobia, as caused by a
 qualitative alteration of the blood by the
 poison, i. 410 ; prognosis, i. 410 ; treat-
 ment of the bite, i. 410; Youatt's objec-
  tions to excision of the bitten  parts, i.
 410 ; South on the  excision of the bitten
 parts, i. 411; Cline's  directions for the
  excision of the bitten parts, i. 411; South
  on  the excision of the scar, i. 412; inter-
  nal prophylactics of hydrophobia, i. 412;
 plan oftreatment recommended by Wendt,
  i. 412 ; Brera and von Schallien's treat-
  ment, i. 412; Marochetti on the presence
  of  pustules  under  the tongue  after the
  bite of a  mad  animal, i. 413;  Maro-
  chetti's plan of treatment, i. 413; Wat-
  son's objections  to Marochetti's views, i.
  414; general treatment of hydrophobia,
 i. 414.
Hydro-thorax, iii. 190.
Hypospadias, and its treatment, iii. 98.
Hysterical Affections of the Joints.  See
  Inflammation of the Joints.

Iliac aneurism, ii. 531.
----artery, common  ligature of,  ii.  532;
  internal,  ligature of, ii. 533;  external,
 ligature of, ii. 537.
Ilium, fracture of, i. 596.
Incised wounds, i. 364.  See Wounds.
Induration,  or hardening, i. 65.
Inflammation, definition  of,  i. 32; the
  term objected to by Andral, and  that  of
  hyperemia substituted, i. 33;  Hunter's
  opinions on inflammation, i. 33; Muller's
  i. 34; al I organs of the body may become
 inflamed, except the  cuticle,  hair, and
 nails, i. 34 ; the  capillary, vascular, and
 ganglionic nervous systems, the  actual
 seat of inflammation,  i. 34; Hunter on
 the  susceptibility for  inflammation, and
 the  influence of the  constitution  with
 respect to its local effects, i. 34 ; symp-
 toms of  inflammation, i. 35;  South on
the attendant pain,  i. 35;  Dr. Alison's
description of inflammation, i. 35: expla-
nation  of the  symptoms, i.  35;  the
changed condition and increased plasti-
city of the blood shown  by the crusta
inflammatoria, i. 36; comparison of the
local appearances of  inflammation, and
those coming in with inflammatory fever,
i. 36; the cause of the increased action of
the nerves, 36 ; Travers and Hunter on
the cause of the pain, i.  36; Henle's
opinion that the exciting cause of inflam-
mation  operates  through  the  nervous
system, i. 37; its mode of  action, i. 37;
Hunter on the causes  of inflammation, i.
37, 41; Travers' remark, that pain is not
necessarily an attendant on inflammation,
i..37; Hunter and Travers on the attend-
ant redness, i. 37; Hunter's experiments
on  the increase  of heat, i.  38; Travers'
remarks on that symptom, i. 38 ; Hunter
and Cullen  on  the enlargement of the
vessels,  i.  38; Dr.  John Thomson's
observations  on the  variation  of the
current of the blood  through  the capil-
laries,  resulting from the application of
different substances, i. 38;  Earle's com-
ments on these, i. 39; Dr, Wilson Philip's
experiments, i. 40;  Gendrin's account of
the steps by which the stagnation of the
blood in inflammation is produced, i. 40 ;
Dr. John Thomson's experiments repeated
by Travers,  i.  40;  Travers and  Ben-
nett on the  oscillation attending the re-
covery of the circulation, i.  40,41; Whar-
ton Jones' description of the phenomena
of inflammation under the microscope, i.
41; Emmert and Vogel's description of
the same phenomena, i. 41;  incidental
causes of inflammation, i. 42; results
of  inflammation, i.  42;  Resolution.-—
signs of resolution, i. 42 ;  distinguished
from' the recession of inflammation, i. 43;
Dr. J. H. Bennett on the process of reso-
lution, i. 43; Schonleinand  Zimmermann
on the elimination of the molecular fibrin,
i. 43 ;  Exudation .•—period  of  its  occur-
rence,  and   its results, adhesion  and
edema, i.  44; the term synonymous with
effusion, i. 4 i; Dr. J. H. Bennet, Travers,
Wharton  Jones, and Hunter on the pro-
cess of effusion, i. 44, 45;  Gerber's sub-
divisions  of effusion, i. 45;  Gerber on the
microscopic  resemblance  between the
lymph-corpuscles and the exudation-cor-
puscles, i. 45; this resemblance denied by
Gulliver,  i. 46;  Valentin on the exuda-
tion-corpuscles,  i.  46.  Suppuration;—a
natural result of severe inflammation, i.
64; the secretion of pus, i.  46; formation
of abscess, i. 46; opinions of Simpson,
De  Haen, Morgan, Hunter, Brugraans, 
868
ANALYTICAL  INDEX.
 Pinel, Boerhaave, Bell,Gotter;Quesnay,
 Hoffmann, Grashuis, Stewart, Pearson,
 Hewson, E.  Home, Berzelius,. Gruit-
 huisen, Fischer, Donne, Gluge, Valentin,
 Gueterbock, Wood, Bonnet, Mandt, Vo-
 gel, and  E. V. Bibra relative  to the for-
 mation of pus, i. 46;  symptoms of ap-
 proaching suppuration, i. 47; occurrence
 and signs of  fluctuation, i; 47;  symp-
 toms of deep  seated suppuration, i. 48 ;
 hectic  fever  accompanies  every consi-
 derable  suppuration,  i.  48;  formation
 of the walls of an abscess, and the circum-
 scription of the pus, i. 48; the circum-
 scription of the pus does not  take place
 unless the inflammation is connected with
 plastic exudation, i. 48; the walls of an ab-
 scess are secreting and  absorbing sur-
 faces,  i. 48;  resorption  of pus,  i. 48;
 metastatic abscesses, i. 48; Vogel and'
 Bonnet on the effects of the  resorption
 of pus, i. 48 ; Hunter on the  cause and
 results of suppuration,  i. 48;  Valen-
 tin  on  the microscopic  results of sup-
puration, i. 49; Hunter on suppurative in-
flammation, i.  49 ; Travers on  the lining
 membrane of  an  abscess,  i.  49;  Hun-
ter  and Travers  on the circumstances-
which  determine  an abscess to the sur-
face, i..50; qualities of pure good pus,  i.
50;  formation of pus, i. 51; Travers on the
purpose which the formation of pus serves
in theeeonomy, i. 51; Hunter on the qua-
lities of pus and the pus-globules, i. 51;
Hunter and Gulliver on the putrefaction
of pus, i.  51; Senac on the globular struc-
ture of pus, i. 51; Gueterbock on the
composition and  chemical analysis  of
piis, i. 52; composion of the  serum of
pus, i.  52; fatty  vesicles, discovered in
the  serum of pus by Henle, i.  52;  Gue-
terbock's  discovery  of  pyine,  i. 52;
characters of pus-globules, i. 52 ; Mandt
on the  pus-globules, K 53; discovery of
the  difference in size of the pus-globules
by Gueterbock, i. 53; Mayodeseribes pus-
globules as occasionally seen in healthy
blood, it53; denied by Gulliver, i, 53;
 Gerber's account of the formation of pus,
and of  the reproductive organization in
suppurating  wounds, i. 53; Travers on
the  constitution of pus, i.  54; varieties of
pus, i. 55 ; distinguishing characters of
laudable pus, and ichor or sanies, i. 55;
the  presence  of globules in the  serum
proved by Bauer, Faraday, and  Mandt,
i. 56; characters of the albumen in pus,
i. 56;  Grassmeyer and Fischer on the
distinguishing tests, for pus and mucus,
 i. 56; Gruithuisen's microscopic tests for
pus and mucus, i, 56; Gerber's descrip-
 tion of ichor, puriform mucus, and serous
 exudation, i. 56; pus cannot be produced
 without inflammation, i. 57; cold or lymph
 abscess, i. 57; the diathesis purulenta, i.
 57; abscess of congestion, i. 57; symp-
 toms of cold abscess, i. 57;  cold abscess
 not to be confounded with  Hunter's col-
 lections of matter without inflammation,
 nor with the cold abscess of the surgeons
 of the Saracen school, the chronic abscess
 of modern surgeons, i. 58; South's case of
 cold abscess, i. 58; Dr. Rigby'on puerperal
 abscess following contagious or adynamic
 puerperal fever, i,  60;  Beinl, Rust, and
 others, regard the so-called lymph-swel-
 ling as being an extravasation of lymph,
 i. 60; Walther proves that the  term
 lymph-swelling is incorrect,i. 60; Beinl's
 opinion that the strongest and most heal-
 thy  are  more subject  to lymph-abscess
 than the weakly, and men  than women,
 and  that it does not occur without exter-
 nal  injury disproved  by Rust, i.  61;
 Nasse's case of lymph-swelling from ex-
 ternal  injury, i. 61  ;  such cases  exceed-
 ingly rare, i. 61; opinions of Langenbeck,
 Ekel, and Zembsch on the lymph-swell-
 ing, k 61; South's case of lymph-abscess,
 i. 61;  Ulceration:—causes, i. 62; Hunter
 on  ulcerative inflammation, i.  62; on
 ulcerative absorption, i. 63 ;  progressive
absorption, i. 63; absorption with suppu-
ration, i. 63; Travers  on the process of
 ulceration,  i. 64;  Induration or  Hard-
ening;—Causes and results, i. 65; occa-
sional  terminations  in  inflammation, ul-
ceration, and  cancer, i. 65; induration
most likely to occur after long-continued
insidious inflammations in organs with a
 low degree of vitality, i. 66; Softening
 occurs only in long-continued dyscratic
and cacfietic  inflammation, i.  66;  may
be regarded as the intermediate condition
between ulceration and mortification, i.
 66.   Mortification .■—divided  into   hot
 and cold, i. 66 ; Travers' objection to the
terms mortification and sphacelus, i. 66;
 definition of  mortification, i. 67 ; symp-
 toms, i. 67; Travers' acute gangrene, i.
 67; destruction of the mortified parts oc-
curs either as dry, moist, or hospital  gan-
 grene, i. 68 ;  South on vesications filled
 with a bluish or bluish-black fluid in cases
 of severe bruise, or when the bandages in
 cases  of fracture  are  too tight, i.  68;
 causes of mortification, i. 68; Brodie on
 sudden loss of blood as a cause of morti-
 fication,!. 68; Travers on deep and exten-
 sive effusions, and injuries of nerves as
 causes of mortification, i.  68;  South's
 case of mortification of the lower extre-
 mity from effusion of blood causing dis-
 tension of the limb, i. 68;  mortification 
ANALYTICAL  INDEX.
569
in cases of aneurism caused by the disten-
sion from effusion, i. 69; mortification in
cases  of simple fracture, the principal ar-
tery being uninjured, i. 69 ; South's cases
of mortification after fever, i. 69 ; senile
gangrene, i. 71; d istinction between senile
gangrene consequent on injury, and that
resulting from constitutional causes, i. 71;
Travers' chronic gangrene, i. 72; causes
of dry gangrene,  i. 72; South's case of
dry gangrene consequent on  abdominal
typhus, i.  72; Dupuytren on arteritis, a
cause of dry gangrene, i. 72, 89 ; South's
case of dry gangrene from organic disease
of the heart, i. 72 ;  Brodie's case of dry
gangrene from inflammation of the prin-
cipal artery and vein of the limb, i. 72;
Brodie on the cause of the distinction be-
tween dry and moist gangrene, i. 73; gan-
grene from arterial inflammation, a com-
paratively rare disease, i. 73;  this state-
ment  denied by Cruveilhier and Dupuy-
tren, i. 73; South's case of arteritis with-
out gangrene, i. 73; Solly's case of gan-
grene, i. 73; mortification from continued
pressure, i. 74; mortification from the use
of the spurred rye, i. 74; Thomson's ac-
count of this form of the disease, i. 74;
Sigebert and Bayle's remarks, i. 74 ; the
disease firstnoticed by Dodard, afterwards
bySaviard,Noel,Langius,Quassoud,Bos-
sau,and Duhamel, i. 74; Dr. Elliotson's
case of gangrene of the leg, after the use
of ergot, the arteries of the limb being ossi-
fied, i. 74; Model's opinion that spurred
rye does not cause gangrene  in brutes,
i.74;  disproved by Tessier,i. 75; Block's
experiments on the subject, i. 75 ; Dr. C.
Woolaston's cases of gangrene, i. 75; mor-
tification of the cheek, called "noma" by
Vogel, i. 75; a rare and generally fatal
disease, i. 75; description of noma by Drs.
Evanson and Maunsell, i. 75; the term
cancrum oris incorrectly applied to noma,
i. 76; cancrum oris, a form of mortifica-
tion commencing with ulceration, gene-
rally first in the gums, and thence spread-
ing to the lips and cheeks, i.  76;  de-
scribed by Dr. Cumming, i. 76; South's
case of noma in the adult, i. 76; mortifi-
cation, when a consequence of contagious
influence, results  in malignant pustule,
or hospital  gangrene,  i. 77;  malignant
pustule, its  causes and symptoms, i. 77 ;
contagious from  beast to man, but not
between man and man, i. 77 ; Elliotson
on  glanders in the human subject, i. 78;
Lawrence's cases of malignant pustule, l.
78; Beer and  Delpech's cases, i. 79;
Turchetti's  cases of malignant pustule,
described by him  as anthrax,  i. 80;  Dr.
Wagner's  cases  of malignant pustule,
produced by contact, and by eating the
flesh  of  diseased  animals,  i. 80; Dr.
Bourgeois' observations  on  malignant
pustule, i. 81; hospital gangrene, i. 82;
description of the disease, i. 82;  local
and general symptoms, i. 82; Liston's
account of the hospital gangrene in Uni-
versity College Hospital  in 1841, i. 82;
Arnott's cases of hospital  gangrene at the
Middlesex  Hospital, i. 83;  the  disease
exceedingly rare  in the London  hospi-
tals, 63 ;  Lawrence  on  sloughing pha-
gedena, i.  83; Welbank on sloughing
phagedena, i. 84; this disease regarded
by  S. Cooper as resembling  hospital
gangrene, i. 84; denied by South, i. 84;
South on the sloughing state of  stumps
from want of power, i. 84; the character-
istics  of  hospital  gangrene, i. 84; the
cause of hospital gangrene is the opera-
tion of a peculiar contagious matter, i.
84; it is always a very dangerous com-
plication of  wounds and sores,  i. 85.
Varieties  of Inflammation :—inflam-
mation may  be  classed, 1st, according
to its  appearances and  course;  2ndly,
according  to  its  causes;  and   3rdly,
according to the structure of the parts at-
tacked, i. 85; acute and chronic  inflam-
mation, i. 85; division of inflammation
into simple, erethitic, torpid, malignant,
and obscure, i. 85; idiopathic, sympto-
matic, specific, and sympathetic, i. 86;me-
tastatic inflammation, i. 86; inflammation
of the skin, i. 86 ; of the cellular tissue, i.
86; South on inflammation of the cellular
tissue, i, 86; inflammation of the  glands,
i. 87;  of the mucous membranes, i. 87;
Hunter on inflammation  of- the mucous
membranes, i. 87;  inflammation of serous
membranes, i. 87 ; Hunter on inflamma-
tion of serous membranes, i. 87 ; South
on the tendency of serous membranes to
adhesive inflammation, i. 88 ; Hunter on
the occasional termination of inflamma-
tion Of serous membranes in suppuration,
i. 88; inflammation of the fibrous tissues,
i. 88; inflammation of the coats of arteries,
arteritis, i. 88;  Bouillaud on arteritis, i.
89; Hodgson's cases of arteritis, i. 89 ;
Portal's case of inflammation of the aorta,
consequent on the recession of measles,
i. 89; redness not always present in in-
flamed arteries, and sometimes  occurs
when  there is not any  inflammation, i,
89; Bouillaud on the redness of the in-
ternal arterial membrane, i. 89 ;  Dupuy-
tren  on  mortification as the result of
arteritis, i. 89 ; South's case of arteritis,
i. 89; Portal on the ossification of arteries
in  young children, i. 91; Brande's ana-
lysis  of the earthy concretions in arteries, 
AL INDEX.
870

  i. 91;  Miescher on  the ossification of
  arteries, i. 91; inflammation of veins,
  phlebitis, i. 92; causes, symptoms,  and
  terminations, i. 92; Cruveilhier on phle-
  bitis, i. 92; South on  phlebitis, i.  92;
  Hunter on the coagulation of the blood
  in phlebitis, i. 93;  Hunter, Abernethy,
  Hodgson,  Carmiehael, Bouillaud,  Tra-
  vers, and Arnott, on  severe phlebitis, i.
  93; Ribes'  cases  of phlebitis,  i.  94;
  Arnott  on  the  morbid appearances in
  phlebitis, i. 95; Dr.  Robert  Lee on in-
  flammation of the femoral and iliac veins,
  an occasional cause of phlegmasia dolens,
  i. 95; inflammation of the absorbent ves-
  sels, i. 95;  South  on the causes of in-
  flammation of the absorbent vessels, i.
  95; Hunter on the red streaks accom-
  panying inflammation of the absorbents,
  i. 96;  South on earthy deposits in the
  absorbents, i. 96;  inflammation  of the
  nerves, or theirsheathsd.96; of the bones,
  i. 96;  of the periosteum, i. 96 ; of the
  medullary membrane, i. 96;  prognosis of
  inflammation, i. 96; treatment, i. 97; the
  first indication to induce resolution, i. 97;
  employment of antiphlogistic remedies,
  i. 97;  in erethitic inflammation, opium
  combined  with  proper  antiphlogistic
  means, should be exhibited, i. 97; gas-
  tric impurities  should  be removed by
  vomiting and purging, i. 97; in  malig-
  nant, specific, and dyscratic  inflamma-
  tions, antiphlogistic remedies should be
  used cautiously, i. 97; Hunter  on in-
  ducing resolution by constitutional means
  i. 97; Hunter's directions respecting the
  employment of blood-letting, i. 98; local
  treatment of inflammation by abstraction
  of blood,  cold, moist,  or dry warmth,
  salves, and plasters, astringent, anodyne,
  and derivative means, i. 98 ; Hunter on
  the local means of inducing resolution, i.
  98; local bleeding by leeches, scarifica-
  tions, and cupping glasses, i. 99; em-
  ployment of cold, i. 99 ; ice or freezing
  mixtures must not be used too long, lest
  they destroy the vitality of the part, i. 99;
  moist,  warm remedies, fomentations, and
  poultices, i. 99 ; Hunter on fomentations
  or steams, washes, and poultices, i. 100;
  Abernethy on poultices, i. 101; medicated
  poultices, i.  101; treatment of torpid in-
  flammation, i. 101; derivative remedies,
  i.  101; Hunter  on  derivation, i.  102;
  treatment  of receding  inflammation, i.
  102 ; treatment after exudation has taken
  place, i. 102; treatment during and after
  suppuration, i. 102; when the abscess is
  ripe, it either opens of itself, or it must
  be opened, i. 102;  small abscesses just
  beneath the skin, and those in glandular
structures,  should alone be- allowed to
burst, i. 102; circumstances under which
the early opening of abscesses is required,
i. 103;  circumstances  under which ab-
scesses  are opened late, i. 103; South
recommends  the  early opening  of ab-
scesses  just  beneath  the skin, and in
glandular structures, i. 103; opening of
abscesses,  oneotomia,  effected  by the
knife, escharotics, or the seton,  i. 103;
deep  abscesses  with  thick coverings,
should be opened with a bistoury, i. 103;
South's condemnation  of pressure and
squeezing  an abscess,  i. 104;  mode in
which escharotics are employed, i. 104;
passing a seton through an abscess, i. 104;
opening an abscess with a cutting instru-
ment generally preferable, i. 104; South
on the opening an abscess, i. 105; treat-
ment of cold abscess,  i. 105;  various
plans of opening a cold abscess, recom-
mended by Abernethy, Beinl,  Walther,
Schaack, Rust, Nasse,  Zang, and Calli-
sen,  i. 105 ; in selecting his plan of ope-
rating, the surgeon must be guided by the
difference of constitution, by the more or
less weak state of the cellular walls, and
by the size of the swelling, i. 105; con-
stitutional treatment also required, i.105;
Kluge's plan of treating lyrnph-abscess-
es, i. 106; further treatment after opening
the abscess, i. 107; if there be deficiency
of power in the part, stimulants  may be
used, but moist warm poultices are more
effectual, i. 107; tonics  may  be given
internally,  i.  107; if the opening close
too soon, the  edges may be drawn asun-
der,  or  separated  with  a probe,  i. 107;
proud flesh repressed by caustic, i. 107;
formation of  fistulous  passages, i. 107;
membrane  of the fistula first pointed out
by Hunter, since described by  Villerme,
Laennec, and Breschet, i. 108 ;  Hunter's
description of the membrane of the fistula,
i. 108; treatment of the fistulous passage,
i.108; plans of treatmentrecommended by
Langenbeck, H.Dewar,Cramer,Walther,
and others, i. 108;  Langenbeck's recom-
mendation of the ligature, i.109; attention
to the general health requisite during sup-
puration, i. 109;  treatment of induration,
i. 109; first indication to promote resolu-
tion, i. 109;  the second, its removal by
the knife, i. 109; treatment of  gangrene,
i. 109 ;  when connected with  active in-
flammation, and inflammatory fever, mo-
derate antiphlogistic treatment  to be em-
ployed, i. 110; if caused by the constric-
tion  of  unyielding  aponeuroses, they
must be divided, i. 110; when  connected
with general  debility, tonics and mineral
acids indicated, i.  110;  local  treatment 
ANALYTICAL INDEX.                       871
 of gangrene, i. 110; if there be active in-
 flammation, soothing poultices ;  if the
 part be  free from pain  and   shrivelled,
 stimulant  applications  are required,  i.
 110; remedies which prevent the influ-
 ence of the gangrenous juices, i.110; their
 action aided by scarifications in  the gan-
 grenous parts, i. 110 ; the latter must not
 penetrate into the living parts, i.  Ill; the
 scarifications are  dangerous in gangrena
 senilis, i. Ill; amputation not applicable
 in  gangrene depending  on an  internal
 cause still  in operation, i. Ill;  applica-
 ble  after the  line of demarkation  has
 formed, or in gangrene from external vio-
 lence, even while  still  proceeding,  i.
 Ill; South's  opinion that  amputation
 should never be performed while  the gan-
 grene is in progress, i. Ill; treatment of
 senile gangrene, i. Ill;  when resulting
 from an injury, soothing  or dry aromatic
 applications, or leeching  if the inflamma-
 tion be  active, i.  Ill;  Dupuytren  em-
 ploys  the  antiphlogistic  plan of treat-
 ment in plethoric subjects, i. Ill ; when
 from constitutional  causes,  tonics  and
 opium are  necessary, i. Ill; treatment of
 gangrene from  pressure, i. 112;  from the
 use of spurred rye, i.  112; Thomson
 and S. Cooper's cases, i. 113; treatment
 of malignant pustule, i. 113 ;  local treat-
 ment by cutting out  the  pustule,  and
 cauterizing the wound, i. 113 ; if pustule
 not deep, but the  slough much  spread,
  deep scarifications, and the application of
 caustic recommended, i.  113;  employ-
 ment of  constitutional treatment, i. 113 ;
  treatment  of hospital gangrene, i.  113;
  emetics  advised  by  Pouteau  and  Dus-
 sausoy, i.  113; washing the sore with
 vinegar, or solution of arsenic at the
 commencement of the  disease, i. 113 ;
 the entire surface to be touched  with ni-
 trate of silver, i. 114;  the free  applica-
 tion of the actual cautery most effectual,
 i. 114;  constitutional treatment should
 be employed at the same time, i. 114.
Inglis, Dr., on the age at which  broncho-
 cele most usually occurs, ii. 389; objec-
 tions  to Coindet's  mode  of  exhibiting
 iodine, ii.  394.
Ingrowing of the nail, i. 221; causes, i.
 221;  Wardrop and  Dupuytren on in-
 growing of the nail, i, 222;  Dupuytren
 states it has been  mistaken for  gout, i.
 222; Colles on the ingrowing of the nail,
 i. 222; Colles  on  the disease of the nail
 liable to  be mistaken for gout, i. 223;
 treatment in slight cases, i. 223;  Desault,
 Richerand, and Biessey's plans  of treat-
 ment, i. 223 ; Zeis on the introduction of
 charpie under  the edge of the nail, and
  the use of foot-baths,i. 223; Meig's plan of
  treatment by a compress and linen-roller,
  i. 223 ;  Sir  A. Cooper says the applica-
  tion of a blister will bring away the nail,
  i.224; this opinion contravened by South,
  i. 224; Dupuytren's operation for dividing
  and removing the diseased nail, i. 224;
  Scoutteten's operation for the destruction
  of the matrix of the nail,  i. £24; the
  operation recommended  by Pare, Faye,
  Michaelis,  Sachs, and Zeis, i. 224; Sir
  Astley Cooper's operation, i. 224; Colles
  and South condemn Cooper's operation,i.
  224; Colles' operation, i. 225.
Inguinal rupture and its varieties, ii. 316.
Innominata, ligature of, ii. 521.
Internal strangulation, ii. 359.
Intestines, Wounds of, i.  507; symp-
  toms, i. 507;  Travers,  Green, Tyrrell,
  and South's cases of wounded intestines,
  i. 507, 508; Travers  on wounds of the
  intestines communicating directly with
  the surface, i. 508; varieties of  wounds
  of the intestines, i. 508; Travers on the
  varieties of wounds  of  the intestines, i.
  508; difference of opinion as to the treat-
  ment of  wounded and  protruded intes-
  tine, i. 509 ; different  kinds of stitches
  employed, i. 509 ; Scarpa and Larrey's
  practice, i. 509; Denans, Beclard, Jobert,
  Lembert,  and  Reybard's  practice  in
  wounded intestine,  509, 510;  Shipton
  and  Travers'  experiment,  511 ;  Else,
  Benjamin Bell,  John Bell, and  Hennen
  on  the  use of  the suture  in wounded
  intestine, 511, 512, 513;  objections to
  the use of stitches in  wounded intestine,
  i. 513 ;  reasons in favour of  their use, i.
  513; Travers on the objections to returning
  a  wounded  intestine,  without suture,
  into the  abdomen, i. 514;  Travers and
  Benjamin  Bell   on  the withdrawal  of
  the suture, after union has  taken place,
  i.  514;  Travers'  directions for stitching
  a  wounded intestine, i. 514; approval
  of Lembert's plan,i. 515; Astley Cooper's
  practice in  small wounds  of the  intes-
  tines, i.  515; Dupuytren's  modification
  of  Lembert's plan, i. 515;  Travers
  on  the reparation by artificial  connex-
  ion of the  divided parts of a wounded
  intestine, i. 516;  treatment  of a perfectly
  divided  intestine, one  end  only  being
  found,  i. 516;   treatment   of  wounded
  intestine, i. 516; treatment of wounded
  intestine when  the faeces escape by the
  wound,  i.  516;  Travers and South  on
  the treatment  of wounded intestine with-
  out faecular discharge or prolapse, i. 517;
  Travers  on  spontaneous  reparation  in
  wounded intestine, i.  517;  contraction of
  the intestine  sometimes the result of a 
.L  INDEX.
872                      ANALYTICS

  wound, i. 517; effusion of faecal matter,
  blood,  or  other  fluid constitutes  the
  most dangerous complication  of  pene-
  trating wounds of the abdomen, i. 517;
  Travers  and  Hennen on effusion into
  the cavity  of the abdomen under such
  circumstances, i.  518; extravasation of
  the intestinal contents, i. 518; Travers
  on the impediments  to effusion of the
  intestinal contents, i.  518; symptoms of
  effusion, i. 519; effusion of blood into the
  cavity of the abdomen,  i. 519; the ef-
  fused blood is either collected in  a  cir-
  cumscribed  space, or diffused over the
  abdomen, 520 ; treatment of  extravasa-
  tion, i. 520 ; Hennen's case  of musket-
  shot  wound  of the  abdomen,  the ball
  passing afterwards per anum, i. 520; fo-
  reign bodies in the intestines, iii. 104.
Introduction:—definition of surgery,  i. 13;
  division of,  i. 15.
Ippolito,  Nunciante,  on ligature of  the
  vertebral artery, ii. 527.
Ireland on the use of arsenic in the bites
  of the great lance-headed viper of Mar-
  tinique, i. 396; operation for prolapsus
  uteri, ii. 379.
Ischiatic artery, ligature of, ii. 535.
--------rupture, ii. 350.
Ischuria, and its varieties, iii. 125.
Issues, making of, iii. 617.

Jacobson's lithotritie  instrument, advan-
  tages and disadvantages of, iii.  288.
Jacquier's case of reduction of the conse-
  cutive dislocation  in  hip disease, i. 297.
Jaeger on the mercurial treatment  in hip
  disease, i. 296; on the general treatment
  of coxalgy, i. 296;  views on the reduction
  of consecutive dislocation in coxalgy,  i.
  297 ; on  the treatment of abscesses of the
  hip. i. 298;  recommends  free  incisions
  in opening these abscesses, i. 298; exci-
  sion of the carious  head of the  thigh-
  bone  recommended by, i. 299; opinion
  that the  preparations  of fractured  spine
  united by  callus, only  show that  the
  fracture may be cured, but not the palsy,
  i. 583; on the operation for trepanning a
  fractured spine, i. 590; treatment of frac-
  tured clavicle, i. 605; case of imperfect
  fracture  of the coronoid process of the
  ulna, i.  615 ;  on the inlocking of the
  ends of the bone in fracture of the neck
  of the femur, i. 618;  objection to  dress-
  ing  the  wound after  the  operation for
  rectal fistula, ii.  167; on  the division
  of the  sphincter  muscle in recto-vesi-
  cal and recto-urethral fistula,  ii. 185;
  on the  treatment  of vesico-vaginal fis-
  tula   by drawing off  the  urine,  and
  by compression, ii.  189; on the nature
  of strangulation in rupture, ii. 269; on
  the seat of exostosis, iii.  408; on  the
  blood fungus, iii.  461 ; plan of amputat-
  ing the thigh with the flap from the outer
  side, iii. 660;  on amputation at the hip-
  joint, iii. 688 ; mode of operating by the
  circular cut, iii. 689;  on the statistics of
  the operation  for exarticulation  of  the
  leg at  the  knee,  iii. 699;  mode  of ope-
  rating in exarticulation of the fore-arm at
  the elbow, iii. 719;  case of excision of
  part of  the hand, iii. 722;   on  the exci-
  sion of joints, iii. 727; statistics of cases,
  iii. 728; recommends the non-division of
  the ulnar nerve in excision of the elbow-
  joint, iii. 734;  mode of operating in ex-
  cision of the elbow-joint, iii. 734 ; in ex-
  cision of the lower  ends  of the radius
  and ulna,  iii. 734;  in excision  of the
  knee-joint, iii. 740; on the mode of union
  after the  operation, iii. 741 ;  mode of
  operating in  excision of the ankle-joint,
  iii. 743; on  excision of the lower jaw
  with the condyles, iii. 749;  on the pre-
  vious ligature of the carotid artery,  iii.
  750.
James' case of dislocation of the astragalus
  outwards, ii. 252; case of ligature of the
  aorta, ii. 531 ; case of tearing away the
  upper arm and scapula by machinery,
  iii. 763.
Jameson's plan of inhealing a plug of skin
  for the  radical  cure of rupture, ii. 283;
  instrument for  oesophageal  stricture, iii.
  32 ; treatment of  stricture of the urethra,
  iii. 85.
Jamieson's case of accidental cerebral rup-
  ture, ii. 365.
Janson's case  of resection of the scapula,
  iii. 762.
Jaw, lower, fracture of, i. 579; dislocation
  of, ii. 209; excision of, iii. 745; cases
  requiring the operation, iii. 745; circum-
  stances admitting a favourable result, iii.
  745 ;  priority of claim as  originator of
  the operation, iii. 745; Tyrrell's case of
  necrosis of the  lower jaw, iii. 745 ; exci-
  sion of the middle of the lower jaw, iii.
  746 ; mode of operating, iii. 746; retrac-
  tion of the tongue, iii. 746 ; Dupuytren,
  Graefe, and  Astley  Cooper's cases,  iii.
  746 ; removing a portion of the side of the
  lower jaw without the condyle, iii. 747 ;
  mode of operating,  iii. 748; Deadrick,
  Mott, and  Wardrop's cases, iii. 748; ex-
  cision of the  lower jaw with its condyles,
  iii. 748;  Mott, Schindler, von  Graefe,
  Syme, Jaeger, and  Cusack's modes  of
  operating,  iii.  749;  Mott, von  Graefe,
  Dzondi, Jaeger,  and Schindler  on  the
  previous ligature  of the  carotid  artery,
  iii. 750;  White's case of excision of 
ANALYTICAL TNDEX.
873
•  the  lower  jaw, iii. 750; Graefe  and
  Mott's cases of exarticulation of one side
  of the lower jaw,  iii.  751 ; Cusack on
  the  non-necessity  of tying the carotid
  artery prior to the operation,  iii.  752;
  Cusack's cases of exarticulation of  the
  lower jaw,  iii. 752; Liston's mode of
  operation, iii. 752; Perry's case of ne-
  crosis of the lower jaw, iii. 753.
Jaw, upper, fracture of, i. 578; resection of,
  iii. 753;  cases in which the operation is
  indicated, iii. 753 ; Dupuytren's  cases of
  extirpation  of the upper jaw doubted by
  Gensoul, iii.  754;  Akoluthus' case, iii.
  754;  Dr. T. White's case   of almost
  complete extirpation of the upper jaw, iii.
  754; mode of operating, iii. 755; section
  of the skin  and  muscles, according to
  Gensoul  and  Dieffenbach, iii. 755;  Li-
  zars the first to recommend the entire re-
  moval  of the upper jaw, iii. 755; his
  description of the proposed operation, iii.
  755;  Lizar's cases in which he  attempt-
  ed to perform the operation, but failed on
  account  of the  haemorrhage, iii. 756;
  Lizar's  cases in  which  he  performed
  the operation, iii. 756;  Gensoul's case of
  extirpation  of the  superior  maxillary
  bone, iii. 756; cutting away the diseased
  jaw, iii. 757; Heyfelder's operation for
  the resection of both jaws, iii. 758; Syme,
  Liston, and Fergusson's modes of ope-
  rating, iii.  758; O'Shaughnessy's  case
  of removal of the upper jaw, iii. 759; Het-
  ling's case of osteosarcoma of the jaws,
  in which he removed part  of  the upper,
  and part of the lower jaw, iii.  760;  Lis-
  ton on M>e prospect  of ultimate success
  in this operation in  cases  of malignant
  disease,  iii.  761 ;  dressing the wound,
  and  after-treatment,  iii. 761;  dangerous
  symptoms  which  may occur after the
  operation, iii. 761; recurrence of the dis-
  ease, iii. 761.
Jeaffreson on the extirpation of the ovary,
  iii. 210; case of extirpation of the ovary,
  iii. 211; on the statistics of the operations1
  for ihe extirpation of the ovary, iii.  213.
Jenner's,  Dr.,  discovery  of vaccination,
  iii. 622.
Jewel, Dr., on the  distinguishing signs
  between leucorrhea and gonorrhea, i. 181.
Joachim's artery-compressor, i.  331.
Jobert's practice  in wounded  intestine, l.
  509 ; on the introduction of the seton in
  false joints, ii. 20;  on the treatment of
  vesico-vaginal fistula by transplantation,
  ii. 195; case of ligature of the  popliteal
  in the internal epichondyloid  pit. ii.  543.
Johnson's, Dr., case of obstruction of the rec-
  tum, by a large collection of peas, in. 10H.
Joikts, excision of, iii. 726; first performed
      Vol. iii.—74
on  the  knee-joint,  iii. 726;  afterwards
extended to the  other joints, iii. 726;
Filkin, Vigaroux, David, White, Bent,
Orred, Park, Moreau, Graefe, and Davie's
cases, iii. 726;  Sabatier, Percy,  Roux,
Moreau, Larrey, Guthrie, Syme, Textor,
and Jaeger on the excision of joints, iii.
726; Wachter, Vermandois, Kohler, and
Chaussier's experiments, iii. 727; objec-
tions  to this operation as compared  with
amputation, iii. 727; advantages  of the
operation,  principally referable to  the
joints of the upper  extremities, iii.  727;
not so great in  operations on the other
joints, iii. 727; statistics of Jaeger, Syme,
and Moreau's cases, iii. 727;  Crampton
on the excision of joints, iii. 728; cases
in which excision of the ends of bones is
preferable  to  amputation, iii. 728;  con-
tra-indications to the operation, iii.  729;
mode of operating, iii. 729; direction and
extent of the incision in  the skin, iii.
729 ;  excision of the diseased bone, iii.
729 ;  extent of  bone required  to be re-
moved, iii. 729; instruments for excising
the ends of bones, iii. 730; arrest of the
subsequent haemorrhage, iii. 730; dress-
ing the wound, iii.  730; after-treatment,
iii. 730;  untoward occurrences  during
the after-treatment, iii. 731;  after-bleed-
ing, iii. 731;  abscesses, iii.  731  ;  fistu-
lous passages, iii. 731 ;  necrosis  of rare
occurrence after this operation, iii. 731;
after-treatment of the sawn ends of the
bone, iii. 731;  excision  at  the shoulder-
joint, iii. 731 ; mode of  operating in ex-
cision of the  head  of the humerus, iii.
732;  C. White, Orred,  Bent, Sabatier,
Moreau, and Syme's modes of operating,
iii. 732; motions of  the arm subsequent
to the operation, iii. 732  ; excision of the
elbow-joint, iii. 733; Moreau's mode of
operating, iii. 733; Dupuytren and Syme's
modes of operating, iii. 733; Moreau on
the division  of  the ulnar nerve  in this
operation,  iii. 733;  Dupuytren, Cramp-
ton, Jaeger, and Syme   recommend its
 preservation, iii. 733; Jaeger's mode of
 operating, iii. 734;  condition of the arm
 after excision of the elbow-joint, iii. 734;
 Crampton  and  Syme's  cases, iii.  734;
 excision of the wrist-joint, 734 ; Roux and
 Jaeger's modes  of  operating in excision
 of the lower ends of the  radius and  ulna,
 iii. 734 ; dressing  the wound and  after-
 treatment,  iii.  735} Dubled and  Vel-
peau's operation, iii. 735; Butt's case of
 excision of part of the necrosed ulna, iii.
 ■735; excision of the hip-joint, iii. 735;
mode of operating, iii. 735;  by a simple
longitudinal cut, iii.  736; by the forma-
tion of a flap, iii. 736; by Textor's oval 
874
ANALYTICAL INDEX.
  cut, iii.  736; dressing the wound, iii.
  736; White,  Carmichael, Oppenheim,
  Hewson, Seutin, and Textor's cases, iii.
  737; C. White on excision of the  head
  of the femur, iii. 737; A. White and  Fer-
  gusson's cases of excision of the head of
  the  femur, iii. 738, 739; excision of the
  knee-joint, iii.740; Moreau, Park, Mulder,
  Sanson, Begin, Jaeger, and Syme's modes
  of operating, iii. 740 ; Jaeger's  operation
  preferred, iii. 740;  Moreau, Park, and
  Jaeger on the  mode  of union  after the
  operation, iii. 740;  Syme  on the treat-
  ment after  the operation, iii.  741  ; A.
  White's case of compound  dislocation of
  the  femur behind the leg, iii. 741; ex-
  cision of the ankle-joint, iii. 742; Moreau,
  Jaeger,  Mulder, and Kerst's  modes of
  operating, iii. 743;  South on excision of
  the  ankle-joint, iii. 743;  dressing  the
  wound, and after-treatment, iii. 744 ; ex-
  cision of the joints of the metacarpus and
  metatarsus,  iii. 744; mode  of operating,
  iii. 744; after-treatment, iii. 744; Textor,
  Kramer,Roux,and Fricke's'cases,iii.744.
Joints, Inflammation  of :—inflammation
  may be set up as the primary disease in
  any part of the joints, such as the  liga-
  ments,  synovial membranes, cartilages,
  and spongy ends'of the bones, i. 229;
  Hunter  on  inflammation of the joints, i.
  230; causes  and nature,  230; Inflam-
  mation of the ligaments, i. 230; Brodie
  on the rarity of affections of the ligaments j
  independent of other structures, i.  230;
  Mayo's  case of injury to the  ligaments
  of the  knee, i.  230;  Wickham's obser-
  vations on inflammation of the ligaments,
  i. 231; symptoms of acute inflammation
  of, i. 231; South on  the absence of dis-
  criminating signs between acute inflam-
  mation of the ligaments and rheumatism,
  i. 231; symptoms of chronic inflamma-
  tion of the ligaments, i. 232; terminations
  of the acute and chronic form of inflam-
  mation, i. 232; changes of structure in
  the joints,  i. 232; Key on ulceration in
  ligamentous fibre, i.233; South  on relaxa-
  tion of the ligaments, i. 233;  treatment
  of inflammation of, i. 233 ; treatment of,
  thickening and swelling of  the cellular!
  tissue, i. 233; of suppuration external to
  the joints, i. 234; of suppuration internal
  to the joints, i. 234; this latter malady is
  Wickham's disease of the  cellular mem-
  brane of joints, i. 234; Wickham's de-
  scription of the disease, i. 234 ; South's
  cases of abscesses external to the joint,
  i. 235;  South on the position of the limb
  during disease of the knee-joint, i. 235;
  Inflammation of the synovial membrane, i.
  235; W. Hunter on the structure of sy-
novial membrane, i. 236; Henle  on the
continuity of synovial membrane over the
cartilage of joints, i. 236; Toynbee on the
synovial membrane, i. 236; Clopton Ha-
vers,  and  Goodsir on the mucilaginous
glands, i. 237; Brodie on the diseases of
the synovial membranes, i. 237;  symp-
toms  of inflammation of, i. 237; Brodie
on the two varieties of synovial inflamma-
tion, i. 238 ;  Brodie's case of acute syno-
vial inflammation terminating in suppu-
ration and  ulceration, i. 238; Wickham's
case of synovial inflammation terminating
in ulceration, i. 239; suppuration  of the
synovial membrane, after wound  of tbe
joint,  i. 239 ; Brodie on the sub-acute or
chronic form of synovial inflammation, i.
239;  symptoms  and progress of the dis-
ease,  i. 239; Lawrence on the diagnosis
of fluctuation in  synovial  inflammation,
i. 240; Lawrence on hydrarthrus or hy-
drops articuli, i. 241;  Dr. Watson on
the difference  between synovial inflam-
mation and inflammation of the ligaments,
i.241; Astley Cooper on gonorrheal rheu-
matism and gonorrheal ophthalmia,i.242;
Cooper's case  of gonorrheal rheumatism
and ophthalmia,]. 242; Brodie on gonor-
rheal  rheumatism and ophthalmia, i. 242;
Brodie and Lawrence on  the pulpy de-
generation of the synovial membrane, i.
242;  South on  the non-malignancy of
this pulpy degeneration,  i. '243 ; Brodie
on its causes and progress, i. 243; post-
mortem appearances, i. 244;  South on
the nature of the respective diseases, as
indicated by the post-mortem appearances
i. 244; causes of synovial inanimation,
i.  244; prognosis, i. 244; treatment, i.
244; Brodie and  South on the local treat-
ment, i. 245;  if suppuration  ensue, the
swelling should  be punctured early, i.
246;  treatment to be  adopted, after the
inflammation is subdued, there remaining
swelling from effusion  of fluid, i. 246;
South on the use of blisters for promoting
the absorption of the effused fluid, i. 246;
Brodie  on the use of friction in such
cases, i. 246; treatment of the  chronic
form  of inflammation, i. 246; after the
occurrence of suppuration,  with destruc-
tion of the cartilages and bones, i. 246;
South on irritantapplications in the treat-
ment of the chronic form of the disease,
i. 246; South's case of disease of the
synovial  membrane of  the  knee-joint,
attended with evidence of fluctuation, in
which the swelling was punctured with-
out benefit, i. 247: Inflammation of the
cartilages, i. 248; William  Hunter on the
structure  of cartilage, i. 248; Miescher
says  " no difference between permanent 
ANALYTICAL  INDEX.
875
cartilage and that which is to be con-
verted into bone," i. 249; he differs in
opinion with W. Hunter  as respects the
fibrous structure  of articular cartilage, i.
249 ; Todd and Bowman consider there
is a difference between  temporary  and
articular cartilage, i. 249; Henle on the
fibrous structure of articular cartilage, i.
249;  Henle and Toynbee on  the non-
vascularity of cartilage,  i.  250; Toyn-
bee on  the  development of cartilage,
i. 250;   Toynbee  on  the  supply  of
nutrient  fluid to  articular  cartilage,  i.
250;  Toynbee on the vessels by which
the articular cartilages  are nourished, i.
251; Toynbee's description of the canals
in  adult cartilages, i.  252;  Meckel, Bi-
chat, and Muller on the vessels of carti-
lage, i. 252, 253; Brodie's  opinion  that
cartilages are vascular, i.  253;  Toynbee,
Beclard,  and Cruveilhier distirictly of
opinion that cartilages are devoid of vas-
cularity, i. 253 ;  W. Hunter's  views on
the structure  of cartilage generally cor-
rect, i. 253; symptoms of inflammation
of cartilage, i. 253; Mayo on three distinct
forms of ulceration of joint-cartilages, i.
254; Wilson on inflammation of cartilage,
i. 254; Hunter,  Wilson, and Brodie, on
the ulcerative absorption of, i. 254, 255;
Lawrence on ulceration of cartilage as an
original  affection of the  joints, i. 255;
Key on the conditions under which ulcera-
tion of the cartilages is effected, i. 255;
Key on the absorption of cartilage by a
new membrane produced by inflammation
of the  synovial membrane, i. 256; Key
on  the progress of ulceration in cartilage,
i. 256; Goodsir holds with Key that the
deposit from the synovial membrane is the
cause of ulceration in cartilage, i. 257 ;
accordance of Key's views with those of
Wilson, i. 258; Key on the changes in the
synovial  membrane, when suppuration is
the result of a wound in it, i. 258; they
induce ulcerative absorption of the articu-
lar  cartilages, i. 258; Brodie does not ac-
cord with Key's views, and considers that
absorption of cartilage may take place
under such circumstances as  to admit of
no other agrency  than that of the vessels
of the cartilage, i. 259 ; Lawrence's case
of  rapid  ulceration of cartilage, i. 260;
Lawrence on the necrosis of long bones as
a cause of inflammation and absorption of
cartilage, i. 260; Key on the formation of
an adventitious membrane in joints under
such circumstances, i. 261;  this is a re-
pairing process, preparatory toanchylosis,
r. 261; Henle explains the absorption of
cartilage from want of nutriment, l. 261;
Key on ulceration of cartilage, an action
altogether  different  from absorption,  i.
261 ; Key on the process of  ulceration
generally, i. 261; Key on the process by
which ulceration of the cartilage is effect-
ed, i. 261;  it leads  to the formation of
abscess, i. 262; post-mortem appearances,
i. 262; Schumerand Gendrin never found
any trace of inflammation in cartilage,  i.
262;  Brodie and South consider  ulcera-
tion of cartilages differs from common
inflammation of the synovial membrane,
and of the spongy ends of bones, i. 262;
Brodie on  the degeneration  of cartilage
into a fibrous structure, i. 2b3;  this change
Key describes as the third mode of ulcera-
tion of cartilage, i. 263; causes of the
disease, i. 263 ; Brodie on the period at
which ulceration of the articular cartilages
may occur,  i. 264; prognosis always un-
favourable,  i. 264; treatment, i. 264; In-
flammation  of the joint-ends of bones,  i.
264; symptoms, i. 264; Brodie on inflam-
mation of the joint-ends of the bones, its
symptoms and progress, i. 264; Brodie on
the consequence of this inflammation,  i.
264 ; Key on the two forms of disease in
the bone, resultingin absorptionof the car-
tilage, i. 265;  the chronic form  is of a
strumous nature, i. 265; the acute form
differs from the former in the suddenness of
the attack, and in the appearance of the
bone, i. 265; progress of the acute disease,
and appearance of the bone, i. 265; Good-
sir on the scrofulous disease of the cancel-
lated texture of the heads of bone, i.  266 ;
post-mortem appearances, i. 266; situation
and causes of the disease, i. 266;  Brodie
and Key on  the period at which itis likely
to occur,  i. 266;  Brodie observes  that
it is likely  to occur in several joints at
once, or in succession, i. 266;  Brodie and
South's opinion that the occurrence of
scrofulous disease in the joint has sus-
pended the  progress  of some other and
perhaps more serious disease elsewhere, i.
266;  Brodie on the  diagnosis between
scrofulous  disease of the joint-ends of
bones and ulceration of the articular car-
tilages, i. 267; prognosis and treatment, i.
267; favourable consequences  of  ulcera-
tion of  the cartilages, i. 267 ;  may occur
in one  of two ways,  i 267;  in the first
the cartilage is  replaced by a layer of
ivory-like bone, and the  motions of the
joint continue, i. 268 ; in the second, the
opposed ends of the  bones  are  united,
either by a ligamento-fibrous structure or
by  bone, i. 268 ; South has seen the con-
necting medium composed partly of liga-
mento-fibrous, and partly of bony  matter,
i. 268;  South on the  ivory-like covering
of the joint surfaces of bones, i. 268; Key 
876
ANALYTICAL  INDEX.
 and Toynbee on the removal of the arti-
 cular cartilages in  old age, i. 26S; South
 and Brodie on the removal of the articular
 cartilages in old age as the result of pre-
 vious ulceration, i. 268; John Hunter on
 anchylosis, i. 268;  anchylosis effected by
 the whole substance of the articulation, i.
 268; of two kinds, i. 269; Hunter on the
 inflammatory and scrofulous diseases  of
 joints causinganchylosis,i.269; Hunter on
 soft anchylosis from granulations, i. 269 ;
 Hunter on bonyanehylosis, i.269; South's
 views on anchylosis differ somewhat from
 those of Hunter, i. 269;  South on soft
 anchylosis from granulations, i. 269; Key
 on the formation of a vascular membrane
 in joints as a preliminary to anchylosis,
 i. 270; South's case of fibrous anchylosis,
 i. 270; South's case of the complication
 of  bony  and fibrous  anchylosis, i. 271;
 Hunter's case of soft anchylosis from the
 extension of inflammation from the  sur-
 rounding parts to the joint, i.272; Mayo's
 caseof injury to the ankle, followed by ab-
 sorption of the cartilages, and effusion and
 organization of lymph between the ends of
 the bones, i. 273; process of bony anchy-
 losis, i. 274 ; the most important form  of
 bony anchylosis,  i.  274; Cruveilhier's
 case of bony anchylosis of the right con-
 dyle of the lower jaw, i. ^74; other kinds
 of anchylosis, i. 274; treatment of the soft
 or ligamento-fibrous  anchylosis, i. 274;
 Velpeau  on the treatment of complete
 anchylosis, i. 275;  Barton's  operation  of
 cutting out a wedge-shaped piece of bone,
 i. 275; also performed by Gibson, i. 275;
 operation for the establishment of a false
joint, i. 275 ; Velpeau favourable to this
 proceeding, i. 275; performed by Barton
 and  Rodgers with success, i. 275; the
 operation of breaking through the anchy-
 losis, i. 275; condemned by Velpeau, i.
 275; Amussat's case, i. 275; Velpeau on
 the  consequences of the adhesion of the
 knee-pan to the condyle  of  the femur,
 i. 276; Louvrier's apparatus for the rup-
 ture of the anchylosis, i.  276; Velpeau's
 objections to the use of that apparatus,  i.
 276 ;  hysterical affections of  the joints,
i. 277; Brodie on the symptoms of hyste-
rical affections of the joints, i. 277; Tyr-
 rell on the diagnosis between inflamma-
tion and hysterical affections of the joints,
i. 277; Bell's case  of hysterical affection
of the hip-joint, i. 277; Coulson's case, i.
278;  Coulson  on the symptoms of  this
disorder, i. 278; Goodlad's objection  to
the  term  "hysterical" being applied  to
 these affections, i. 278; South on the con-
 stitutional treatment of the  disorder,  i.
 278; Brodie and Goodlad on the local ap-
plications,!. 278; inflammation of the hip-
joint (coxalgia,) i. 278; the three stages of
the disease, i. 278;  symptoms of acute
inflammation of the hip-joint, i. 279; Key
on the greater frequency of chronic than
of acute inflammation of,  i. 279 ; symp-
toms when suppuration takes place,i. 279;
symptoms of first stage of chronic inflam-
mation of the hip-joint, i. 279; Brodie on
ulceration  of the cartilage, the primary
affection in diseased hip,  i. 280; Key's
opinion that the ulceration of the cartilages
is proceeded by inflammation of the liga-
mentum teres,  i.  280;  South  on  the
pain on the inside  of the knee in hip-
disease, i, 280 ; Bell  and  Coulson's ex-
planation of that symptom, i. 280; symp-
toms  of the second  stage of  chronic
inflammation of the  hip-joint,  i. 280;
Astley Cooper on the second  stage of
hip disease, i. 280; Key on the symptoms
which indicate the special part  of the
joint affected, i. 281; symptoms  of the
third  stage, i. 281 ; Fricke's method of
examining the length  of the limb during
the progress of the disease, i. 281; Astley
Cooper and Coulson on the  bursting of
abscesses  of the hip-joint, i. 282;  Dr.
Mackenzie and Scott's cases of abscesses
of the hip-joint, i. 282; Brodie on the
difference  between hip disease from ulce-
ration of the cartilage, and that from scro-
fulous deposit in the cancellous structures
of the  bones,  i. 282;  shortening and
lengthening of the diseased limb, i. 284;
Hunter on these symptoms, i. 284; Cline
and Lawrence on these symptoms, i. 284;
the shortening only apparent, i. 284; Rust
and Fricke's explanation incorrect, i. 284;
South on the shortening of the limb, i.
284; the lengthening of the limb may be
either seeming or real, i. 285; explanation
of the lengthening of  the limb by Petit,
Camper, Valsalva, Monro, Van der Haar,
de Haen, Vermandois, Schwenke, Calli-
sen, Plenck, Portal,  Ficker,  Duverney,
Clossius,  Boyer, Falconer, Rust, Lan-
genbeck, Richter, Schreger, Larrey, Che-
lius, Fricke, Brodie, and  Crowther, i.
283; Weber's experiments show that the
head of the thigh-bone is retained in  the
socket by atmospheric pressure, i. 285;
these experiments of great importance in
reference to diseases of the hip-joint, i.
286; South's explanation of the lengthen-
ing of the limb, i. 286; Astley Cooper
on  the lengthening  of the  limb  from
effusion into the joint, i. 286 ; Lawrence
on the lengthening of the limb, i. 286 ;
dislocation of the,head of the thigh-bone,
i. 287 ; Nester, Van  der  Haar, Berdot,
Schreger, and Textor  on the  dislocation 
ANALYTICAL  INDEX.
877
of the head of the thigh-bone downwards j
and inwards, i. 287 ; Hoffman's case of
separation of the head of the femur, and
its removal by the surgeon, i. 287; South
on the appearances after death in hip dis-
ease,  i. 287;  Earle on  dislocation into
the ischiatic  notch, i. 287; Boyer, Bro-
die, and Coulson on dislocation into the
foramen ovale, i. 287;  Ducros jun. on
dislocation forwards on the share-bone,
i. 287; the formation of a new socket, i.
287 ;  Samuel Cooper on the  substance
which fills up  the  acetabulum, i. 287 ;
diagnosis  of  coxalgia  from  congenital
luxation of the thigh, shortening of the
extremity  from recession and twisting of
the hip-bone, nervous sciatica, and ma-
lum coxae senile, i. 288; coxalgia cannot
well be confounded with phlegmasia alba
dolens,  psoas abscess, or primitive dis-
location of the thigh, i. 289; may be con-
founded with fracture of the neck of the
thigh-bone under certain circumstances,
i. 289; Bell on the pain in hip* disease, i.
289 ;  South on the  sympathetic pain in
the hip from disordered bowels, i. 289 ;
South, Smith, Wernherr, Astley Cooper,
and Charles Bell on the morbus coxae
senilis, i.  289 ; Coulson on the diagnosis
between hip disease in the third  stage,
and psoas  abscess, i.  2891; post-mortem
appearances, i. 290; post-mortem appear-
ances in William  Adams' case, i. 290;
etiology of  hip-joint  disease,  i. 291;
Fricke  on the distinction between cox-
algy and coxarthrocacy, i. 291;. prognosis
always unfavourable, i. 291; treatment,
i. 291; in the first stage  of acute coxal-
gia, i. 291; Coulson on salt-water bathing
in hip-disease, i. 292; treatmentof chronic
coxalgia, i. 292; Nicolai and  Klein  re-
commend  the use of the  apparatus for
fractured neck of the femur, i. 292; Phy-
sick on the treatment of coxalgia, i. 292;
Scott's plan  of treatment, i.  293; Law-
rence's observations on  the plan of treat-
ment advocated  by Scott, i   293;  has
been  employed by Fricke with advan-
tage,  i, 294;  treatment of the second
stage, i. 294;  application  of  the actual
cautery, i. 294; Rust objects  to the use
of issues, i. 294; approved of by South,
i.  294;  the actual cautery on burning
cylinders  preferable in all cases  where
the limb is much lengthened, the muscles j
relaxed, and where there is great swell-
ing from collection of fluid, i. 294; Volpi
has not found  benefit from the  actual
cautery, when the first symptoms of dis-
ease occurred in the knee, and  not at the
hip-joint, i. 294 ; Brodie on the influence
of the primary irritation of the issue, and
on the maintaining it by repeated appli-
cations of caustic potash and sulphate of
copper, i. 295; approved of by South, i.
295 ;  Duval's local steam-bathing appa-
ratus, i. 295; Brodie on the use of a seton
in the groin, i. 295; results of the treat-
ment, and management  of convalescence,
i. 296; Rust and Brodie on warm bathing,
i.  296;  Fritz,  Rust, and Jaeger on the
mercurial  treatment, i. 296; Brodie on
the importance of restand position, i. 296;
general treatment in  the first two stages
of coxalgy, i. 297;  Jaeger, Rust, Dieffen-
bach, and Frank on the  general treatment
of coxalgy, i. 297 ; Fricke's plan, i. 297;
treatment of the consecutive dislocation,
297;  reduction  of the dislocation  fre-
quently not successful, i. 297 ; views of
PetitjCallisen, and Jaeger on the reduction
of consecutive dislocation, i. 297; cases
by Berdot,  Hagen,  Ficker, Thilenius,
Mozilewsky, Schneider, B   Heine,  F.
Humbert, M. N. Jacquier, Textor, Volpi,
Schreger, von Winter,  Harless,  Fricke,
and J. Heine, i. 297, 298; treatment of
suppuration, i. 298 ; the abscesses to be
freely opened, 298; Ford, Wend, Van der
Haar, Rust, Brodie, and Jaeger on the
treatment  of these abscesses,  i.  298;
Sabatier and Ficker advise their being
opened with caustic, i. 298; Larrey, with
the red-hot trocar, i. 298 ; Rust, with the
actual cautery, i. 298; Rust advises pass-
ing a seton through the  joint,  i. 299;
Bredie and Jaeger recommend free inci-
sions in opening these  abscesses, i 291;
Brodie and South on the management of
abscesses-at the hip, i.  299;  subsequent
treatment, i. 299'; resection of the carious
head of the thigh-bone, i. 299 ; excision
of the head of the femur recommended by
Jaeger, Kirkland1, Richter, and  Verman-
dois,  i. 299; performed by  White and
Hewson, i. 299"; Kerr  and Baffos exarti-
culated the thigh*bone, i.  299>;  Charles
Bell's proposition, h 299 ; Barry's case of
accidental  reduction' of the dislocation,
i. 299;  inflammation  of the shoulder-
joint—omalgia, \.  300; three stages of
the disease, i.  300; symptoms and re-
sults, i. 300; dislocation-of the  head  of
the bone, i. 300; abscesses and' caries-
of the bone, i. 301; post-mortem; appear-
ances, i. 301; etiology, prognosis, and
treatment,  i. 301;  inflammation of the
knee-joint (gonalgia), i. 301 ; symptoms
and progress, i. 301; difference between
rheumatic and scrofulous white swelling
of the knee-joint, i. 301;  post-mortem
appearances, i. 302; South and Brodie on
the diagnostic symptoms of the diseases
of the knee, i. 302; Brodie on ulceration 
878                       ANALYTICAL INDEX.
  of the cartilages, i. 302; Rainey oa a pe-
  culiar degeneration of  the cartilage in
  disease of, i. 303; Brodie on scrofulous
  disease in the cancellated structure of the
  bones of, i. 304;  progress of caries, i.
  304 ; white swelling, i. 304; application
  of the term, i. 304; the disease very fre-
  quent in Great Britain, but rare in Italy,
  Vienna, and many other parts  of Ger-
  many, i. 3.05.;  Russell and Gotz on the
  appearances of white swelling on dissec-
  tion, i. 305; Nicolaion the symptoms and
  progress of white swelling, i. 305; Nicolai
  on the anatomy of white swelling, i. 306 ;
  prognosis and  treatment, i. 307 ;  inflam-
  mation in the joints of the vertebrae (Pott's
  disease), i. 307; locality and symptoms of
  the  disease, i.  308; curving of the spine,
  i. 308; Pott on the symptoms and progress
  of the disease,  i. 308 ;  caries of the verte-
  brae, the cause of curvature of the spine,
  i. 308 ; connexion of the disease with
  lumbar and psoas abscess, i. 308; Law-
  rence and  Brodie on  the curvature from
  caries, i. 308; Pott on the so-called palsy
  pf the limbs, i. 309 ; Brodie onthe occur-
  rence  of suppuration in caries of the ver-
  tebrae, i. 309;  Brodie on the disappear-
  ance of psoas abscess, and its appearance
  elsewhere,  i 309; Brodie on the pain in
  vertebral caries, i.  309; Brodie on the
  extent of the curvature in dorsal caries,
  i. 309; post-mortem appearances, i. 310 ;
  Brodie, Key, and Lawrence on the patho-
  logy of spinal  caries,  i. 310;. Brodie on
  chronic  inflammation  of the vertebrae,
  with ulceration of the intervertebral car-
  tilage, i. 311;  causes of the disease, i.
  311 ;  diagnosis  and prognosis, i.  311 ;
  diagnostic signs of the disease, accord ing
  to Copland, Wenzel, Stiebel, Melker, and
  South, i.  311  ;  South,  Lawrence, and
  Brodie on the  diagnosis between curva-
  ture of the spine from caries and that from
  rickets, i. 312 ; treatment of the disease,
  i. 313;; Brodie  on the applicability of
  issues  in  this disease, i.. 313;  Astley
  Cooper, Lawrence, and  Brodie  on the
  manner in which the disease is cured by
  anchylosis,  i;  314;  symptoms  of the
  disease in the  cervical vertebrae, i. 315;
  Brodie and Astley Cooper on vertebral
  caries in tho neck, i.  315;  Brodie  on
  abscess  connected with vertebral caries
  in the neckv i.  315 : post-mortem appear-
  ances, i. 316 ; symptoms and progress, of
  the disease in. the sacro-iliac synchon-
  drosis, i. 31G.
Joints, Wounds of, i. 536; symptoms, i.
  536; probing the wound objectionable, i.
  537; danger of  joint-wounds, i. 537; Hun-
  ter  on the suppurative  inflammation of
  wounded joints*i, 537; Astley Cooper on
  wounds of joints, and their results, i. 537;
  treatment, i. 537 ; Astley Cooper's treat-
  ment of wounded joints by a fine suture,
  i. 53H ; Abernethy's practice, i. 538; com-
  mended by South, i. 538;  treatment of
  the accompanying  inflammation, i. 538 ;
  of the suppuration, i. 538 ; cases requiring
  amputation, i. 539;  gunshot-wounds of
  the joints, i. 539.
Joints, Unnatural, ii. 13;  definition, ii.
  14; John  Hunter on  the  formation of
  false joints, ii. 14; causes, ii. 14; Brodie,
  Gibson, and Amesbury on  the formation
  of a false joint, with a fibro-ligamentous
  capsule, and a lining membrane, ii. 14 ;
  false joints most frequent  in the upper
  arm, ii. 14; Amesbury, South, and Astley
  Cooper on the causes of the non-union of
  fractured bones, ii. 14; Macmurdo'scase
  of  false joint of the  humerus, ii. 15;
  treatment  of  false joints,  ii. 15; John
  Hunter on the treatment of false joints, ii.
  15; rubbing the ends of the broken bone
  together, ii. 15; Celsus, Boyer, and South
  on rubbing the ends of the broken bone
  together, ii. 15; Cittadini's case, ii. 16;
  pressure, ii. 16 ; application of pressure,
  ti.  16; application  of blisters, caustic
  potash and tincture of iodine, ii.  16;
  South on  the application of pressure in
  false joints, ii. 16; South  objects to ex-
  ternal  irritation, ii.  17; application  of
  strong  caustics to  destroy  the  cartilagi-
  nous surfaces on the ends of the bones, by
  OHenroth,Clinejun.,Hewson,Weilinger,
  and Kirkhide, ii. 17; Mayor and Hulse's
  plans of treatment, ii. 17 ;  White, Cline,
  Lehmann, and Barton's cases of cure of
  ununited fractures, ii. 17; Cline jun. and
  Hewson's eases of cure by the application
  of caustic potash to  the broken ends of
  the bones, ii.  17 ; the operation of sawing
  off the  cartilaginous ends of the fractured
  bone,  ii.  l~t;  Dupuytren, Pigne, and
  Brodie on this operation, ii. 18  ; Guy de
  Chaujiac's account of  this operation, as
  practised by the Arabian physicians, ii.
  18;  Charles  White and   Lawrence on
  sawing off ihe ends of the broken bone, ii.
  18;  Green's operation  on  an  ununited
  fracture of the femur, ii. 19; South's re-
  marks  on  this case, ii. 19; the introduc-
  tion of a seton, ii. 20 ; Weinhold, Oppen-
  heim,, and Jobert. oa the introduction of
  the seton,  ii.  20; danger  attending the
  use of the seton in oblique fracture, ii. 20;
  Physick on the use of the  seton, ii. 20;
  Fricke and Cittadini's operations for saw-
  ing off the ends of  the fractured bones
  successful, ii. 20.
Joints, cartilaginous bodies in,.iii. 443; am-
  putation through, yL 686„
Jonas on puncturing the distended intestine 
ANALYTICAL INDEX.                        879
  after the  operation for strangulated her-
  nia, iii. 107.
Jqnks' experiments on  the ligature  of ar-
  teries,!. 335; on the application of the liga-
  ture, ii. 492; on the effects produced by
  the ligature on the arterial coats, ii. 493.
Jones, H.  Bence, on the formation of uri-
  nary calculi, iii. 237; on the phosphatic
  diathesis, iii. 247;  on the  treatment of
  uric acid gravel, iii.  259;  on the treat-
  ment of the oxalic diathesis, iii. 261; on
  the treatment of the phosphatic diathesis,
  iii. 264.
Jones', Dr. Wharton,  description  of the
  phenomena of  inflammation under the
  microscope, i. 41 ; on exudation, i. 45 ;
  on the process of union  by adhesion, i.
  322; on healing by the second intention,
  or granulation, i. 326.
Jorg's apparatus  for  keeping  the  head
  straight in wry-neck, ii. 423; on  the in-
  fluence of spinaJ curvature on the trans-
  verse diameter of the pelvis, ii. 427.
Josse's apparatus for fracture of the neck of
  the femur, i.  623.
Joubert on the acarus scabiei, ii. 66.
Jourel's case of puncturing the womb  in
  retroversion, ii. 412.,
Judd on hydriodate of  potash in  syphilis,
  ii. 101.
Junod's apparatus to cause derivation of the
  blood, ii. 101.
Kaltenbrunner on the formation  of new
  vessels,  i. 324,
Kayser on the statistics of  the Caesarian
  operation, iii. 157.
Keate's operation for stone in infants, iii.
  297; case of chimney-sweep's cancer on
  the cheek, iii. 560.
Keckely's apparatus for fractured clavicle,
  i. 603.
Keith's, Dr., case of vesico-vaginal fistula
  cured by a calculus in the bladder acting
  as  a valve to prevent  the  discharge of
  the urine, ii. 197.
Kellie's, Dr.,  remarkable case of exposure
  to cold,  i. 145.
Kendrick  on  the treatment of  haemor-
  rhage consecutive  to  the extraction of a
  tooth, ii. 141.
Kennedy's case of gunshot  wound  on the
  right side of the thyroid cartilage, i. 482;
  case of bands in the vagina, iii. 90.
Kentish's plan of treatment of burns, i.
  130; mode of application of stimulants,
  i. 130; disapproval of frequent dressings,
  i. 130.                        .   .   ,
Kern on the application of caustic for the
  radical cure of hernia, ii. 283 ; on ligature
  of the protruded omentum at the abdomi-
  nal ring for the radical cure of rupture,
  ii. 283; operation for stone in women, in.
  352;  mode of amputating at  the knee
  with the flap-cut, iii. 699.
Ker's case of procidentia uteri treated with
  the secale cornutum, ii. 379.
Kerr's mode of amputating at the hip-joint
  by the circalar cut, iii. 689.
Kerst's  mode of operating in excision of
  the ankle-joint, iii. 743.
Key on  ulceration  in ligamentous fibre, i.
  233 ; on the  conditions under which ul-
  ceration of the cartilages takes place, i.
  255; on the absorption of cartilage by a
  new membrane produced by inflammation
  of the synovial membrane, i. 256; on the
  progress of  ulceration in  cartilage, i.
  256; accordance of his views with those
  of Wilson, i. 258 ; on the changes in the
  synovial membrane, when suppuration is
  the result of a wound in it,  i. 258;  they
  induce ulcerative absorption of the  arti-
  cular cartilages, i. 258 ; on  the formation
  of an adventitious membrane in joints, in
  cases of necrosis of the long bones, when
  it causes inflammation and absorption of
  the cartilages, i. 261; this  is a repairing
  process preparatory to anchylosis, i. 261;
  on ulceration of cartilage, an action alto-
  gether different to absorption, i. 261;  on
  the process of ulceration generally, i. 261;
  on the process  by which ulceration of
  cartilage is effected, i.  261; it leads to
  the formationof abscess, i. 262; describes
  the degeneration of  cartilage  into  a
  fibrous  structure as a third mode of ul-
  ceration, i. 263; on the two forms of dis-
  ease in bone, resulting in  absorption of
  the cartilage, i. 265;  the chronic form is
  of a strumous nature, i. 265;  the acute
  form differs from the chronic in the com-
  parative suddenness of the attack, and in
  the appearance which the bone presents,
  i.  265; on the period at which  the  in-
  flammation in the joint-end of  the bones
  is likely to occur, i. 266 ; on the removal
  of the  articular cartilages in old age, i.
  268 ;■;  on the formation  of a vascular
  membrane in joints, as a preliminary to
  anchylosis, i. 270i; on the greater  fre-
  quency of chronic than of  acute inflam-
  mation of the hip-joint, i. 279; is of opi-
  nion that the ulceration  of the cartilage
  in hip disease is preceded by inflamma-
  tion of the ligamentum teres, i. 280,289;
  on the symptoms which indicate the spe-
  cial part of the joint affected, i. 281 ;  on
  the pathology of spinal caries, i. 310; on
  the propriety of active, general, and local
  depletion in strangulated omental hernia,
  prior to the operation, ii. 272; on the  re-
  duction en masse, ii. 274; advises the
  unfolding the omentum before cutting it
  off, ii. 300 ; on  abscesses in the sac oc- 
880                        ANALYTICAL INDEX.
  casionally reproducing the symptoms of
  strangulation,  ii.  301 ; on the operation
  of dilating the abdominal ring, without
  opening the sac, ii. 302; views with re-
  gard  to this operation, ii.  303; on the
  siorns indicative of gangrene of the  intes-
  tine, ii, 305; case of gangrenous  intes-
  tine, in which a fetid smell was percep-
  tible before the sac was opened, ii. 306;
  on suppuration of the sac, ii. 306; case
  of sloughing  of the intestine  after its
  return into the abdomen, ii. 309 ; on the
  occurrence of gangrene in  the  intestine
  some days after the operation, in persons
  of an enfeebled constitution, ii. 310; on
  the fatal  termination  of cases after the
  operation, when preceded  by great de-
  pression, ii. 311; case of strangulated in-
  guinal rupture, the testicle  being at the
  external ring, ii.  324; on  the seat of
  strangulation in femoral rupture, ii. 335 ;
  on the operation  for  femoral rupture, ii*
  337;  on the post-mortem appearances in
  a case in  which he tied the  subclavian
  twelve years previously, ii  524;  mode
  of operating for stone in the bladder, iii.
  313;  on suppurative inflammation  of the
  cellular tissue surrounding the bladder,
  the most  frequent cause of death  after
  lithotomy, iii. 340;  on the advantages
  and applicability of  lithotrity, iii.  357 ;
  on lithotrity with  reference  to  the size
  of the calculus, iii. 358;  on, the appli-
  cability  of lithotrity  or lithotomy,  ac-
  cording  to the age of the calculous pa-
  tient, iii.  358;  on  the  requisite  con-
  dition of the bladder for the operation of
  lithotrity,  iii 358 ; on irritability of the
  bladder, iii. 358; case of sarcomatous
  scrotum,  iii. 548;  case of exarticulation
  of metatarsal  bones, with  the  diseased
  bones of the tarsus, iii. 710.
Kidneys, wounds of, i. 527;  nature, symp-
  toms, and treatment, i. 527;  stone in,
  iii. 265.
Kilian on the application of the suture in
  vesico-vaginal fistula, ii. 192.
Kino on artificial anus at the  umbilicus,
  connected with the diverticulum ilei, ii.
  158;  on  ligature of the  innominata, ii.
  522;  on the extirpation of the ovary, iii.
  210;  case of extirpation of the ovary, iii.
  211.
Kirby on the effects of the scorpion  sting,
  i. 387; cases in which severe symptoms
  followed  the use of the ligature in  piles,
  ii. 584;  on tracheotomy  in croup, iii.
  115.
Kirkbridk  on the use of caustic to destroy
  the ends  of the broken bone  in   false
  joints, ii.  17.
Kirkland, Dr.,  advises  to let lumbar or
  psoas abscess break of itself, i. 213; re-
  commends the resection  of the carious
  head of the femur in hip-disease, i. 300;
  on the arrest of haemorrhage by nature, i.
  329.
Kleberg on congenital dislocation of the
  knee, i. 248.
Klein recommends the  use of the appara-
  tus for fractured neck of the femur in the
  treatment of hip disease, i. 292; on the
  exhibition  of  prussic acid in  tetanus,  i.
  419; apparatus  for fracture of the neck
  of the femur, i. 624; on the treatment of
  prolapse of the rectum, ii. 401;  on sound-
  ing the bladder, iii. 277; operation for the
  division  of the  middle  branches of the
  facial  nerve,  and  of  the infra-orbitar
  nerve,  iii. 633; operation for dividing the
  facial nerve,  iii. 633;  operation for di-
  viding the inferior maxillary  nerve, iii.
  634; operation for destroying the trunk
  of the facial  nerve at  its  exit from the
  stylo-mastoid foramen, iii. 634 ; the ope-
  ration performed in two cases without a
  permanent cure, iii. 634; considers  it to
  be entirely free from  danger, iii. 635;
  objections  to  the  upper flap  in partial
  amputation of the  foot, iii. 705.
Klimatis on the solution of  the chloride of
  lime in the treatment of foul, gangrenous,
  or torpid ulcers, ii. 44.
Kluge's  plan of treating lymph abscesses,
  i. 106; torsion-apparatus, i. 342; appara-
  tus for fracture of  the lower jaw, i. 580;
  bandage  for fractured  clavicle, i.  603;
  method of  replacement of the  dislocated
  femur, i. 239,  401.
Knee-cap, fracture of, i. 630; dislocation
  of, ii. 247.
Knee-joint, dislocation of, ii. 248;  curva-
  tures  of, ii. 443;  exarticulation of the
  leg at, iii. 699 ;  excision of, iii. 739.
Kohler on the  torsion of bony  vessels,  i.
  344;   experiments on  the excision  of
  joints,  iii. 727.
Kolletscha on the formation of new ves-
  sels, i. 324.
Koppenst^dter's apparatus for fractured
  clavicle, i. 603; fracture-bed,  i. 625.
Kramer's case of  excision of the heads of
  metatarsal  bones,  iii. 744.
Krause  on  the  existence of itch without
  eruption, ii. 64; on the microscopic cha-
  racters of medullary fungus, iii. 458.
Krimer on the removal of the edges of the
  cleft in staphyloraphy, ii. 31; plan for
  bringing the edges of the cleft together,
  ii. 32; operation when  the cleft is very
  large  and  complicated,  ii. 33; on the
  operation of amputation at the hip-joint,
  iii. 688.
Kuh's operation for  varicocele, ii. 578. 
ANALYTICAL INDEX.
881
Kuhl's case  of  ligature of both carotids,
  ii. 508.

Labarraque on the solution of the chloride
  of lime in the  treatment of foul, gangre-
  nous, or torpid ulcers, ii. 44.
Labat's case of bands  in  the  vagina, iii.
  89; modification of the  Indian method
  of rhinoplasty, iii. 584.
Labia, abscess of,  i. 180; enlargement of,
  iii. 399.
Lacerated  and  contused  wounds.    See
  Wounds.
Lacroix on the  nervous symptoms attend-
  ing sudden retroversion of the womb, ii.
  409.
Laennec on the  membrane of the fistulous
  passages, i. 108; on the physical charac-
  ters of dropsy of the pericardium, iii.201;
  on the division of tumours, iii.  381
Lafond, Jalade, on the reduction of con-
  genital dislocation of the femur, ii. 245 ;
  pad with a reservoir for caustic, used for
  radical cure of hernia, ii. 282.
Lalle»iand on iodine in hard swellings of
  the testicles, ii. 100 ; on the appearances
  presented on  post-mortem  examination,
  some time after the cure of artificial anus,
  ii. 155; on cauterization as a  means of
  cure in vesico-vaginal fistula, ii. 190;  on
  the application of sutures in vesico-vagi-
  nal fistula,  ii. 193;  caustic holder for
  stricture  of the  urethra, iii. 83; on  the
  treatment of complete retention of urine
  in stricture, iii. 145 ; on the operation for
  cutting into the urethra in the perinaeum,
  iii. 147;  on the  retention of the catheter
  in the urethra, iii. 150.
Lampe's artery compressor, i. 331.
Langenbeck's   opinion  on  the  lymph-
  swelling, i. 61;  on  the treatment of fis-
  tulous  passages  by ligature, i. 109; treat-
  ment of  long  fistulae  in  the breast, i.
  171; condemned by South, i. 172; on the
  lengthening of the limb in hip-disease, i.
  285; artery-compressor, i. 331; onjiydro-
  phobia as caused by a  qualitative altera-
  tion of the blood by the  poison, i. 410;
  employs  trepanning  in  injuries of  the
  head only when secondary symptoms of
  irritation and  pressure require it, i. 454 ;
  on the  treatment of fractured patella, i.
  632; on  the nature of strangulation in
  rupture, ii. 269; on increased pressure
  and the supine posture in the radical cure
  for hernia, ii. 282;'on ligature of the her-
  nial sac for its  radical cure, n. 283;  on
  excision  of the prolapsed and  scirrhous
  womb, ii. 382; on ligature of the external
  iliac, ii. 538 ; operation for division of the
  inner fold of the prepuce, m. 58 ; on the
  ligature of the carotid, prior to  the extir-,
  pation of the parotid, iii. 525 ; operation
  for amputation of the penis, iii, 545; case
  of extirpation of the cancerous womb, iii.
  569, 570; operation for the division or
  excision of the facial nerve at  the stylo-
  mastoid foramen, iii. 635; operation  for
  flap amputations, iii. 642; mode of ampu-
  tating the  thigh with two flaps, iii. 659 ;
  mode of amputating at the hip-joint with
  the  flap-cut  with  a single flap, iii. 691;
  objections to the upper flap in partial am-
  putation of the foot, iii. 705; mode of
  operating in exarticulation of  the  meta-
  tarsal bone of the great  toe, iii, 709; in
  amputation at the shoulder-joint, iii. 714;
  mode of operating in  exarticulation of
  the  metacarpal bones  of the ring and
  little  fingers, iii. 721,
Langius on mortification from  spurred rye,
  i. 74.
Langlet's case of a ball remaining in the
  brain for eighteen months, i. 439.
Langstaff's case of a madman who  swal-
  lowed a silver spoon,  iii. 104; on tu-
  mours of nerves of stumps, iii. 506.
Larrey's, Baron, plan of treating burns, i.
  129;  on the effects of  frost-bite, i. 145;
  observations on the effects of too suddenly
  warming a frozen or benumbed limb, i.
  148;  on the  lengthening of the limb in
  hip-disease, i. 285; on opening abscesses
  at the hip with the red hot trocar, i. 298 ;
  on the union  of the nerves of a stump in
  loops, i. 365; on amputation in tetanus, i.
  419 ; on the removal of foreign bodies in
  injuries of the brain, i. 438; case of loss
  of memory after concussion, i. 450; on
  the  subsequent effects of the closure of the
  opening in the skull after trephining, i.
  467; case of excision of a portion of a rib
  for  the removal of a ball, i. 490; practice
  in wounded intestine, i.  509; on the treat-
  ment for compound fractures,  i. 561; on
  the  immoveable  apparatus  in  fractured
  ribs, i. 599;  on inversion of the foot in
  fracture of the neck of the femur, i. 618 ;
  apparatus for fracture of the neck of  the
  femur, i. 623; on the internal opening of
  reetal fistula, ii.  162;  moxa of  rotten
  phosphorescent wood,  iii.  631; case of
  amputation through the head of the tibia,
  iii.  670; mode of amputating at the hip-
  joint  with two flaps, iii. 692; at  the
  shoulder-joint, iii. 714; operation for the
  excision of  the  head  of the humerus,
  when fractured by a musket-shot, iii. 717;
  case of  excision of part of ihe hand, iii.
  722;  on excision of joints, iii. 727.
Larrey's, H., cases of regular shaped gun-
  shot wounds, iii.  373.
Laryngotomy, iii. 115.
Laryngo-tracheotomy, iii.  120. 
882                        ANALYTICAL  INDEX.
Larynx, fracture  of the cartilages  of, ii.
  581; wounds of, i. 475;  foreign bodies
  in, iii. 109.
Laserre's apparatus for fractured clavicle,
  i.  603.
Latour's case of accumulation of blood in
  the womb, and  rupture of the organ, ii.
  530.
Latta on tapping lumbar or psoas abscess
  with a trocar, and passing a seton through
  the abscess afterwards, i.  212; his prac-
  tice condemned by South, i. 212.
Lawrence's cases of malignant pustule, i.
  78 ;  on sloughing phagedena, i. 83 ;  on
  incisions in pseudo-erysipelas, i. 125; op-
  posed to the treatment of  erysipelas  by
  moderate  compression,  i.  125;  case of
  alarming  hemorrhage from  puncturing
  an immature tonsillar abscess, i. 162; on
  the hemorrhage following the extirpation
  of the tonsils, i. 166; on  gonorrhoea be-
  nigna  and virulenta, i. 182;  on  gonor-
  rhoea virulenta, i. 183; on lumbar abscess
  generally connected  with  carious  verte-
  brae,  i. 209; supports Abernethy's treat-
  ment of lumbar abscess,  i.  213;  on the
  diagnosis  of fluctuation in  synovial in-
  flammation,  i.  240 ; on hydrarthrus  or
  hydrops arliculi, i.  241;  on  the pulpy
  degeneration of the synovial membrane,
  i. 255;  on ulceration of cartilage  as an
  original aff'ection of the joints, i. 255; case
  of rapid ulceration  of cartilage, i. 260;
  on the necrosis  of long bones as a cause
  of inflammation and absorption of carti-
  lage,  i. 260;   on the lengthening and
  shortening of  the affected limb  in hip-
  disease,!. 284,  286 ; observations on the
  plan  of  treatment advocated  by Scott in
  hip-disease, i. 293 ;  on  curvature of the
  spine  from caries, i. 308;  on  the patho-
  logy  of spinal caries, i. 310 ; on the diag-
  nosis between curvature of the spine from
  caries, and that from  rickets, i. 312;  on
  the manner in which the disease is cured
  hy anchylosis, i. 314; objection to the term
  " inflammation " in reference to union by
  adhesion, ii. 323 ; on the after-manage-
  ment of the ligature on arteries, i. 338 ;
  on the absorption of poisonous  matter
  in  dissection  wounds, i. 384; details of
  Dr. Pen's case, i. 386; on the fatal  effects
  of  the stings of bees and  wasps, i. 387;
  case of hydrophobia, i, 403 ; on the com-
  munication of  hydrophobia  from  one
  human being  to another, or from man to
  beasts, i. 403 ;  on the peculiar delirium
  of  hydrophobia, i. 407; on  a  costive state
  of the system preceding tetanus, i. 416;
  on the  proximate cause  of tetanus, i.
  417; case of pistol-shot  wound  of the
  brain,  i. 438 ;  on puncturing the  dura
 mater to evacuate effused  blood, i. 448;
 on bleeding from the tongue from bites
 made during  a fit, i.  471;  cases  of
 partial  or complete dislocation of  the
 spine, i. 587; case of complete dislocation
 of the fourth from the fifth cervical ver-
 tebra, i.  587;  occurrence of vertebral
 dislocation specially in the neck, i. 588;
 case of fracture of the os calcis, i. 639 ;
 sawing off the ends of the broken bone in
 false  joints, ii.  18; on  the period  at
 which the operation for hare-lip should
 be performed, ii. 23; on the use of scis-
 sors with knife-edges in the operation, ii.
 23;  on the  sutures in the operation for
 hare-lip,  ii.  25;  on the   progress   of
 syphilis  from one part  of the  body  to
 another, ii. 71;  on the progress  of  ulce-
 ration in a syphilitic  sore, ii. 72 ; on the
 five kinds of syphilitic sores, ii. 73 ; on
 the four kinds of* syphilitic eruptions, ii.
 78;  on  the exhibition  of mercury  in
 cases  of chancre, and on the rarity of the
 occurrence of secondary symptoms when
 mercury  has been used, ii. 87;  on the
 extent to which  the use of  mercury may
 be pushed,  ii.  87; case of a syphilitic
 child  infecting  the  nurse,  ii.  105;  on
 syphilitic iritis and ulceration about the
 anus in infants, ii. 106; on the possibility
 of infection  from secondary syphilis, ii.
 106 ;  on the  combined effects of mercury
and syphilis in the production of the mer-
curial disease, ii. 103; definition of caries,
ii. 114; on the treatment of caries, ii. 118;
 case of necrosis from irritation, i-  120;
 on the terms "necrosis" and "exfolia-
 tion," 124 ;  on salivary calculi, ii. 150;
 on the appearances  presented  on  post-
 mortem examination some  time after the
 cure of artificial anus, ii.  156 ;  on Du-
 puytren's operation   for  artificial anus,
 ii. 158;  on  dislocations  from muscular
 action, ii. 159; on the double hernial sac,
 ii. 261; on the statistics of rupture, ii. 26;
 on the nature of strangulation, ii. 269; on
 the reduction en masse, ii. 274; objections
 to operations for the  radical cure of her-
 nia, ii. 289;  modification of Petit's opera-
 tion, ii. 304; ascribes the fatal result after
 the operation for strangulated hernia, not
 to the exposure  of the parts to air and
 light, but to the protracted constriction to
 which they  have been subjected, ii. 305;
 recommends opening thesacand dividing
 the stricture from within, ii. 307; on the
 statistics of wounds  of the epigastric  or
 obturator artery in operations for femoral
 rupture, ii. 342; case of fatal hemorrhage
 from a wounded branch of the epigastric,
 ii. 342; case of successful operation for
 strangulated umbilical ruptures during 
ANALYTICAL  INDEX.
883
pregnancy, ii. 346; case of rnpture of the I  rations for the extirpation of the ovary,
recti abdominis, ii. 348;  on  thyroid  rup-l  iii. 213.
ture, ii. 352; on the symptoms of internal \ Leeches, application of, iii. 612.
 strangulation, ii. 359; on the bruit de souf
flet, ii. 472 ; on the effects, produced by
 the ligature on the arterial coats, ii. 493;
 on Brasdor's operation,  ii. 504; on the
 peculiar noise  heard  in an  aneurismal
 varix, ii. 549 ;  on the application of the
 ligature in teleangiectasy, ii.  562; on the
 spongy excrescence of the rectum, iii. 45;
 on stricture of the rectum, iii. 46; on the
 use of bougies in stricture of the rectum,
 iii. 50; on the use of bougies armed with
 caustic potash in stricture of the urethra,
 iii. 80;  on the  use of the armed bougie,
 iii. 84; case of  the neck of a wine-bottle
 in the rectum,  iii. 109; cases of worms
 and  larvae discharged  from  the urethra,
 iii. 134; on catheterism  in inflammation
 of the prostate, iii. 137 ; on chronic en-
 largement of the prostate, iii. 139; on the
 treatment of enlarged  prostate, iii. 142 ;
 on the  treatment of  retention of urine
 from enlarged  prostate, and on  cathe-
 terism in such cases, iii. 143; on the tran-
 sition between new or accidental produc-
 tions and changes of  structure, and de-
 generations of organs, iii. 379;  case of
 very large fatty tumor, iii. 427; case  of
 cellular membranous tumors, iii.  448 ;
 case of amputation just above the ankle,
 iii. 675.
Lawrence, John, on the immoveable ap-
 paratus for fractures, i. 553.
Lawrie,  Dr.,  on the part  played  by  the
  dead bone in necrosis in the process  of
  reproduction, ii. 128; on the  cause of the
  difficulty  experienced  in reducing dislo-
  cations of the thumb from the metacarpal
  bone, ii. 235;  on the use of the actual
  cautery in prolapsus uteri, ii. 379 ; on the
  results of amputation,iii. 656 ; objections
  to amputation  below the knee, iii. 675.
Leacock's case of fatal phrenic rupture, ii.
  358.
Leber's  artery-compressor,  i. 331; on the
  stanching the bleeding  from an inter-
  costal artery, i. 492.
Leblanc on incision of the hernial sac, etc.,
  for its radical  cure, ii. 283 ; on dilatation
  of the stricture  in strangulated hernia
  without cutting, ii. 298.
Lecat on  dilatation of  the   stricture  in
  strangulated  hernia without cutting,  ii.
  298; mode  of operating for stone, iii.
  324.
Lee,  Dr. Robert, on inflammation of  the
  femoral  and  iliac veins, an occasional
  cause of phlegmasia dolens, i. 95.
Lee, Stafford, on the statistics of the ope-
Leg, fracture of the bones of, i. 635; arti-
  ficial, iii. 593; amputation through, iii.
  668;  exarticulation of, at  the  knee, iii.
  699.
Lehmann's case of  cure of ununited frac-
  ture, ii.  17 ;  operation for varicocele, ii.
  578.
Lemaire on the solution of the chloride of
  lime in the treatment of foul, gangrenous, •
  or torpid ulcers, ii. 44.
Lembert's practice in wounded intestine, i.
  509;  approved of, i. 509;  Dupuytren's
  modification  of, i. 515.
Lenoir on  the causes of varicocele, ii. 577;
  on dropsy of the bursae in the sole of the
  foot,  iii.  181  ;  mode  of  amputating
  through  the  leg in its lower  third, iii.
  670;  mode  of amputating  at the  hip-
  joint  with the flap-cut with the single
  flap, iii.  692.
Lentin on neuralgia of the heel, treated by
  deep  incisions, iii. 636.
Leroy d'Etiolles  on the statistics of the
  operations for cancer, iii. 510.
Leucorrhea  distinguished   from gonor-
  rhea, i.  180;  Dr.  Locock on leucor-
  rhea, i. 180; characters of the secretion,
  i.  180; Locock and Jewel on the distin-
  guishing signs between leucorrbcea and
  gonorrhoea, i. 181.
Lesenberg's plan for bringing the edges of
  the cleft together in staphyloraphy, ii. 32.
Lewin's, Dr., experiments on colchicum as
  a cause of an increased production of uric
  acid in the urine, ii. 55.
Lewis  on  the  treatment of hydrocele by
   punctures, iii.  224.
Liber on the torsion of arteries, i. 341.
Lieber on torsion of arteries, ii. 501.
Lieutaud on  incision  of the hernial sac,
   etc., for its radical cure, ii. 283.
Ligaments, Inflammation of.  See Inflam-
   mation of the Joints.
 LiGHTFOOT'scaseof prolapse of the bladder,
   in which he performed the operation of
   episioraphy, ii. 396.
 Limbourg's, De, case of wound of the head
   with a ramrod, i. 471.
 Lingual artery, ligature of, ii. 513.
 LinnjEus  on the acarus scabiei, ii. 67.
 Lips, cancer of,  iii. 515.
 Liordat's emporte-pieee, ii.  158.
 Lisfranc's plan of treating burns with a so-
   lution of the chlorate of lime, i. 129; on
   the use of  the stethoscope in the diag-
   nosis of fractures, i. 545 ; case of fracture
   of  the  os calcis, i. 640; on the solution
   of  chloride of lime in the treatment of
   foul, gangrenous,  or torpid  ulcers, ii. 
884
ANALYTICAL  INDEX.
  44; case of reduction of an old dislocation
  of the elbow-joint, ii. 231;  on the cause
  of the difficulty experienced in reducing
  dislocations of the thumb from the meta-
  carpal  bone, ii. 234 ; on  the relative fre-
  quency of aneurism in the sexes, ii. 475;
  on the relative frequency of aneurism in
  the arteries, ii. 475; on the ligature of a
  diseased artery,  without  opening  the
  sheath, ii. 496; on the section of the sca-
  lenus anticus in ligature of the subclavian,
  ii. 518; on ligature of the external iliac,
  ii. 538 ; vestibular cut in lithotomy in wo-
  men, iii. 351; operation for cancer of the
  corpora cavernosa, iii. 547; operation for
  scirrhous cervix uteri, iii. 567; case of
  fatal haemorrhage  from  leech-bites, iii.
  635; mode of amputating at the hip-joint
  with two flaps, iii. 692; in exarticulation
  of the metatarsal bones, iii. 706; at  the
  shoulder-joint,iii. 713; modification of the
  operation when  performed  prior to  the
  age of fifteen, iii, 717; mode of operating
  in exarticulation of the hand at the wrist,
  iii. 720; on exarticulation of the middle
  and ring fingers, iii. 723  ; flap-operation
  of the fingers, iii. 723.
Liston's account of  the hospital gangrene
  in University College Hospital in 1841,
  i. 82 ; on the formation of new vessels, i.
  324; adhesive plaster, i. 360;  mode of
  operating in  staphyloraphy, ii.  33 ; on
  epulis,ii. 136 ; case of speedy reduction of
  a dislocated  femur, ii. 203; on the mode
  of reducing dislocation of the thumb from
  the metacarpal bone, ii. 235; on the causes
  of splay-foot, ii. 457 ; on compression in
  the treatment of aneurism, ii. 486; case
  of ligature  of the subclavian above the
  clavicle,  ii.  519; on spontaneous  aneu-
  rism of the brachial, ii. 528; on ligature
  of the arteries of the fore-arm, ii. 528; on
  the peculiar noise heard in an aneurismal
  varix, ii. 549; case of aneurismal varix
  in the femoral vein and  artery, ii. 549;
  on the seat of stricture in  the rectum, iii.
  46 ; case of foreign body in the bronchus,
  in which  tracheotomy was performed,
  and the foreign body extracted  with for-
  ceps, iii. 118; case of partial solution of a
  stone in the bladder, iii. 280 ; on the dila-
  tation  of the  female urethra, iii. 283
  mode of operating for stone in the bladder
  iii. 350; operation for stone in women, iii
  350 ; on the incontinence of urine conse
  quent on lithotomy in women, iii. 353; on
  the breaking  or  bending of  lithotritie
  instruments  in the bladder, iii.  356 ; on
  the cases in which lithotrity should be
  performed, and on  those  in which litho-
  tomy should be preferred, iii. 360; cases
  of a small brass ring encircling the penis,
   iii. 363; case of sarcomatous tumor of the
   scrotum, iii. 449; on tumors of nerves, iii.
   506; case of sarcomatous  scrotum, iii.
   550; operation for raising a sunken nose,
   iii. 591; on the use of the saw in amputa-
   tions, iii.  643; preference of the flap ope-
   ration, and objections to the circular ope-
   ration,  iii.  0.33;  mode  of amputating
   through the  thigh  by the flap operation,
   iii. 600; account of eighteen amputations
   through the thigh, iii. 661 ; mode of am-
   putating through the leg  with two flaps,
   iii. 673 ; statistics of amputation through
   the leg, iii. 675 ; statistics of amputation
   through the upper arm, iii. 679; cases of
   amputation through the fore-arm, iii. U>2;
   on  amputation  through   the metacarpal
   bones, iii. 666; mode of amputating at the
   hip-joint with two flaps, iii.  0y2 ; case of
   amputation at the shoulder-joint, iii. 71? ;
   mode  of  operating  in  excision  of the
   lowerjaw, iii. 753; mode  of operating in
   resection of the upper jaw, iii. 756; on
   the prospect  of ultimate success in  this
   operation in cases of malignant disease,
   iii.  761 ; case of resection of the scapula,
   iii.  762; employment of ether by inhala-
   tion prior  to  the  performance of impor-
   tant surgical operations, iii.  76?.
Literature of surgery, i. 21.
Lithotrity, iii. 2»5.
Lithotomy, iii. 296; recto-vesical lithotomy,
   iii. 344 ; lithotomy in the female, iii. 34?.
Lithectasy, iii. 375.
Little, Dr., on the diagnosis between club-
   foot and the deformity of the tarsus caused
   by rickets, ii. 447 ; case of amputation of
   the thigh, with the flap behind, iii. 660.
Littre's  mode of  operating in ovarian
   dropsy, iii. 206.
Lizars  on the  large operation for ovarian
   dropsy, iii. 212;  the first  to recommend
   the entire  removal of the  upper jaw, iii.
   755 ;  description of the proposed opera-
   tion, iii. 755; casein wThich  he attempted
   to perform the operation, but  failed on
   account of the haemorrhage which ensued,
   iii.  756 ; cases in which he performed the
   operation, iii. 756.
Liver,  wounds  of, i.  525; symptoms,  i.
   525;  danger  of such wounds, i.  525;
   Astley  Cooper on stabs of the liver,  i.
   525;  South on rupture of the liver, i.
   525 ;  treatment,  i. 525 ;  wounds  of the
   gall bladder, i. 525; consequences of such
   wounds, i. 525;  symptoms of effusion
   of bile  into the cavity of the abdomen,
   i. 525; Hoering and Emmert's experi-
   ments on the injection of bile into the
   cavity of the peritoneum, i. 526 ; Dupuy-
   tren's  experiments,  i.  526;  case of 
ANALYTICAL  INDEX.                        885
  wounded gall-bladder quoted bv Goech,
  i. 526.                       J
Locher on vesicles on the spleen in hydro-
  phobia in dogs, i. 409.
Locock,  Dr., on leucorrhea, i.  180;  cha-
  racters of the secretion,  i. 180; on the
  distinguishing signs between leucorrhea
  and gonorrhea, i. 181; on pudendal dis-
  charges in females during dentition, i.
  181 ;  case of bands  in  the vagina from
  previous difficult labour, iii. 89 ; case of
  spontaneous rupture of the ovarian cyst,
  iii. 214.
Lode on two  kinds of curvature of  the
  hand, ii. 464.
Loeffler on puncturing the  distended in-
  testine after the operation for strangulated
  hernia, ii. 298.
Lonnes', Imbert de, case  of sarcomatous
  tumour of the scrotum, iii. 449.
Lorch on the effects of torsion, i. 343.
Lordosis, ii. 428.
Lottery on stanching  the bleeding from
  an intercostal artery, i. 492.
Louis on the rotation of the foot outwards
  in fracture of the  neck  of the femur, i.
  618 ; on the reduction en masse, ii. 274 ;
  case of a foreign body remaining a  long
  while in the windpipe, iii. 112; mode of
  amputation by the circular incision, iii.
  640.
Louvrier's apparatus  for  the  rupture of
  anchylosis, i. 276  ; Velpeau's objections
  to its  use, i. 277; on the more general
  application of the trephine,  i. 454;  on
  the friction cure in syphilis, ii. 94.
Lowe  on puncturing the distended intes-
  tine after the operation for strangulated
  hernia, ii. 298.
Lugol  on iodine  in scrofula, ii. 51;  for-
  mulae for the exhibition of iodine, ii. 51;
  dispute with Alibert  on  the  acarus sca-
  biei, ii. 67.
Luke on the use of the ligature in rectal
  fistula, and on the mode  of operating, ii.
  168 ; on the  dilatation of a strangulated
  rupture on coughing, ii.  270 ; on reduc-
  tion en masse, ii. 275; on the signs  indi-
  cative of reduction en masse,  ii. 276 ;  on
  the operation required when reduction en
  masse has occurred, ii. 277 ;  description
  of the  operation for dividing the stricture
  external to the sac, ii. 307;  on the diag-
  nosis of the  seat of stricture,  ii. 307 ;  on
  incision of the sac, or on partial division
  of its neck in several places, when the
  stricture is  caused by  it,  ii.  308;  case
  of resection of the  scapula, iii. 762.
Lumbar muscles,  inflammation of; lum-
  bago,  psoitis :—seat of the  inflamma-
  tion, i. 207;  symptoms, i. 207;  forma-
  tion of abscess, i. 207; general symptoms
     Vol hi.—75
of suppuration not present if the abscess
be not large, i. 208; this disease not what
is usually called " lumbago," but psoas
or lumbar abscess, i. 208; Astley Cooper
on the symptoms of psoas abscess, i. 208;
Pearson on the symptoms preceding and
accompanying the formation of the ab-
scess, i. 208;  causes, i. 208; English
surgeons generally consider disease of the
vertebrae to be the cause, i. 206 ; Pott on
the diseased condition of the spine in this
complaint, i. 208 ; Astley Cooper on the
origin of psoas or lumbar abscess in in-
flammation of the spine and intervertebral
substance, i. 209; Abernethy, Lawrence,
and Dupuytren on lumbar abscess gene-
rally  connected with  carious vertebrae,
i. 209 ;  South on the origin of the disease
from external violence, its seat then being
in the spine, i. 209;  South on the dis-
tinctive characters of psoas abscess from
femoral hernia, i. 209; John Pearson on
the situation of the external abscess, i.
210;  Samuel Cooper's notice of Rams-
den's case of lumbar abscess, i. 210;
treatment of inflammation of the lumbar
muscles, i. 210 ;  South on  the insidious
progress of the disease, i. 210 ; abortive
treatment of  lumbar  abscess, i. 211 ;
opening the abscess, i. 211 ; Dupuytren
on the changes that sometimes take place
in the abscess, i. 211; Astley Cooper re-
marks that the abscess must be allowed to
take its course, i. 211; this opinion con-
troverted  by South, i. 211; Cline and
Abernethy's experiments to cause the ab-
sorption of the pus, i. 211;  South on
issues in the treatment of lumbar or psoas
abscess, i. 211 ; difference  of opinion as
to propriety of wasting the self-evacuation
of the  abscess, or of puncturing and
emptying it, either entirely or  partially,
i. 212;  Deckers,  Benjamin  Bell, and
Crowther on tapping  the abscess with  a
trocar, i. 212; Latta recommends the use
of a seton in addition, i. 212 ; this latter
practice condemned by South,who prefers
opening the abscess with a lancet, i. 212 ;
Abernethy's  plan of  treatment, i. 212;
Astley  Cooper and  Lawrence support
Abernethy's views, i. 213 ; Kirkland ad-
vises to let the abscess break of itself, i.
213;  John  Pearson  prefers making a
small aperture, and treating the ulcer in a
very  gentle manner, i. 213; Dupuytren
leaves  the  abscess to nature,  i. 213;
South's plan of treatment, i. 213 ; treat-
ment to  be pursued after the abscess  is
opened,  i. 213;   Pearson  and  Astley
Cooper on the treatment of the sinuous
cavities resulting from the abscess by in-
jections, i. 214; Dupuytren recommends 
886                        ANALYTICAL INDEX.
  cauterization or weak injections of nitrate i
  of silver, or nitric acid, i. 214 ; treatment
  of the abscess, if inflammation supervene,
  after it has been  opened, i.  214 ; Aber-
  nethy on the symptomsof the  supervening
  inflammation, i. 214; Pearson mentions
  that the larger arteries sometimes ulce-
  rate into the abscess, i.  214  ; M'Dowell
  mentions a case in which ulceration took
  place in a portion of the ileum adhering
  to the cyst of the  abscess, i.  214.
Lungs, wounds of, i. 483, 485 ;  See Wounds
  of the Chest.
Lupus, or herpes exedens, ii. 58.
Lynn's performance of the Taliacotian ope-
  ration, iii. 577.

Macaulay's  case of  phrenic  rupture, de-
  pending  on malformation  of  the dia-
  phragm, ii. 356.
McClellan, Dr. on the cause of broncho-
  cele, iii. 389; on bronchocele as a variety
  of scrofula, iii. 389; case of resection of
  the scapula and clavicle together,iii. 764;
McCormac, Dr., on careful traction of the
  skin in prolapse of the rectum, ii. 404.
M'Dowall,  Dr., on the large operation for
  ovarian dropsy, iii. 212.
M'Dowell mentions a case in which ul-
  ceration took place in a portion  of the
  ileum adhering to the cyst of a lumbar
  abscess, i. 214.
Macgill's case of ligature of both carotids,
  ii. 507.
McGrigor, Sir James, on the period of the
  accession of tetanus  after the receipt of
  the injury, i. 415.
Mackenzie's, Dr., case of abscesses of the
  hip-joint, i. 282.
Mackintosh, Dr., on  an epidemic vaginal
  catarrh, i. 182.
McLaughlan's, Dr., case of a large  plug
  of wood in the rectum, iii. 107.
Macmurdo's case of rupture of a vessel in
  the penis  during  coition, i. 178; case of
  secondary haemorrhage in cut throat, i.
  476; case of false joint of the  humerus, ii.
  15; case of aneurismal varix  between the
  internal jugular vein and carotid artery,
  ii.  546;  case of cellular  membranous
  tumor, iii. 449.
Macrae's case of  a  foreign  body in  the
  bronchus, iii. 118.
McSweeny,  Dr.,  on  the  silk-worm  gut
  ligature, i. 339.
Magendie's experiment on the communi-
  cability of hydrophobia from  man to man,
  and from  man to beasts, i. 403; case of
  hydrophobic patient biting another person,
  i. 407; on the  formation of urinary cal-
  culi, iii. 237 ; on hairy gravel, iii.  256;
  on the treatment to  be adopted when air
i   enters  a vein  during an  operation, iii.
   603 ; on the cause of death from entrance
   of air into a vein, iii. 603; on the injec-
   tion of warm water into the veins in hy-
   drophobia, iii. 626.
 Maiden's case of penetrating wound of the
   chest, i. 483.
 Maingault's mode of amputating at the
   knee with the flap cut, iii. 699 ; mode of
   operating  in  partial amputation of the
   foot, iii. 705.
 Malagodi's case of excision of a portion of
   the ischiatic nerve in the  region of the
   knee-joint, iii. 636.
 Malgaigne on the  local treatment of frac-
   tured  ribs, i. 599 ; on the frequency of
   dislocation in the different joints, ii. 202.
   on the primitive  direction of dislocation
   of the humerus, ii. 221 ; case of reduction
   of an old dislocation of the elbow, ii. 230;
   on the cause of the difficulty experienced
   in reducing the  dislocation of the thumb
   from the metacarpal bone, ii. 235; on the
   seat of strangulation in ruptures, ii.  268;
   case of resection of the fibula, iii. 767.
 Mammary, internal, ligature of,  ii. 525.
 Mandt on the chemical and microscopic
   characters of pus, i. 46 ; on the pus-glo-
   bules, i. 53 ; on the presence of globules
   in the serum, i.  56.
 Manec on  the introduction  of  a piece of
   bougie into an ossified artery after ampu-
   tation,  i. 336; on ligature of the inno-
   minata, ii. 522; mode of amputating at
   the hip-joint by the flap-cut with a single
   flap, iii. 693.
 Manovy's case of division  of the posterior
   tibial nerve, iii. 636.
 Marcet, Dr., on the premonitory pains of
   hydrophobia, i. 408 ; case of knife-swal-
   lowing, iii. 115.
 Marchetti's case of swine's  tail in the
   rectum, iii. 109.
 Marjolin on excision of the prolapsed and
   scirrhous womb, ii. 381.
 Marochetti on the presence of pustules
   under the tongue after the  bite of a  mad
   animal, i. 413; plan of  treatment  pro-
   phylactic of hydrophobia, i. 413 ; views
   objected to by Watson, i. 414.
 Marshall  on the application of flour in
   cases of burns, i.  133.
 Martin on the causes of club-foot, ii. 446.
 Martineau's cases of very  small urinary
   calculi, iii. 273; operation for stone in the
   bladder, iii. 317.
 Martin^re's, Dela, case of a foreign body
   in the windpipe, iii. 110.
 Mauchart on incision and scarifications of
   the hernial sac, for its radical cure, ii. 283.
 Maunoir on the effects produced by the
   ligature on the arterial coats,  ii. 493 ; on 
ANALYTICAL INDEX.                        887
 the ligature of the spermatic artery in va-
 ricocele, ii. 578; treatment of bronchocele
 by puncture and irritating injections, and
 by seton, iii. 397; on simple serous cysts
 of the neck, iii. 432; on the chemical con-
 stituents of  the  brain-like  substance  in
 medullary fungus, iii. 458; on ligature of  Med1n on the stanching the bleeding from
 the  spermatic artery in sarcocele, iii-1   an intercostal artery,  i. 492.

Maun'sell's, Dr.,  description of noma, jMeding's experiments  on incomplete frac-
 75; on the  suppuration of mumps, i. 169 ; |   ture' K 544' on t{?e Production of callus,
 on the communication of syphilis to the1   u
 foetus in the womb, ii.  106; on the 8ymp-i Mbddli-a**' Fungus, iii. 453;  characters,
bral rupture, ii. 365 ; on the influence of
spinal curvature on the transverse diame-
ter of the pelvis, ii. 427; on the division
of tumours, iii. 382; opinion that melano-
sis is the same as  medullary fungus, iii.
462.
  toms of syphilis in infants, ii. 106 ; on its
  treatment, ii. 106.
Mauriceau on the  operation for the treat-
  ment of lacerated perineum, ii.  39 ; on
  the application of the sutures, ii. 39.
Maxillary sinus, disease of, iii. 478 ; bone,
  lower,  fracture  of, i. 579;  excision of,
  iii. 715 ; upper, resection of, iii. 784; frac-
  ture  of, i. 579; artery, external,  ligature
  of, ii. 514.
Mayo describes the occasional occurrence of
  pus-globules in healthy blood, i. 53; case
  of injury  to the ligaments  of the knee, i.
  230; describes  three distinct forms of
  ulceration of joint-cartilages, i. 254 ; case
  of injury to the ankle, followed by absorp-
  tion  of the cartilages, and effusion and
  organization of lymph  between the ends
  of the  bones, i. 273 ; on the progress of
  caries,  ii. 115;  on inflammation as the
  cause of caries, ii. 117 ; on the treatment
  of caries, ii. 118; on the application of
  caustic in varix, ii. 573 ; on haematocele,
  iii. 175 ; on dropsy of the bursae mucosae,
  iii.  178;  on the formation of bursae from
  pressure, iii. 178 ; case of large calculus,
  iii. 273 ; on tumours of nerves in stumps,
  iii. 506.
Mayor's treatment of fractured clavicle, i.
  603; treatment of false joints, ii. 17;  on
  the sutures in  the operation for  hare-lip,
  ii. 25; operation  for the radical cure of
  hernia, ii. 285 ; on extirpation of broncho-
  cele by ligature, iii.  398;  on ligature of
  the neck of the womb, iii. 567 ; on ampu-
  tation of the phalanges with the  tachy-1
  tome, iii. 686.
Mead, Dr., on viper's fat as a local remedy
  in viper's bite, i. 390 ; case of the bite of
  a rattlesnake, i. 390; experiments on viper-
  poison, i. 391; on the protraction of the
  period of incubation in hydrophobia, l.
  404; on the increase of muscular strength
  in hydrophobia, i. 408.          _
Meckel on the vessels of cartilage, i. 252 ;
  on  the three kinds  of  union of divided
  parts—quick union, by adhesion, and by
  granulation, i. 319 ; on the causes of cere-
  bral rupture, ii. 365 ; case of cure of cere-
 iii. 454; symptoms and situation, iii. 455;
 medullary fungus of the testicle, iii. 455;
 symptoms  and termination, iii. 455; of
 medullary fungus of bone, iii. 457; Astley
 Cooper on medullary fungus of bone, iii.
 457;  appearances of the parts  on  dis-
 section, iii. 457; chemical  examination
 of the brain-like substance, iii. 457; Hecht,
 Maunoir,  and  Muller  on the chemical
 constituents of the brain-like substance,
 iii. 458 ; Krause on the microscopic cha-
 racters  of medullary  fungus, iii. 458;
 Gluge on  the nature  of, iii.  458 ;  me-
 dullary fungus occasionally  encysted,iii.
 458;  characters of the  brain-like sub-
 stance in medullary fungus of the testicle,
 iii. 459 ; characters of medullary fungus,
 iii. 459; Allan Burns and von Walther on
 the difference between fungus haematodes
 and sarcoma medullare, iii. 460; Aber-
 nethy on  fungus haematodes, iii. 460;
 Muller on  the  applicability of the term
 "medullary fungus "to the different forms
 of soft cancer, iii. 461;  Vogel  on the
 essential element of medullary fungus, iii.
 461;  Bradley, Jaeger, and Vogel on the
 blood fungus, iii. 461; Meckel's  opinion
 that melanosis is the same as medullary
 fungus, iii  462; this  opinion only  par-
 tially correct, iii. 462 ;  diagnosis between
 medullary fungus and scirrhus, iii. 463 ;
 Breschet's different kinds of carcinoma,
 merely different degrees of  development
 of medullary fungus, iii. 464; Abernethy's
 sarcoma   tuberculatum considered  by
  Meckel to be medullary fungus, iii. 464 ;
  this opinion incorrect, iii. 464; etiology
  of medullary fungus, iii.  464  ; diathesis
  fungosa, iii. 464; seat and mode of forma-
  tion  of medullary fungus, iii.  464; treat-
  ment of the disease almost entirely  inef-
  fective, iii. 464 ; early  ablation of the part
  or amputation of the limb affords the
  only  chance of cure, iii. 465; the disease
  generally  returns  sooner  or later, iii.
  465.
Meig:s plan of  treatment in  ingrowing  of
  the nail by a compress and linen-roller, i.
  223. 
888
ANALYTICAL INDEX.
Melier's apparatus for  dislocation  of  the
  clavicle forwards, ii, 219.
Melker's  diagnostic  sign for  vertebral
  caries, i. 312.
Melle's case of dislocation of the scapular
  end of the clavicle downwards, ii. 220.
Mendaga on the hydrarg. cyan,  in syphilis,
  ii. 93.
Mende  on  the seeming retroversion of the
  womb at the latter periods of pregnancy,
  ii. 409.
Menzel on the operation for  the treatment
  of lacerated perineum, ii. 39.
Mercier's opinions on  the changes which
  the substance  of the bone  undergoes in
  advanced age, i. 545 ; on inversion of the
  foot in fracture of the neck of the femur,
  i. 618; on the characters of horns, iii.
  403;  on the treatment to be adopted when
  air enters a vein during an operation, iii.
  604.
Mercurial  disease, ii. 107.
Merrem, Dr., on wounds of  the uterus, as
  predisposing to rupture in subsequent la-
  bours, i. 53.1 ; explanation of this fact,  i.
  531.
Mery  on  incision  of the hernial sac  and
  the introduction of lint tents for its radical
  cure, ii. 283.
Mesenteric and mesocolic ruptures, ii. 358.
Metacarpal bones, amputation through, iii.
   682; exarticulation of,  at the carpus, iii.
  721 ; excision of, iii.  722.
Metacarpus, excision of  the joints of, iii.
  744.
Metastatic abscesses, i, 48.
Metatarsal bones, amputation through, iii.
   682; exarticulation of, iii,  706 ; excision
   of, iii. 723; fracture of the  bones of, i.
  615.
Metatarsus, excision of the joints of, iii.
  744.
Mettauer, Dr., on the operation of staphy-
  loplasty by granulation, ii. 27.
Meyer on the application of nitric acid  to
   the scar of nerves, i. 364;  apparatus for
  fracture of the neck of the femur, i. 624 ;
   case  of strictured oesophagus communi-
   cating with the left bronchus, iii.  28;
  case  of resection of the clavicle, iii.  764.
Michaelis on the treatment of  gonorrhoea,
   i. 197; on the operation for the ingrowing
   of the nail, i.  224; on the division of the
   tendo Achillis in  club-foot,  ii. 453; on
   the doubtful character of the  old cases  in
   which the Caesarian operation is reported
   to  have been performed  several times
   successfully on the same woman, iii.  157;
   case in which  the  operation was  per-
   formed  four times on the same  woman,
   iii. 157; on the danger attending the  effu-
   sion  of the secretions from the wound
  into the belly, iii. 162; on the exhibition
  of opium, and on the necessity of keeping
  the bowels open after the operation, iii.
  162 ; on the greater probability of success
  attending the repetition of the operation,
  than in the first instance, iii.  164.
  iescher on the ossification of arteries, i.
  91; says nodilference between permanent
  cartilage, and that which is  to be con-
  verted into bone, i. 249; differs in opinion
  with W. Hunter  respecting  the fibrous
  structure  of articular cartilage, i. 249;
  on the production of callus, i. 545 ; sum-
  mary of views  on the formation of  the
  primary and  secondary  callus,  i.  54.5;
  experiments  to induce  suppuration  in
  compound fractures, i. 559; summary of
  experiments  to  ascertain the processes
  under which suppurating fractures  are
  united, i. 566; on the granulations attend-
  ing caries, ii. 114; on the characters of
  caries, ii. 115; on  the  seat  of various
  kinds of caries, ii. 117; on the signs of
  exfoliation, ii. 125;  on the absorption of
  part of the dead  bone in the process of
  exfoliation, ii.  126;  on  the  process of
  cicatrization after necrosis, ii. 128.
Mirault's operation for the ligature of the
  tongue, iii, 521.
Mobus' case of vertebral aneurism, ii, 527.
Model's opinion that spurred rye does  not
  cause gangrene in beasts, i. 74; disproved
  by  Tessier,  i. 74; Block's experiments
  on the subject, i.  75.
Mohrenheim's apparatus for fracture of the
  patella, i.  633.
Moj'sisovic's equilibrium  plan in fracture
  of the femur, i. 629.
Moller's case of gangrene of the penis,
  from the constriction of a metal ring, i.
  534.
Monnier's, Le, operation of staphyloraphy,
  ii. 31.
Monro on the lengthening of the limb in
  hip-disease, i. 285;  slippers for rupture
  of the  tendo Achillis, i. 542; on the ap-
  plication of caustic for the radical cure of
  hernia, ii. 283; on the  dilatation of the
  abdominal ring,  the  hernial sac  being
  unopened, ii. 303 ; cases of half-pence in
  the oesophagus, iii. 97;  case  of a foreign
  body in a sac behind the oesophagus at
  its origin, iii. 97.
Montain on the operation for the treatment
  of lacerated  perineum, ii. 39 ; on the ap-
  plication of the sutures, ii. 39.
Monteiro's case  of ligature of the aorta,
  ii. 532.
Montgomery, Dr., on the origin of scirrhus
  uteri in the ova  Nabothi, iii. 562; case
  of cancer  uteri, iii. 563.
Morand on the arrest of haemorrhage by 
ANALYTICAL INDEX.                        889
  nature, i. 329; on the extirpation of the
  ovary,  iii. 210; mode of amputating  at
  the  shoulder-joint with the circular cut,
  iii. 715.
Moreau's case of excision of a joint, iii.
  726; on the excision of joints, iii. 726 ;
  statistics of cases, iii. 727;  mode of ope-
  rating in excision of the  head of the
  humerus, iii. 732;  in excision of the
  elbow-joint, iii. 733 ;  on the division  of
  the ulnar nerve in excision of the elbow-
  joint, iii. 733; mode of operating in ex-
  cision of the knee-joint, iii. 740 ;  on the
  mode of union after  the  operation, iii.
  740; mode of operating in excision of the
  ankle-joint, iii. 741.
Morere's case of abscess of the womb, i.
  532.
Morgagni on the causes of varicocele,  ii.
  577.
Morgan's opinions relative to the formation
  of pus, i. 46; on the reduction of the dis-
  located femur by placing the foot between
  the thighs, and  making extension and
  rotation, ii. 242;  case of a pouch formed
  at the mouth of the tunica vaginalis,  ii.
  262.
Morris', Dr., case of injurious effects pro-
  duced by the inhalation of ether, iii. 769.
Mortification:—divided by Chelius into
  the hot and cold, i. 66;- Travers' objection
  to the terms mortification andisphacelus,
  i. 66;  definition of mortification, i. 66;
  8ymptoms,i.67; Travers' acute gangrerie,
  i. 67;  destruction of the mortified parts
  occurs either as dry, moist,  or hospital
  gangrene,  i.  67; South on. vesications
  filled with  a bluish  or bluisb>black fluid
  in cases of severe  bruise, or when the
  bandages in  cases  of fracture  are too
  tight, i. 68; causes of mortification, i. 68;
  Brodie on sudden loss of blood, a cause
  of mortification, i. 68; Travers on deep
  and extensive effusion, and' on injuries
  of  nerves,  as  causes  of mortification, i.
  68; South's case of mortification of the
  lower  extremity from effusion of blood
  causing  distention  of the limb, i. 68;
  mortification in cases of aneurism caused
  by distention from teffusion, i. 69 ;  mor-
  tification in cases of simple fracture, the
  principal artery of the limb being un-
  injured,  i. 69;  South's cases of  mor-
  tification after fever,  i. 69»,  senile gan-
  grene, i. 69; distinction between  senile
  gangrene consequent on injury, and that
  resulting from constitutional causes, 1.71;
  Travers' chronic gangrene, i. 72; causes
  of dry gangrene, i. 72; South's case of
  dry gangrene consequent on abdominal
  typhus, i. 72; Dupuytren  on arteritis a
  cause of dry gangrene, i. 72, 89; South s
75*
case of dry gangrene from organic disease
of the heart, i. 72; Brodie's case of dry
gangrene from inflammation of the prin-
cipal  artery and vein of a limb, i. 72;
Brodie on  the cause of the distinction
between dry and moist gangrene, i. 72 ;
gangrene  from  arterial  inflammation a
comparatively rare disease, i. 73;  this
statement  denied  by Cruveilhier  and
Dupuytren, i. 73; South's case of arteritis
without gangrene, i. 73 ;  Solly's case of
gangrene, i. 73 ; mortification from con-
tinued pressure, i. 74;  mortification from
the use of the  cock-spurred rye, i. 74;
Thomson's account of this form of  the
disease, i. 74 ; Sigebert and Bayle's re-
marks, i. 74; the disease first noticed by
Dodard, afterwards by Saviard, Noel,
Langius, Quassoud, Bossau, and Duha-
mel, i. 74 ; Elliotson's case of gangrene
of the leg after the use of ergot, the arte-
ries of the limb being also ossified, i. 74;
Model's opinion that spurred rye does not
cause gangrene in beasts, i. 74; disproved
by Tessier, i. 74; Block's experiments on
the subject, i. 75; Dr.  C. Woolaston's
cases of gangrene, i. 75; mortification of
the cheek, called noma  by Vogel, i. 75;
a  rare and generally fatal disease, i. 75;
description of noma by Drs. Evanson and
Maunsell, i. 75; the term, cancrum oris,
incorrectly applied to noma, i.- 76; can-
crum oris, a  form  of  mortification com-
mencing with  ulceration, generally first
in the gums, and thence spreading to the
lips and cheeks, i. 76;. described by Dr.
Gumming, is 76; South's case of noma
in the adult, i. 76; mortification, a con-
sequence of contagious influence, results
in  malignant pustule, or hospital  gan-
grene, i.  77;   malignant pustule,  its
causes and symptoms, i. 77 ; contagious
from  beasts to man, but not from man to
man, i. 77 ; Elliotson on glanders in the
human subject, u 78; Lawrence's cases
of malignant pustule, i. 78;  Beer's  and
Delpech's-cases, i. 79; Turchetti's cases
of malignant pustule, described by him
as anthrax, i. 79 ; Dr. Wagner's cases of
malignant pustule, produced by contact,
and by; eating the flesh  of diseased  ani-
mals, L. 80;-Dr. Bourgeois' observations
on malignant pustule, L-81; hospital gan-
grenej i. 82; description  of the disease,
i. 82;  local and  general symptoms, i.
82; Liston's account of the hospital gan-
grene in University College Hospital in
1841, i. 82; Arnott's cases of hospital
gangrene at the Middlesex Hospital, i.
83; the disease exceedingly rare in  the
London  hospitals-, i.  83; Lawrence on
sloughing phagedena, i.  83;  Welbank 
890                       ANALYTICAL  INDEX.
on sloughing phagedena, i. 84 ; this dis-
ease regarded by S. Cooper as resem-
bling hospital gangrene, i.  84; denied
by South, i. 84; South on the sloughing
state of stumps  from want of power, i.
84;  the  characteristic  of hospital gan-
grene, i.  84 ; the cause of hospital gan-
grene is the operation of a peculiar con-
tagious matter, i. 84; it is always a very
dangerous  complication of wounds and
sores, i.  84;  treatment of gangrene, i.
109 ; when connected with active inflam-
mation, and  inflammatory fever, mode-
late antiphlogistic treatment to be em-
ployed, i. 110; if caused by the constric-
tion of  unyielding aponeuroses, they
must be divided, i. 110; when connected
with general debility, tonics and mineral
acids indicated,  i. 110;  local treatment
of gangrene, i. 110; if there be active in-
flammation, soothing poultices :  if  the
part be free from pain, and shrivelled,
stimulant applications  required, i. 110;
remedies which  prevent the influence of
the grangrenous juices, i. 110 ; their ac-
tion aided by scarifications in the gan-
grenous parts, i. 110;  these latter must
not penetrate into the living parts, i. 110;
scarifications are dangerous in gangrena
senilis, i. Ill; amputation not applicable
in gangrene depending  on an  internal
cause still in operation, i. Ill; applicable
after the  line of demarcation has formed,
or in gangrene  from external violence,
even  while  still  proceeding,  i.  Ill;
South's opinion  that amputation should
never be  performed  while the gangrene
is in progress, i. Ill; treatment of senile
gangrene, i.  Ill; when resulting from
an injury, soothing or. dry aromatic  ap-
plications, or leeching, if the inflamma-
tion be active,  i. Ill;  Dupuytren em-
ployed the antiphlogistic plan of treat
ment in plethoric subjects, i. Ill; when
from constitutional  causes,  tonics  and
opium necessary, i. 111 ; treatment of
gangrene from pressure, i, 112 ; from the
use of spurred rye, i. 112 ; Thomson and
S. Cooper's cases, i.  113; treatment of
malignant pustule,  i.  113;  local treat-
ment  by cutting out the pustule,  and
cauterizing the  wound, i.  113 ; if the
pustule not deep, but. the slough much
spread, deep scarifications and the appli-
cation of caustic recommended, i.  113;
employment of constitutional treatment,
i. 113 ; treatment of hospital  gangrene, i.
 113; emetics advised by Routeau  and
 Dussausoy,  i.  113; washing the sore
with vinegar or solution of arsenic in the
 commencement  of the  disease, i. 113;
 the entire  surface to   be  touched  with
  nitrate of silver, i. 114; the free applica-
  tion of the actual cautery most effectual,
  i. 114; constitutional treatment should be
  employed at the same time, i. 114; gan-
  grenous destruction of parts from burns,
  i. 126; treatment of mortification caused
  by burns, i.  129;  cold  wet sufficient to
  induce mortification, if  continued suffi-
  ciently long  to reduce the natural heat
  below  a certain standard,  i. 144; gan-
  grene the result of too suddenly warming
  a frozen limb, i.  147;  treatment of a
  frozen  part  in which mortification is
  threatened, from its having been too has-
  tily warmed, i. 148; when  mortification
  has taken place, it must be treated in the
  usual manner, i. 148; treatment of gan-
  grenous chilblains, i. 149;  gangrene of
  the testicle a rare termination of inflam-
  mation, i. 201; causes and treatment of
  mortification  in compound fractures,  i.
  558; South on mortification in compound
  fractures, and its  treatment, local and
  general, i. 560 ; sloughing of the omen-
  tum in strangulated hernia, ii. 301; gan-
  grene of the intestine  in  strangulated
  hernia, ii. 302.
Morton on the inhalation of ether prior to
  the extraction of teeth, iii. 767.
Moscati on the extirpation of the  tonsils
  by cutting, i. 164.
Moseley's, Dr., case  of scorpion sting, i.
  357; on the chigoe, i. 388.
Mothe on the primitive direction of dislo-
  cation of the  humerus, ii. 221.
Mott  on  the  treatment of fistula  of the
  rectal sheath, ii. 169;  on the operation
  for tying the innominata, ii. 521; opera-
  tion for the ligature of the common iliac,
  ii. 533; mode of amputating at the hip-
  joint with two flaps, iii. 692; case of ex-
  cision of part of the  side  of the lower
  jaw, without the condyle, iii. 748; mode
  of operating in excision of the lower jaw
  with the condyles,  iii. 749; on  the pre-
  vious ligature of the carotid artery, iii.
  750; case of articulation of one  side  of
  the lower jaw, iii. 751; case of resection
  of the clavicle, iii. 764.
Motte, La, on the  operation for the treat-
  ment of lacerated  perineum, ii. 39; on
  the application of the sutures, ii. 39.
Mouffet on the acarus scabiei, ii. 66.
Mouth, narrowing and closing of, iii. 24;
  foreign bodies in  the, iii. 94.
Moxas, application of, hi- 631.
Mozilewsky's  case  of  reduction of the
   consecutive dislocation  in hip-disease, i.
  297.
Mulder's mode of operating in excision of
   the knee-joint, iii. 740; in excision of
   the ankle-joint, iii.  742. 
ANALYTICAL  INDEX.                       891
Muller on inflammation, i. 34; comparison Nasal bones, fracture of, i. 577.
  of the effects of  heat and cold on  the Nasse's case of lymph-swelling from  ex-
  body, l. 144; on the vessels of cartilage,
  ii. 253; on tire causes of necrosis, and on
  the process of regeneration, ii.  120; on
  the production of  new bone after necro-
  sis, ii. 127; on the division of  tumors,
  iii. 381; on enchondron, iii. 409; on the
  varieties of fatty tumors,  427;  on  the
  chemical constituents of  the brain-like
  substance in medullary fungus, iii. 458;
  on the applicability of the term " medul-
  lary fungus" to  the  different forms of
  soft cancer, iii.  461; on the four several
  kinds of carcinoma, iii. 498; on carcinoma
  simplex et fibrosum, iii.498; on carcinoma
  reticulare, iii.498; on carcinoma alveolare,
  iii. 498; on carcinoma fasciculatum, iii.
  498; proposal to separate the fibrous part
  of the blood prior  to transfusion,  iii. 628.
 Munzenthaler's  mode of operating in ex-
  articulation of the metatarsal bones, iii.
  707.
 Murray's, Dr., case of ligature of the aorta,
  ii. 531.
 Mursinna on the more general application
  of the trephine, i. 454 ; on the treatment
  of fractures of  the neck of the  femur, i.
  624;  on the operation for the  treatment
  of lacerated  perineum,  ii. 39;  on  the
  primitive  direction of dislocation of the
  humerus, ii. 221.
 Muscles, lacerations of,  i. 542.
 Mussey's, Dr., case of ligature of  both ca-
  rotids, ii. 507;  on the treatment to be
  adopted when air enters  a vein during
  an operation, iii.  604; case of resection
  of the scapula and clavicle together* iii.
  764.
 Mutter's plastic operations for the relief
  of deformities from burns, i. 142; on the
  period at which the operation for hare-lip
  should  be performed, ii. 23; on the ad-
  vantage of operating early in  hare-lip
  and cleft-palate, ii. 26; on the treatment
  of  cleft-palate  after  the  operation for
  hare-lip, ii. 27; on the use of obturators
  in cleft-pal ate, ii. 27;  on the operation of
  staphyloplasty  by granulation,  ii.  27;
  successful operation  in a  case of loss of
  substance in the hard palate from chronic
  mercurial disease, ii. 28.
 Mynors' mode of amputating by the circu-
  lar incision, iii. 640.
Naegele on the use of the suture in vesico-
  vaginal fistula, i. 190, 191.
Naegele's, jun., case of womb at the eighth
  month  of  pregnancy,  ruptured by exter-
  nal violence, i. 532.
Nannoni on amputation at the shoulder-
  joint, with the circular cut, iii. 715.
  ternal injury, i. 61;  on injecting a solu-
  tion of neutralized nitrate of mercury into
  a cold abscess, i, 105.
Naumburg on the causes of club-foot, ii.
  446.
Neck, wounds of the, i. 473; nature of the
  wounds, i. 473; Astley Cooper on wounds
  of the throat, i. 473; deep penetrating
  wounds, with injury of the large vessels,
  i. 473;  Travers' case of suicidal  wound
  of the lingual or  facial artery near its
  origin, with unsuccessful ligature of the
  common carotid, i.  473.; injuries of the
  pneumo-gastric nerve, i. 475;  of  the re-
  current  nerve,  i. 475.;  of the laryngeal
  nerve, i. 475 ; Dupuy's experiments on
  the division of both pneumogastric nerves,
  i.  475;  injury of  the sympathetic  or
  phrenic nerve, or of the spinal marrow,
  i. 475;  wound of the windpipe,  i. 475;
  loss of voice in large wounds of the wind-
  pipe,  i.  475; Hennen on emphysema in
  wounds of the windpipe, i. 475; treatment
  of transverse wounds of the windpipe, i.
  475;  Fricke on the  treatment of severe
  wounds of the neck, i. 476; South on po-
  sition in the treatment of  wounds of the
  windpipe, i. 476; South on the treatment
  of such wounds, i. 476; treatment of the.
  general symptoms  accompanying  such
  wounds, i. 476.; subsequent treatment, i.
  476;  South  on the  treatment of  such
  wounds, when there is  much  inflamma-
  tion,  i.  477; South's  case  of fistulous
  wound  between the thyroid  and  cricoid
  cartilages, i. 477;  Astley Cooper's case
  of fistulous opening in the thyroid car-
  tilage, i.  477;  South  on secondary he-
  morrhage in cut throat,  i. 477; Macmur-
  do's case, i. 477; stabs  of the windpipe,
  i.477; bruised wounds of the larynx and
  windpipe, i.  478; shot-wounds with loss
  of substance, i. 478; South on the ma-
  nagement of the resulting fistula,  i. 478;
  wounds of the gullet, i. 478;  signs and
  treatment, i. 478;  the  oesophagus-tube,
  i. 478 ; Astley Cooper's objection to the
  use of the tube, i. 478;  Stark's case, i.
  478 ; Dr. Ryan's case, i. 479 ; Hennen's
  case  of wound of  the  larynx and< oeso-
  phagus, i. 480; healing of wounds of the
  gullet, i. 480; stabs of the gullet,  i. 480;
  deep  wounds at the back  of the neck,
  i..480;  Hennen's case of severe nervous
  symptoms following gunshot wound, of
  the  throat,  i. 480;  Kennedy's case  of
  gunshot wound of  the  right side of the
  thyroid cartilage, i. 481.
 Necrosis, ii. 120; definition and divisions,
  ii. 120; situation, ii. 120; causes,  iL 120; 
892                        ANALYTICAL  INDEX.
  Muller on the causes of necrosis, and on
  the process of regeneration, ii. 120; Brom-
  field and Lawrence's casesof necrosis from
  irritation, ii. 120; symptoms, ii. 120; John
  Hunter on the ossific inflammation pre-
  ceding necrosis, ii. 121; diagnosis, ii. 121;
  distinguishing characters of caries  and
  necrosis, ii. 122; separation of the dead
  bone as sequestrum, ii. 123; the processes
  of  exfoliation, and of compensation for
  the dead  bone, ii. 124; the reproduction of
  bone not dependent on the periosteum, ii.
  124; Lawrence on  the terms " necrosis "j
  and " exfoliation," ii. 124; Weinhold's
  objection to  the term " exfoliation," ii.
  124; John Hunter on the process of exfo-
  liation, ii. 124; John Hunterand Miescher
  on the signs of exfoliation, ii. 125; Mie-
  scher and South on the absorption of part
  of the dead bone in the prOcessof exfolia-
  tion, ii. 126 ; Troja on the incipient pro-
  duction of new  bone after  necrosis, ii.
  126; Weinhold on the cloacae in necrosis,
  ii. 127; Muller on the production of new
  bone, ii.  127;  Lawrie on the part played
  by the dead bone in the process of repro-
  duction, ii. 128; Miescher on the process
  ■of cicatrization, ii.  128; John Hunter on
  the species of exfoliation, ii. 128;  prog-
  nosis, ii.  129 ; cases of necrosis indirectly
  affecting  the joints, and requiring ampu-
  tation, ii. 130; Porter's case of wound of
  the popliteal  artery by a  sequestrum, ii.
  130; treatment, ii.  130;  separation and
  removal of the sequestrum, ii. 131;  treat-
  ment in cases of necrosis of old standing,
  ii. 131; cases in which amputation  is in-
  dicated, ii. 131.
Negrier on fresh walnut leaves, and their
  decoction in scrofula, ii. 53.
Nelken's,  Dr., instrument for applying
  the ligature in rectal fistula, ii. 169.
Nember on the exhibition of purgatives in
  strangulated hernia, ii. 291.
Nephrotomy, iii. 267.
Nerves, division of, in neuralgia, iii.  632.
Nester on the dislocation  of the.head of
  the thigh-bone downwards and inwards
  in hip-disease, i. 287.
Neuralgia,  division of nerves in, iii. 632.
Nevermann on the stanching the  bleeding
  from an intercostal artery, i. 492 ;  mode
  of operating, i. 492; treatment of lacerated
  perineum, by cauterizing  with  unslaked
  lime, and afterwards by position, ii.  40;
  statistics  of  tracheotomy  in  laryngitis
  and tracheitis, iii. 115.
Nicolai recommends the use of the appara-
  tus for fractured  neck of the femur  in the
  treatment of hip-disease, i. 292; on  the
  symptoms and progress of white swelling,
  i. 305; on the anatomy, of white swell-
  ing, i. 306; apparatus for fracture of the
  neck of the femur, i. 624.
Niel on gold and its preparations in pri-
•  mary and secondary syphilis, ii. 100.
Nipples, inflammation and fissure of.  See
  Inflammation of the Breast.
Noel on mortification from spurred  rye, i.
  74;  on the operation for the treatment of
  lacerated perineum, ii. 39 ; on the appli-
  cation of the sutures, ii. 39.
Noma.  See  Mortification.
Nose,  double, Hi. 597;  nose-making, iii.
  575.
Nostrils, growingtogetherand narrowing of,
  iii. 22; foreign bodies  in the, iii. 94.
Nuck on ligature of the hernial sac for its
  radical cure, ii. 283; on the diverticulum
  of the peritoneum in the female, ii. 328.
Nymphae, abscess of, i. 181.
Nysten on the cause of death from the en-
  trance of air into a vein, iii. 603.

O'Beirne, Dr., on  the  fatal character  of
  tetanus, i. 419 ; on the introduction of a
  thick elastic tube through the rectum into
  the sigmoid flexure of the colon in stran-
  gulated hernia, ii. 291; case of simple
  serous cysts of the neck; iii. 432.
O'Bryen's case  of displacement of  the
  heart, ii. 361.
O'Callaghan's, Dr., case of the lodgment
  of a  foreign body in the frontal sinuses,
  i. 435.
Occipital artery, ligature  of, ii. 515.
OS'sophagotomy, iii. 99.
QEsophagus, wounds of, i. 478; stricture of,
  iii. 25; foreign bodies in the, iii. 95.
Oesterlen's observations on the re-break-
  ing  a badly united fracture, i. 576;  ap-
  paratus for re-breaking the bone, i. 576,
O'Ferrall's, Dr.,case of sarcomatous scro-
  tum, iii. 551.
Ogle's case of puncturing  the  dura mater
  to remove the effused blood, i. 447.
Olecranon, fracture of, i. 615.
Oliver's case of fatal  haemorrhage from
  leech-bites, iii.  614.
Ollenroth on the use of caustic to destroy
  the ends of broken bone in false joints, ii.
  17;  modes of operating in ovarian dropsy,
  iii. 210.
Ollivier on  dislocation  of the femur di-
  rectly downwards, ii. 237.
Omalgia, inflammation  of the shoulder-
  joint, i. 299; three stages of the disease,
  i. 299; symptoms and results, i. 299;
  dislocation  of  the head  of the bone, i.
  300;  abscesses and caries of the bone, i.
  300; post-mortem  appearance,  i. 300;
  etiology, prognosis, and treatment,  i. 300.
Onsenoort's, van,  plan to  prevent  the
  needles tearing out after the operation for 
ANALYTICAL INDEX.                        893
  hare-lip, ii. 26;  on the treatment of hy-
  drocele by seton, iii. 228; mode of ampu-
  tating at the shoulder-joint, iii. 713.
Onychia, maligna.  See Ingrowing of the
  Nails.
Oppenheim on the introduction of the seton
  in false joints, ii. 20; case of excision of
  the  head of the femur, iii. 737.
Orchitis.  See Inflammation of the Testicle.
Organic parts  lost, restoration of:—
  history  of nose-making, iii. 577;  the
  Indian method, iii. 375; the Talacotian
  operation, iii. 577;  practised in England
  by Lynn, Sutcliffe, and Carpue, iii. 577;
  Graefe's  modification of the Taliacotian
  operation, iii, 577; the second  Indian
  method, iii. 578; South on the practice df
  plastic surgery in England, iii. 578 ; the
  several methods of reparation by a  fold
  of skin from the neighbourhood, iii. 579;
  the value of plastic operations, iii. 579;
  rhinoplasty, and its occasional unfavour-
  able results, iii, 580; subsequent changes
  in the new nose, iii. 580; the Indian ope-
  ration preferable, iii. 580; Balfour, Braid,
  South, Barthelemy, and Regnault's cases
  of reunion of separated  parts, iii,  581;
  nose-making from the skin of the forehead,
  iii. 582; the Indian method of rhinoplasty,
  iii. 582; directions for the operation, iii.
  583; Graefe, Dieffenbach, Delpech, and
  Labat'smodificationsuii. 584; subsequent
  symptoms and treatment, iii. 585; occur-
  rence of gangrene, iii. 585; removal of the
  stitches or pins, iii. 585; division of the
  fold of skin after complete union of the
  new nose, iii.  585; after-operations for
  perfecting the form of the nose, iii. 586 ;
  Graefe on. the  proper formation of  the
  nostrils, iii. 586; defects of the wings of
  the  nose, iii. 586 ; Dieffenbach's opera-
  tion, iii. 587; deficiency of the side-edge
  as well as of the wing of the nose, iii. 587;
  the  bridge of the nose sunken in,  iii, 587;
  directions  for  the operation, iii. 587 ;
  Dieffenbach's  modification of the opera-
  tion, iii. 587; deficient columna  narium,
  iii. 587 ; the operation,  iii. 587 ; bottle-
  nose, and the operation to remedy the de-
  formity, iii. 587; Gensoul's modification
  of  the operation  for deficient colurnna
   narium, iii. 588; Gensoul's case of chilo-
   plasty, to remedy the deformity caused by
  gangrene, iii. 588; forming the nose from
   the  skin  of the arm, iii. 588 ;  a more
   troublesome and uncertain operation than
   the Indian method, iii. 589; directions for
   the German operation, iii. 589; Benedict
   and  Galenzowski's modifications of the
   operation, iii. 589  ; the  Italian operation,
   as  modified by Graefe, iii. 590; raising a
  sunken nose, iii. 590; Dieffenbach's opera-
 tion,  iii. 590;  dressing and  after-treat-
 ment, iii. 591;  Liston and Fergusson's
 operations, iii. 591; Dieffenbach's opera-
 tion for dropping in of the bridge of the
 nose, from destruction of part of the sep-
 tum, iii. 592;  the  inhealing of metallic
 frames to remedy sunken noses, iii. 592;
 Tyrrell's case, iii. 592;  Dieffenbach's
 operation to remedy the turning down-
 wards of the tip of the nose, iii. 592; me-
 chanical compensation for  lost parts,  iii.
 593 ; artificial legs, iii. 593 ; the  wooden
 leg, iii. 593; Pare, Ravaton, White, Addi-
 son, Wilson, Briinninghausen,Stark, Ber-
 rens, Heine, Graefe, Ruhl, Palm, Dorn-
 bluth, Schmucker, Wals,  Miles, and
 Serre's artificial legs, iii. 593 ; selection
 of an artificial leg,  iii. 593; description of
 Ruhl's artificial  leg, iii. 594;  of Stark's
 artificial thigh, iii. 594; description and
 application of the  wooden leg, iii. 594;
 Ruhl's wooden leg, iii. 594; artificial foot,
 iii. 595 ; artificial hands, iii. 595; Pliny,
  Gotz von Berlichingen, Pare, Wilson,and
  Ballifs  artificial hands, iii. 595; artificial
 upper arms,  iii. 595 ;  description of  the
 apparatus, iii. 596 ; artificial noses and
 ears, iii. 596;  supply  of lost portions of
 the hard palate, iii.  596; use of obturators,
  iii. 596 ; replacement of the teeth, iii. 596;
 transplantation of teeth, iii. 596;  applica-
 tion of artificial teeth, iii. 596.
——  superfluity  of : — supernumerary
 fingers and  toes, iii. 597 ;  two different
 forms, iii. 597; treatment by operationjii.
  597; supernumerary teeth, iii. 597; causes,
  iii. 597; deformity caused by the irregular
  position of the teeth, iii. 597; treatment,
  iii. 597; double nose, iii. 598; either con-
  genital  or acquired, iii. 598; enormous
  degeneration of the nose,  and its treat-
  ment by operation, iii. 598; treatment of
  cleft nose, iii. 598; Hey's case of immense
  tumour  of the  nose, iii. 598 ; Dalrymple
  on the nature and  characters of these tu-
  mours, iii. 598.
Oribasius on  the removal of  the  relaxed
  uvula by cutting,  i. 166,
Orioli's case  of fungus of the dura mater,
  treated  by operation, iii 425.
Orred's case of excision  of  a joint, iii.
  726; mode of operating in excision of
  the head of the humerus,  iii. 732.
Osborne, Dr., on the application of leeches
   to mucous surfaces, iii. 613;  use of the
   polytome, iii. 616.
Os calcis, fracture of,  i. 639 ;  dislocation
   of, i. 251.
Os hyoides, fracture of, i. 581.
Osiander on the operation  for the treat-
   ment of  lacerated perineum, ii. 39; on 
894                        ANALYTICAL  INDEX.
  the extirpation of the cancerous neck of
  the womb, iii. 566.
O'Shaughnessy's  case  of removal of the
  upper-jaw, iii. 759,
Osteosarcoma, iii. 412.
Osteosteatoma, iii. 412.
Otto on hydrocephalocele, ii. 363; on the
  causes of cerebral rupture, ii. 364.
Outrepont on the  causes  of congenital
  dislocation, ii. 208.
Ovarian dropsy, iii. 209.
Ovaritis regarded by Ricord a complication
  of gonorrhoea, i.  180.
Ovary, extirpation  of, iii. 209.
Owen's case of viper-bite, i. 392;  on the
  post-mortem  appearances  in  Stevens'
  case of  ligature of the internal iliac, ii.
  534.

Paget's case of diseased undescended tes-
  ticle, iii. 558.
Paillaud on iodine in  hard swellings of
  the testicle, ii. 101.
Pailloux on the cause of the difficulty ex-
  perienced in reducing dislocations of the
  thumb  from  the  metacarpal  bone,  ii.
  235.
Pajola's mode of operating for stone, iii.
  324.
Palate, hard, cleft in the, ii. 27.
----, soft, cleft in the, ii. 30.
Palletta on congenital dislocation of the
  hip, ii. 207, 244 ; on the post-mortem ap-
  pearances in, ii, 244; case of congenital
  dislocation of the patella, ii.  247; of ex-
  tirpation of the womb, ii. 570.
Palmer on the torsion of arteries, i. 341.
Paracentesis thoracis, iii. 194 ;  abdominis,
  iii. 204; uteri, iii. 218; of the intestines
  in tympanitis, iii.  218.
Paraphimosis, iii.  60.
Pare Ambrose, used the ligature in cases
  of relaxed uvula, i. 166 ; on the operation
  for the treatment of ingrowing of the nail,
  i. 224;  on the  use of the ligature  for
  wounded  vessels, i. 354;  bandage  for
  fractured clavicle, i, 603; on the rotation
  of the  foot outwards in fracture of  the
  neck of the femur, i. 618; apparatus for
  fracture of the neck of the femur, i. 623;
   on the operation for lacerated perineum,
   ii. 39; on congenital dislocation of  the
   hip, ii. 207; on ligature of the hernial
   sac for its radical  cure, ii.  283; on  the
   operation of dilating the abdominal ring,
   the hernial sac being unopened, ii. 303;
   on the causes of club-foot, ii. 446.
 Parent on the hydrarg. cyan, in syphilis,
   ii. 93.
 Paris', Dr., case of a foreign body remain-
   ing a long while  in the windpipe, iii.
   112; on cancer  of the scrotum, iii.  560.
Park's case of excision of a joint, iii. 726 :
  mode of operating in  excision  of  the
  knee-joint, iii. 740; on the mode of union
  after the operation, iii. 741.
Paronychia, i. 215.
Parotid duct, fistula of, ii. 149.
Parotid gland, inflammation  of, i. 167;
  abscess  of,  i. 168;  cancer of, ii. 522;
  diseases of, iii.  522; extirpation of, iii.
  522.
Patella, fracture of, i. 630;  dislocation of,
  ii. 246.
Pattison's case of teleangiectasy treated by
  acupuncture  with red-hot  needles, ii.
  565.
Pauli on tattooing moles of  the skin, ii.
  566.
PaUlus jEgineta  on the removal  of  the
  relaxed uvula by cutting, i. 166; cau-
  terized it with the aid of the staphylo-
  kauston, i. 166;  on the application of the
  actual cautery for the radical cure  of her-
  nia, ii. 282; on aneurism, iii. 468.
Pearson's,  Dr.,  opinion  relative  to  the
  formation of pus, i. 46.
Pearson opposed to incisions in carbuncle,
  i. 157;  on  the symptoms preceding and
  accompanying the formation of a  lumbar
  abscess, i. 208;  on the  situation  of  the
  external abscess, i. 210; prefers making
  a small aperture in lumbar abscess, and
  treating the  ulcer in  a gentle manner, i.
  213 ; on  the treatment of  the sinuous
  cavities resulting from lumbar abscess, by
  injections, i. 214; states that the larger
  arteries sometimes ulcerate into  the ab-
  scess, i. 214 ; on venereal paronychia, i.
  217; on erethismus mercurialis, ii. 109;
  on  the cachexia  syphiloidea, ii. 110; on
  the eczema mercuriale, ii.  Ill;  on the
  treatment of erethismus mercurialis  and
  eczema mercuriale, ii. 113
Pelletan on  the mechanism  of  the fat
  rupture when it descends  through the
  inguinal canal, ii. 325 ;  case of the exist-
  ence of several aneurisms  in the same
  person, ii. 477.
Pellieux on the symptoms of dislocation
  of  the sternal end of the clavicle back-
  wards, ii. 217.
Pelouze's experiments on stone-solvents,
  iii. 281.
Pelvic  bones, fracture of, i. 595;  disloca-
  tion of, ii. 214.
Penada's case of hydrocephalocele, ii. 363;
Penis, cancer of, iii. 543;  amputation of,
  iii. 544 ; by ligature, iii. 546.
Penis, wounds of, i. 534;  treatment of
   these  wounds,  i. 534;  laceration of the
   cavernous bodies by forcibly binding the
   penis  during erection, i.  534;  conse-
   quences and treatment, i. 534; South on 
ANALYTICAL INDEX.                        895
  incising the spongy body of the penis not
  always a cause  of loss of the power of
  erection, i. 535; Moller's case of gan-
  grene of the penis from the constriction
  of a metal ring, i. 535; South's objection
  to amputation of the penis for lacerations
  of the cavernous bodies, i. 535; rupture
  of  the  urethra,  i. 535;  symptoms  and
  treatment, i. 535; South on the treatment
  of rupture of the urethra, i. 535.
Pennock, Dr.,  on the effects  of  cupping
  glasses in vipers' bites, i. 389.
Pentzlin on the treatment of itch, ii. 68.
Percival, Dr., on an epidemic vaginal ca-
  tarrh, i. 181.
Percy on the removal of foreign bodies in
  injuries of the brain, i. 438 ; on the solu-
  tion of the chloride of lime in the treat-
  ment of foul, gangrenous, or torpid ulcers,
  ii.  44;  on  passing a leaden thread into
  Steno's duct, after the cheek  has been
  penetrated, in the operation for salivary
  fistula, ii. 148; operation for enlargement
  of the tongue, iii. 384 ; moxa made with
  the pith of the sun-flower, iii. 631;  on the
  excision of joints, iii. 726.
Pericardium,  wounds of,   i.  501.   See
  Wounds of the  Chest.
Perineal  fistula, ii. 181; abscess, ii. 181;
  rupture, ii. 355.
Perineum, female, lacerations of, ii. 35;
  causes, situation, and extent, i. 36; slight
  lacerations, ii. 36;  results of extensive
  lacerations, ii. 36;  inability to retain the
  faeces in complete  laceration  from the
  vagina to  the rectum, ii.  36; treatment
  of extensive laceration, ii. 36; by sutures,
  ii. 36; by position, ii. 36; central lace-
  ration, ii.  36;  treatment  of large  and
  recent  lacerations by the  stitch,  ii. 36;
  Duparcque on the treatment of lacerations
  of the perineum, ii. 36;  results of these
  lacerations, ii, 37 ; Dr. Churchill  on the
  treatment of lacerated perineum,  ii. 37 ;
  Duparcque on the scarring of the edges
  of the  torn perineum, ii. 37; operations
  on old lacerations when  extending into
  the rectum uncertain in their consequen-
  ces, ii. 38;  when contra-indicated, ii. 38;
  description of the operation, ii, 38; Am-
  brose  Pare, Guillebonneau, Mauriceau,
  La Motte,  Smellie, Noel, Saucerotte, Du
  puytren, Mursinna,  Menzel,  Osiander,
  Dieffenbach,  Montain, and Roux on this
  operation,  ii. 39;  Guillebonneau, Mau-
  riceau, La Motte, Smellie, Noel,  Sauce-
  rotte,  Dieffenbach,  Roux, Montain, and
  Ritgeon on the  application of sutures, n.
  39; Davidson's successful operation,  n.
  39; subsequent treatment, it. 40; Dief-
  fenbach on the artificial retention of faeces
  for several days  after the operation,  n
  40;  Saucerotte, Roux, and Davidson's
  cases, ii. 40 ; Horner's recommendation
  to divide the sphincter ani, after union
  has taken place, ii. 40; mode of union
  of old lacerations, ii. 40; Nevermann's
  treatment by cauterizing with unslaked
  lime, and afterwards by position, ii. 40.
Peroneal artery, ligature of, ii. 544.
Perrault's case 6f amputation at the hip-
  joint, iii. 689.
Perrez on the physiology of carbuncle, i.
  155;  on the treatment of  carbuncle, i.
  158.
Perry's case of aneurism bursting into a
  vein, ii. 551; case of necrosis of the lower
  jaw, iii, 753.
Petit's explanation of the lengthening of
  the limb in hip-disease, i. 285; on the
  reduction of the consecutive dislocation,
  i. 297;  on the arrest of haemorrhage by
  nature, i. 329 ; on the healing of wounds
  of aTteries, i. 330; on the  more general
  application of the trephine, i. 454;  ban-
  dage and slippers for rupture of the tendo
  Achillis, i.  542; bandage  for fractured
  clavicle, i. 603; on  the rotation  of the
  foot outwards in fracture of the neck of
  the femur, i. 618;  on incision  of the
  hernial  sac, etc., for its radical cure, ii.
  283;  case of impending peritonitis from
  ligature of the hernial sac, ii. 288; on the
  operation of dilating the abdominal  ring,
  the hernial sac being  unopened, ii.  303;
  on the coagula in varicose veins, ii. 568;
  case of varices  in the upper extremity,
  ii. 570 ; cases in which severe symptoms
  followed the application of the ligature
  for piles, ii. 584 ; mode of amputating by
  the circular incision, iii. 640.
Peyronie's M. La, case of abscess of the
  dura mater, i. 439.
Phagedena, sloughing.   See Mortification,
Philip's, Dr. Wilson, experiments on the
  condition of the vessels in inflammation,
  i. 40; on the treatment of uric acid gravel,
  iii. 260.
Phillips' case of  fracture of the first ver-
  tebra, and pivot process of the second, i.
  584 ; post-mortem appearances^ i.  585;
  case of prolapsed womb treated by cau-
  terization of the vaginal parietes, ii. 378;
  on the  application of the actual cautery
  in treating prolapse, ii, 402; on acupunc-
  ture in  aneurism, ii. 503 ; case of a  stick
  in the rectum, iii. 108; on the statistics
  of the operations for the extirpation of the
  ovary, iii. 213;  on the results of ampu-
  tation, iii. 656.
Phimosis, iii. 53.
Phlebitis, i.  92; causes, symptoms, and
  terminations, i.92; Cruveilhierand South
  on phlebitis, i. 92; Hunter on thecoagu- 
896
ANALYTICAL INDEX.
  lation of the blood in phlebitis, i. 93 ;
  Hunter,  Abernethy,  Hodgson, Carmi-
  chael, Bouillaud, Travers, and Arnott on
  severe  phlebitis, i. 93;  Ribes' cases  of
  phlebitis, i. 94;  Arnott on the morbid
  appearances  in  phlebitis,  i.  95;  Dr.
  Robert Lee on inflammation of the femo-
  ral and iliac veins, an occasional cause of
  phlegmasia dolens, i. 95 ; Abernethy on
  the treatment of traumatic phlebitis, iii.
  610.
Phlebotomy,  iii. 608.
Phlegmasia dolens, Dr. R. Lee on inflam-
  mation of the femoral and iliac veins, an
  occasional  cause of, i. 95,
Phrenic rupture, ii. 356.
Physick, Dr., on the treatment of carbuncle,
  i.  157; guillotine instrument for ampu-
  tating the  tonsils, i. 165;  on the treat-
  ment of coxalgia, i. 292;  on the animal
  ligature, i.  339; apparatus for fracture of
  the neck of the femur, i. 623; on the use
  of the seton in false joints, ii. 20; opera-
  tion for  artificial anus, ii. 158; on the
  mode of performing the Caesarian opera-
  tion, iii. 163.
Piedagnel on the cause of death from the
  entrance  of air into a vein, iii. 603.
Pigne on the changes which the substance
  of bone  undergoes in  advanced  age, i.
  545; on sawing off the ends of the broken
  bone in false joints, ii.  18; on the direc-
  tion and position of natural and acquired
  hare-lip,  ii. 22 ; on the solution of the
  chloride of lime in the treatment of foul,
  gangrenous, or torpid ulcers, ii. 44; on
  the treatment of syphilitic phimosis, iii.
  59 ; on  hydrocele caused by gonorrhea,
  iii. 224;  on the nature of corns, iii. 402;
  on the seat of exostosis, iii. 408.
Pilore's case in which he made an artificial
  anus on  the  right  side by opening the
  caecum, iii. 38.
Pinel's opinions relative to the formation of
  pus, i. 47.
Piorry on the physical characters of dropsy
  of the pericardium, iii. 201.
Pitcairn, Dr., on immediate amputation in
  gun-shot wounds, i. 383;  on gold and its
  preparations  in  primary  and  secondary
  syphilis, ii. 101.
Pitschaft's  cases of  suppurating protru-
  sion of the brain in children, ii. 367.
Planchon's case of fatal punctured wound
  of the womb, i. 533.
Plantade's  mode  of amputating at the
  hip-joint with the flap-cut with a single
  flap, iii.  691.
Plattner's artery-compressor, i. 331.
Plenck on the lengthening of the limb in
  hip-disease, i. 285.
Ploucquet's case of foreign body in the
  heart, i. 500.
Pockels on the formation of new vessels, i.
  323.
Poisoned Wounds.  See Wounds.
Poller on puncturing the|bladder, iii. 155.
Polypus, iii. 468 ; of the nostrils, iii. 468;
  of the throat, iii. 478; of the oesophagus,
  iii: 478 ; in the maxillary sinus, iii. 479 ;
  of the womb, iii. 486 ; of the vagina, iii.
  494; of the rectum, iii. 494.
Popliteal artery, ligature of, ii.  542.
Portal's case of inflammation of the aorta,
  consequent on the recession of measles, i.
  89;  on  the ossification of  arteries  in
  young children, i. 91;  case  of fatal
  hemorrhage consecutive to the opening a
  tonsillar abscess, i. 161; on the lengthen-
  ing of the limb in hip-disease, i. 285;
  mode of amputating by the circular  in-
  cision, iii. 641.
Portalupi's  case of very large fatty tu-
  mour, iii. 427.
Porte,  De la, on the  extirpation of the
  ovary, iii. 210.
Porter's case of wound of the  popliteal
  artery by a  sequestrum,  ii. 130;  on the
  passage of foreign bodies into the larynx,
  iii. 110.
Posch's apparatus for fractures  of the leg,
  i. 637.
Posselt's chemical analysis  of the fluid
  contained in ranula, iii. 122.
Post's,  Dr., case of ligature of  the subcla-
  vian above the clavicle, ii.  518, 519;  on
  the ligature of the external iliac, ii. 538.
Pott on the diseased condition of the spine
  in lumbar abscess, i. 208 ; on the symp-
  toms and progress of inflammation in the
  joints of the vertebrae, i. 308; on the so-
  called palsy of the limbs in Pott's disease,
  i. 309 ;  on the puffy, circumscribed, in-
  dolent tumour of the scalp, indicative of
  suppuration between the dura mater and
  the skull, i. 424; on the symptoms accom-
  panying fracture of the skull, not depend-
  ing on the injury  to the bone, but from
  injury to the brain, or of some of the parts
  contained in  the  cranium,  i. 429;  on
  puncturing the dura mater,  when the ex-
  travasation lies beneath, i. 447; on extra-
  vasation between the meninges, or on the
  surface of the brain, i. 447; on the more
  general  application  of the  trephine, i.
  454;  on the bent  position  in fracture of
  the femur, i. 628;  on effusion  of blood
  into cellular tissue of the scrotum, iii.175;
  on hematocele  of the spermatic cord,  iii.
  178 ;  case of fusible calculus in a vesical
  rupture, iii. 273 ; on cancer of the scro-
  tum,  iii. 560; on the age at which
  chimney-sweep's cancer generally occurs, 
ANALYTICAL  INDEX.
897
  iii. 560;  mode of operating  in amputa-
  tion, iii. 642.
PoTTER,on the results of amputation,iii.655.
Pouteau recommends  emetics in hospital
  gangrene, i. 114; on the  application of
  caustic and the actual cautery in car-
  buncle, i. 158;  on the arrest of haemor-
  rhage by nature,  i. 329; objection  to
  dressing  the wound, after the operation
  for rectal fistula, ii. 167.
Powell's, Dr., case of a hydrophobic patient
  biting another person, i. 406.
Powell's case of rupture of the womb not
  fatal, i. 531.
Pravaz on  the reduction of congenital dis-
  location of the femur, ii. 243; case of suc-
  cessful reduction, ii. 244; on acupuncture
  of the aneurismal sac, and the application
  of galvanism, ii. 503.
Preiss on the exhibition of purgatives  in
  strangulated hernia, ii. 291; on the opera-
  tion of dilating the abdominal ring, the
  hernial sac being unopened, ii. 303.
Pring's case of operation for artificial anus
  at the lower end of the colon, iii. 38.
Prochaska's case of sympathetic abscess i
  of the brain, with irritation and suppura-
  tion of the dura mater, i. 442.
Prolapses  :—definition, ii. 368; causes, ii.
  368; prolapse of the womb, ii. 368; varie-
  ties and complications, ii. 369 ;  Sabatier
  and  Blundell on prolapse  of,  ii. 369;
  symptoms of incomplete prolapse, ii. 369;
  Blundell on relaxation and  incomplete
  prolapse, ii. 370; Ramsbotham on the ob-
  struction to the  passage of the  urine in
  prolapse  of, ii. 370;  South on the irrita-
  tion of the rectum in prolapse of, ii. 370;
  complete prolapse, symptoms and results,
  ii. 370; Blundell on the size of the pro-
  lapsed womb and  vagina,  ii. 371;  Cru-
  veilhier and South on the contents of the
  sac formed by the prolapsed vagina, ii.
  371; Clarke on the length  of time during
  which the  prolapse  is forming, ii. 371;
  Cruveilhier on incontinence of urine in
  prolapse  of the womb, ii  372; Clarke on
  the size and shape of the prolapsed organ,
  ii. 372;  Cruveilhier on the altered  form
  and direction of the  os uteri in  prolapse
  of that organ,  ii. 372; Cruveilhier and
  Cloquet on the elongation of the  womb in
  cases of  prolapse, ii. 372; Ramsbotham
  on the general symptoms of prolapse and
  procidentia, ii.  372; Clarke on the con-
  secutive ulceration of the vagina,ii, 372;
  Cloquet and Cruveilhier on the existence
  of calculi in the displaced bladder conse-
  quent on prolapsus  uteri,  ii. 372;  Cru-
  veilhier and Cloquet on consecutive dis-
  placement of the rectum, iL 372;  causes
  of prolapsus uteri, ii. 372;  Blundell and I
      Vol. hi.—76
Ramsbotham on the causes of prolapse, ii.
372;  Elliotson, S. Cooper, and  Rams-
botham's cases of prolapse of the womb
in virgins,  ii. 373; Ullsamer on endemic
prolapse of the womb from the use of the
labour-chair, ii. 375; Clarke's case of pro-
cidentia uteri,  with  separation  of  the
bones of the pelvis, ii. 374; prognosis, ii.
374; treatment, ii. 374; mode of reducing
the prolapse, ii. 374; Ruysch and Sabatier
on the  reduction of the prolapsed and
ulcerated womb, ii.  375;  Sabatier on
the treatment of the prolapsed  pregnant
womb, ii. 375; after-treatment, ii. °375 ;
Clarke on  the after-treatment of proci-
dentia uteri, ii. 375; Clarke on the appli-
cation of injections, ii. 376; Clarke on the
treatment of the ulcerated vagina, ii. 376;
Clarke's objections to sponge as a pessary,
ii. 376; use of pessaries, ii. 376; the oval
pessary and  its  application,  ii.  376;
Clarke's pessary, ii. 377; inconvenience
of pessaries, ii. 377;  Hull's utero-abdo-
minal supporter, ii. 377; King's bandage,
ii. 378; Phillips' case of prolapse  treated
by cauterization of the parietes of the va-
gina, ii. 378; Clarke on  the corrosion of
pessaries in the passage, and on the de-
posit of calculous matter on them,ii. 378;
Hall, Ireland,  Velpeau,  and  Berard's
operation for prolapse, ii. 379; Dieffen-
bach and Lawrieon the use of the actual
cautery in  prolapse, ii. 379 ;  Ker's case
of procidentia treated with the secale cor-
nutum, ii.  379;  Bellini's operation,  ii.
380; Fricke's operation of episioraphy, ii.
380; Gedding's cases in which  episio-
raphy was  performed, ii. 380; symptoms
sometimes  following the reduction of an
old prolapse, ii. 380; removal of the pro-
lapsed  organ when  scirrhous, by  the
ligature or  by incision, ii. 380;  introduc-
tion of the catheter in cases of prolapse, ii.
380;  Recamier, Marjolin,  Cruveilhier,
and Langenbeck on excision of the pro-
lapsed scirrhous womb, ii. 381 ; prolapse
of the womb with inversion, ii. 382; defi-
nition, ii. 382; varieties, ii. 382; Crosse
on  the characters of  the respective  va-
rieties, ii. 382; Crosse on the successive
steps of the  inverting process, ii. 383 ;
Crosse  on  the concavity formed in all
cases of inversion, ii. 383 ; causes,  ii.
384; Hachmann  on spontaneous inver-
sion from  spasm, ii. 3S4;  Clarke and
Crosse on polypus of the fundus uteri as
a cause of  inversion,  ii. 384; Crosse on
coagulated  blood, hydatids and  moles in
the womb as causes of inversion, ii. 384;
symptoms  of the quickly-formed inver-
sion, ii. 384;  Dailliez on  strangulation of
intestine in the concavity formed  by the 
^98                        ANALYTICAL INDEX.
inverted  womb, ii. 385; Clarke on  the
character  of the  discharge  in  inverted
uterus, ii. 385; diagnosis of inversion
from  prolapse, ii. 386 ; reduction of the
inverted  womb, ii. 386; after-treatment,
ii. 386;  treatment when  the reduction
cannot be effected, ii. 386; when the pla-
centa is attached  to  the inverted organ,
ii. 387;  in chronic  inversion,  ii. 387;
Clarke on the treatment of chronic inver-
sion, ii. 387 ; Clarke on the treatment of
recent inversion, ii. 387 ; Clarke on the
diagnosis between chronic inversion and
polypus  uteri,  ii. 387; treatment when
the reduction of  the inverted  organ is
impossible,  ii.  387;  removal of the in-
verted womb, if affected with cancer or
other degeneration, ii. 387; Clarke on the
treatment of the inverted womb, compli-
cated with procidentia, ii.  388 ;  Clarke,
Chevalier, Blundell, Dr. J. Clarke, and
Dr.  Symonds'  cases of removal of the
inverted womb by ligature, ii. 388;  pro-
lapse of the vagina, ii. 389; definition and
varieties, ii. 389 ; Clarke and John Burns
on prolapse of the vagina, ii. 389; charac-
ters of complete prolapse, ii. 389; of im-
perfect prolapse, ii. 389;  diagnosis  be-
tween prolapse of the vagina and of the
womb, ii. 389; Clarke and Blundell on
the symptoms of prolapse of the vagina,
ii.  390;  predisposing and  occasional
causes, ii. 390; Clarke on the causes and
symptoms  of posterior prolapse of  the
vagina, ii. 390; reduction of the prolapse,
ii. 390 ;  Clarke on the treatment of  pos-
terior prolapse, ii.  390 ; after-treatment,
ii. 390; prolapse of the bladder, ii. 391 ;
symptoms, ii.  391;  diagnosis  between
prolapse  of the bladder and of the womb,
ii. 392 ; treatment, ii. 392 ; South's  case
of prolapse of the bladder  relieved by
operation, ii. 393 ; Lightfoot's  case in
which he  performed  the  operation  of
episioraphy, ii. 396 ; prolapse of the rec
turn, ii. 397 ; three forms of prolapse of
the rectum, ii. 397;  Copeland  on  pro-
lapse of the internal  membrane of the
rectum, ii. 398; Syme on prolapsus ani,
ii. 398;  Bushe describes two  forms of
prolapsed rectum, ii. 398 ; Berard jun.'s
case  of  invagination  of  the rectum
through the anus, ii. 398 ;  characters of
prolapse  of the internal coat of the rec-
tum, ii. 398 ; of prolapse of all the coats,
ii. 399; symptoms, ii. 399; Bushe on the
characters of prolapse,  ii. 399;  Syme on
the characters of prolapsus  ani, ii. 399 ;
Copeland, Syme, and Bushe on  the diag-
nosis  between prolapsed   rectum   and
haemorrhoids, and  intus-susception,  ii.
399; causes,  ii.  399;  Bushe on  the
  changes in the mucous membrane of the
  rectum in old prolapses, ii. 399;  treat-
  ment, ii. 400 ; reduction of the prolapse,
  ii. 400; Brodie  and South on the treat-
  ment of prolapse in children, ii  401;
  Dupuytren  objects  to  scarifications  or
  leeches in treating prolapse of the rectum,
  ii. 401; prevention of the return of the
  prolapse, ii. 401; Klein and Schwartz on
  the treatment of prolapse, ii. 401; Brodie
  on  the treatment of prolapsed  rectum
  with piles in the adult, ii. 401  ;  Dupuy-
  tren's  operation for long-standing  pro-
  lapse, ii. 402; Phillips on the application
  of the actual cautery in treating prolapse,
  ii. 402; Hey on the cause of the difficulty
  in reducing the bowel in  old prolapses,
  ii. 402; Hey's  operation,  ii.  402; Vel-
  peau's modification, ii. 403 ; Copeland's
  operation, ii. 403; McCormac on careful
  traction of the skin in prolapse of the rec-
  tum, ii. 404; changes that take place in
  old prolapses, ii. 404; extirpation of the
  degenerated parts, ii. 404; Salmon's ope-
  ration, ii. 404 ; application of the actual
  cautery in  irreducible prolapse,  ii. 404;
  Ansiaux  and Dupuytren on  the actual
  cautery in irreducible prolapse,  ii. 404;
  prolapse of an ensheathed upper intestine,
  ii. 405 ; Bushe on relaxation of the  anus,
  ii. 405;  causes,  signs,  and results,  ii.
  405; Bushe on  relaxation of the  rectum
  with invagination  of the mucous mem-
  brane,  ii.  405;  causes, symptoms, and
  treatment, ii. 405; Somme's case, ii. 405;
  Salmon on the incautious use of enemata
  a cause of relaxed  rectum, ii. 406.
Prostate, retention of urine from  inflamma-
  tion of, iii. 136; suppuration and  abscess
  of, iii. 136; swelling of, from varicose
  veins, iii, 138;  induration of, iii. 138;
  chronic, enlargement of, iii. 139; reten-
  tion of urine from, iii. 141; stones in the,
  iii. 366.
Prout, Dr., on the origin  of oxalic acid in
  the urine, iii. 244;  on lithic or uric acid
  sediments, iii. 253; characters of yellow
  sediments, iii. 253 ; of red or lateritious
  sediments, iii. 253 ; of  pink  sediments,
  iii. 253; white  lithate or urate  of soda
  sediment, iii. 254; characters and accom-
  panying   symptoms of  the  phosphatic
  sediments, iii 254 ; causes, iii. 255; oxa-
  late of lime sediment, iii. 256; charac-
  ters of the urine in cystic oxide calculus,
  iii. 256; characters  and  symptoms of
  crystallized uric acid gravel, iii.  256; on
  the  crystallized  phosphatic  gravel, iii.
  256; on the rarity of crystallized oxalate
  of lime gravel,  iii. 257; on the treatment
  of a fit of the gravel, iii. 260; of  cystic
  oxide gravel, iii. 262; of the  oxalate of 
ANALYTICAL INDEX.                       899
  lime diathesis, iii. 262; of the phosphatic
  diathesis, iii. 263;  on the formation of
  uric acid calculi in the kidneys, iii. 265;
  on renal calculi  of oxalate of lime, iii.
  265; on renal calculi of cystic oxide, iii.
  266;  on the rarity of phosphatic renal
  calculi, iii.267; on the treatment of nephri-
  tis complicating renal calculi, iii. 268; on
  the spontaneous breaking up of calculi in
  the bladder, iii. 275; on the symptoms of
  vesical calculus, iii. 275; on the use of
  stone solvents, iii. 281.
Psoitis.  See Inflammation of the Lumbar
  Muscles.
Psoas abscess, i. 208.
Psora, ii. 63.
Pudic, common, ligature of, ii. 575.
Punctured wounds,  i. 366.   See Wounds.
Pus, the secretion of, i. 46 ;  resorption of, i.
  48 ; Vogel and Bonnet on the effects of,
  i. 48 ; qualities of pure good  pus, i.  50;
  formation  of, i. 51 ; Travers on the pur-
  poses which the formation of pus serves'
  in the economy,  i. 51 ;  Hunter  on  the
  qualities of pus and the pus globules, i.
  51; Hunter and Gulliver on the  putre-
  faction of pus, i. 51 ;  Senac on the globu-
  lar structures of, i. 51 ; Gueterbock on the
  composition and chemical analysis, of, i.
  52; composition of the serum of, i.  52 ;
  fatty vesicles discovered by Henle in the
  serum of,  i. 52;  Gueterbock's discovery
  of pyine, i. 52;charactersofpus globules,
  i. 52 ; Mandt on the pus globules, i.  52;
  discovery  of the difference in size of the
  pus globules by Gueterbock, i. 53 ; Mayo
  describes the occasional occurrence of pus
  globules in healthy blood, i 53 ;  denied
  by Gulliver, i. 53; Gerber's account of
  the formation of pus, and  of  the re-
  productive organization  in suppurating
  wounds, i. 53 ; Travers on the  constitu-
  tion of pus, i. 54 ; varieties of, i. 55 ;  dis-
  tinguishing characters of laudable pus,
  and ichor  or sanies, i. 55; the presence
  of globules in the serum proved by Bayer,
  Faraday, and Mandt, i. 55 ; characters of
  the albumen in pus, i. 56; Grassmeyer
  and Fischer on the distinguishing tests
  for pus and mucus, i. 56 ;  Gruithuisen's
  microscopic tests for  pus and mucus, i.
  56; Gerber's  description of ichor, puri-
  form mucus, and serous exudation, i  56 ;
  pus cannot be produced  without  inflam-
  mation, i.  57 ; diathesis purulenta, i.  57.
Pustule, malignant.   See Mortification.
Puthod's mode of  amputating at the  hip-
  joint with the flap-cut  with a single  flap,
  iii. 691.

Quassoud on mortification from  spurred
  rye, i. 74.
Quesnay's opinion relative to the formation
  of pus, i. 46; on the more general appli-
  cation of  the  trephine, i. 453; on the
  stanching the  bleeding in wound of the
  intercostal artery, i. 492.
Quinsy.   See Inflammation of the Tonsils.

Radial artery, ligature, of, ii. 530.
Radius, fracture  of, i. 610 ; dislocation of,
  ii. 232.
Rainey on a peculiar degeneration of the
  cartilage in disease of the knee, i. 302.
Ramel's case of displacement of the heart,
  ii. 361.
Ramsbotham, Dr., on the obstruction to the
  passage of the urine in  prolapse of the
  womb, ii. 370; on the general symptoms
  of prolapse and procidentia, ii. 372;  of
  the causes of the prolapse, ii. 372 ; cases
  of prolapse in a virgin, ii. 373.
Ramsden's case of lumbar abscess, i. 210 ;
  of fatal contraction and ulceration of the
  intestine, after strangulation, ii. 310 ; of
  ligature of the subclavian above the cla-
  vicle, ii. 519.
Ranby on immediate  amputation in gun-
  shot wounds, i. 380.
Ranula, iii.  120.
Rau's  mode of operating for stone, ii. 307.
Ravaton's slippers for rupture of the tendo
  Achillis, i. 542.
Ravin on increased pressure and the supine
  posture in the radical cure for hernia, ii.
  282.
Rayer on erysipelas, i.  116 ;  opinion that
  carbuncle occurs most frequently inspring
  and  summer, i. 156; on  incisions in car-
  buncle, i. 157.
Raynaud's operation for varicocele, ii. 578.
Recamier on the excision of the prolapsed
  and  scirrhous womb, ii. 381 ; fatal opera-
  tion for ovarian dropsy, iii. 210 ; on com-
  pression in scirrhus, iii.  511; operation
  when the neck of the  womb is softened
  or destroyed, iii. 567; cases of removal
  of the womb by ligature, iii. 569 ; on ex-
  tirpation of the womb, iii. 572.
Rectal fistula, ii. 161.
-----rupture,, ii. 356.
Recto-urethral fistula, ii. 185.
-----vaginal-----, ii. 198.
-----vesical-----, ii. 185.
Rectum, prolapse of, ii. 397;  stricture of,
  iii. 34; foreign bodies in the, iii. 108;
  polypus of, iii. 495.
Regal de Gaillac  on  extirpation of bron-
  chocele by subcutaneous ligature, iii. 399.
Regnault's  case of  re-union  of divided
  parts, iii. 582.
Regnoli's operation for the extirpation of
  the tongue, iii. 521.
Reinhardt on the mode of reducing dis-lo- 
900                        ANALYTICAL INDEX.
  cations of the thumb from the metacarpal
  bone, ii. 235.
Reisinger's apparatus for ligaturing  com-
  plete rectal fistulae, ii.  169 ; mode of ap-
  plying the apparatus, ii.  169.
Renal calculi, iii. 264.
Renaud's apparatus for simultaneous frac-
  ture  of both clavicles, i. 604.
Rennerth on the exhibition of purgatives,
  &,cl, in strangulated hernia, ii. 291.
Renucci on the  existence  of the acarus
  scabiei, ii. 67.
Reybard's canula useless in wounds of the
  intercostal artery, i. 491 ; plan for stanch-
  ing  bleeding from the intercostal artery,
  i. 491; mode of practice in wounded in-
  testine, i. 510;  modification of  Dupuy-
  tren's operation for artificial  anus, ii.
  153.
Reynaud on the treatment of buboes, ii. 90.
Resolution, a result of inflammation, i. 42;
  signs of resolution, i.  42; distinguished  ,
  from the recession of  inflammation, i.
  42 ; Dr. J. H.  Bennett on the process of ]
  resolution, i. 43 ; Schonlein and Zimmer-
  mann on the elimination of the molecu-
  lar fibrin, i. 43; resolution, an ordinary
  termination of orchitis, i. 202.
Rheumatism, gonorrheal, i. 342.
Rhinoplasty, iii.  580.
 Riadore's case of excision of the part of
   the  hand, ii. 722.
 Ribes' case of  phlebitis, i. 96; on the in-.
   ternal opening of  rectal fistula, ii. 102;
   on the application of the taxis in strangu-
   lated hernia, ii. 291.
 Ribieri on local anodyne applications in
   strangulated hernia, ii. 291.
 Ribs,  fracture of, i. 599 ; dislocation of, and
   of their cartilages, ii. 215; resection of,
   iii.  765.                       •
 Richerand on the treatment  of  ingrowing
   of the nail, i. 222; of fractured clavicle, .
   L 603 ; of fracture of  the neck of the hu-
   merus, i. 607; of the neck of the femur,
   i. 624; on the primitive direction of dis-
   location  of the  humerus,  ii. 222;  on
   puncturing the distended  intestine, after
   the operation for strangulated  hernia, ii.
   299; on the occurrence of aneurism in
   dissecting-room servants, ii. 474;  on the
   application of pounded ice to aneurisms,
   ii. 480;  on compression in the treatment
   of  aneurism, ii,  483  ; on  the respective
   origins of benignant and malignant nasal
   polypi, iii, 470; objections to the upper
   flap in partial  amputation of the foot, iii.
   705.
 Richon on the  treatment of gonorrhea, i.
    198.
 Richter on the  extirpation  of  the tonsils
    by  cutting, i,  164; on dry whitlow,  i,
 218; on the lengthening of the limb  in
 hip-disease, i. 285; on the resection of the
 carious head of the femur in hip-disease,
 i. 299; only employs trepanning in inju-
 ries of the head when secondary symp-
 toms of irritation and pressure require it,
 i. 454 ; gutter-shaped piece of card-board
  useless in  wounds of an intercostal artery,
 i. 491 ; bandage for fractured clavicle, i.
  604 ; On the treatment of Salivary fistula,
  ii. 147; objections to the useof the cathe-
  ter in urethral fistula, ii.  182; on the  re-
  duction  en masse, ii. 274;  on increased
  pressure and the supine posture for the
  radical cure of hernia, ii.  282; on  the
  radical cure by incision and scarifications
  of the sac, ii. 283 ; on dilatation of  the
  stricture in strangulated  hernia, without
  eutting, ii. 298; case of yielding of  the
  abdominal parietes, ii. 349;  cauterizes
  ranula in children with lunar caustic,  iii.
,  123 ; mode of amputating by the circular
  incision, iii. 639.
Ricord on acute urethritis in the female, i.
  180; on utero-vaginal gonorrhea, i. 180;
  regards ovaritis  as a  complication of
  gonorrhea, i. 180; on  abscesses compli-
  cating gonorrhea, i. 180; experiments on
  the identity of gonorrhea and syphilis, i.
  183, 186; inferences from the results of
  the inoculation of  gonorrheal matter, i.
  186; opinion that gonorrhea is unattended
  by ulceration controverted, i. 186; on the
  examination of public prostitutes, i. 189;
  treatment  of gonorrhea by  the direct ap-
  plication of nitrate of silver, i. 191; on
  the remedies for  chordee, i. 192;  on the
  arrest of haemorrhage from the urethra, i.
   192; on  the  treatment of gonorrhea in
  women, i. 193; treatment of severe cases
   by the introduction  of a plug  of  lint
  dipped in some emollient narcotic liquid,
  i. 193; treatment of   obstinate cases by
   filling the vagina with dry lint, i. 193;
   ulcerations  and papulous granulations to
   be cauterized, i. 193; on  ulcerations of
   the  mucous membrane  of the womb, i.
   193; vegetations in the interior  of  the
   urethra to  be destroyed  by incision or
   cauterization, i. 193; on gonorrhea in the
   female urethra, i.  194;  on  inoculation
   with gonorrheal matter to cure gleet, i.
   195; on the treatment of balanitis, i.  199;
   on syphilitic swelling of  the testicle, i.
   200; describes it as syphilitic sarcocele,
   i. 200; on  the period  at which chancres
   appear after infection, ii. 71; on inocula-
   tion for  the  purpose of  distinguishing
   syphilitic sores, whether  primary or se-
   condary,  ii. 74; on  the seven kinds of
   buboes, ii. 75;  on the  existence of sy-
   philitic buboes  without primary sore, ii. 
ANALYTICAL INDEX.
©01
  77;  on the non-infectious  character of
  the pus from a secondary syphilitic sore,
  u. 79; on the causes of the varied appear-
  ances  of  chancre or primary syphilitic
  sore, ii. 83>;  en the destruction  of  the
  ulcer by the nitrate of silver, ii. 86 ; on
  the treatment of buboes, ii. 89 ; on iodine
  in gonorrhea and bubo, ii. 101;  on  the
  possibility of infection  from' secondary
  syphilis, ii. 106; on urethroplasty, ii. 179;
  on the application  of the ligature  in  the
  treatment of varix, ii. 572.
Rietgen  on the mode of performing  the
  Caesarian operation, iii. 162
Rokitansky on internal strangulation, ii.
  359.
Roonhuysen on the use of the suture in
  vesico-vaginal fistula, ii. 191.
Roots', Dr., case of human horns, iii. 405.
Rose on the duration of syphilis under the
  non-mercurial treatment, and on the sub-
  sequent occurrence of secondary symp-
  toms, ii. 103.
Roser on dislocation of the thumb from the
  metacarpal bone, ii. 234;  on the cause of
  the difficulty experienced in reducing this
  dislocation, ii: 235; on  the mode of re-
  ducing this dislocation, ii. 235.
Rigby, Dr. on puerperal abscess, following!Rossi's mode of amputating at the knee
  contagious or adynamic puerperal fever,
  i. 60; on wounds of the uterus, as predis-
  posing to rupture in subsequent labours,
  ii. 531; on retroversion of the womb  in
  the unimpregnated state, ii. 407 ; on exa
  mination by the  vagina  and  rectum, and
  by the uterine sound, in retroflexion  of
  the womb, ii. 409; on the symptoms  of
  retroversion, ii. 410; on the mechanical
  support to the womb requisite after the
  reduction of the retroversion, ii. 414; on
  the circumstances authorising the Caesa-
  rian operation, iii. 155;  on the propriety
  of not operating until  after labour has
  commenced, iii.  158.
Ritgen  on  the application of  the sutures
  in the operation for  lacerated perineum,
  ii. 39.
Ritter's idea that  boils depend on the re-
  tention of the animal refuse, i. 153.
Robertson, Dr., on bronchocele as a variety
  of scrofula, iii. 389.
Robertson's case of ligature of the carotid,
  ii. 508.
Robinson, Dr., recommends the removal  of
  the acromion and glenoid cavity in  am-
  putation at the shoulder-joint, iii. 717.
Robinson on the inhalation of ether prior
  to the extraction  of teeth, iii. 768.
Robison's, Dr., case of tetanus, i. 415s
   with the flap-cut, iii. 699.
Rothmund on  the treatment of umbilical
   rupture occurring after birth, ii. 345.
Rousseau's mode of extirpating piles, ii.

Roux on the introduction of  a  piece of
   bougie into an ossified artery after am-
   putation, i. 336; on the removal of the
   edges  of the cleft  in staphyloraphy, ii.
   31; plan for bringing the  edges of the
   cleft together, ii. 32;  operation when the
   cleft is very large and complicated, ii.
   34; fatal case from pneumonia, ii. 35;
   on the operation for lacerated perineum,
   ii. 39; on the application of the sutures,
   ii. 39;  caseof artificial retention of faeces
  after the operation, ii. 40; on the suture
  in vesico-vaginal fistula, ii. 193; cases of
  extirpation of the womb, iii. 573 ; on the
  excision of joints, iii. 726;  mode of ope-
  rating in excision of the wrist, iii. 734;
  case of excision of the heads of metatarsal
  bones, iii. 744; case of resection of the
  clavicle, iii. 764; case of resection  of a
  rib, on account of necrosis, iii. 767.
Rouyer on dislocation of the upper end of
  the radius forwards, ii. 232.
Roy, De, on the making an artificial open-
  ing in the cheek  in the operation for
  salivary fistula, ii.  148.
Rochoux  on hydrocele caused by gonor-  Rudolphi  on the causes of club-foot, ii
  rhea, iii. 222.
Rodgers,  Dr., successful operation for the
  establishment  of a false joint in a case
  of anchylosis, i. 275; mode of operating
  in exarticulation  of the fore-arm at the
  elbow, iii. 719.
Rodriques, Dr., on  the effeets of cupping-
  glasses  in viper bites, i. 389.
Rogers' case  of  trepanning  the spine, l
  590; on
  rism, ii. 564.
Rognetta on  the treatment of vesico-va-
  ginal fistula by  compression with an
  elastic oval pessary, ii. 189; on  disloca-
  tion of the astragalus inwards, n. 252; on
  the causes of splay-foot, n. 457.
                                 446.
                               Rudtorffer's plan to prevent re-union after
                                 the operation for united fingers and toes,
                                 iii.  17.
                               Ruetenich's apparatus for fracture of the
                                 lower-jaw, i. 580.
                               Ruhl's artificial leg, iii. 593 ;  wooden leg,
                                 iii. 594.
                               Rupture (hernia,) ii; 258.
the tTeatment"ofbranching aneu-  Russell on the appearances of white swell-
                                 ing on dissection, i. 305; on the treatment
                                 of scrofulous ulcers, ii. 53.(
                               Russell, Dr.,confirms Celsus' observations
                                 on the innocuous qualities of the poison
                                 of serpents, when introduced into the
                                 mouth, i;390;  on the symptoms produced
76* 
90/2                        ANALYTICAL INDEX.
  by the bite of a cobra di capello, i. 394;
  cases of fatal snake-bite, i. 395;  on the
  treatment of snake-bites in India, with
  the Tanjore pill, i. 395; on the physical
  qualities of snake-poison, i.,395.
Rust's opinion  that the so-called lymph-
  swelling is an extravasation of lymph, i.
  61; on injecting boiling water into a cold
  abscess, i. 105; division oferysipelas into
  true and  false, i. 115; on the application
  of moist warmth  in vesicular erysipelas
  and its varieties,  i. 123; on incisions in
  pseudo-erysipelas, i. 124;  explanation of
  the shortening of the affected limb in
  hip-disease incorrect, i. 284; explanation
  of the  lengthening of the  limb, i. 285;
  objects to the use of issues in hip-disease,
  i. 294 ;  on warm  bathing in, i. 296;  on
  the mercurial treatment in, i.  296;  on
  the general treatment of coxalgy, i. 296;
  on  the  treatment of  abscesses  at  the
  hip, i.  298; advises their being opened
  by the  actual cautery, i.  298; advises
  passing a seton through the joint, i. 298;
  explanation of wounds from the wind of
  a ball, i. 371; case of simple dislocation
  of the spine, i. 586; treatment of chronic
  ulcers of the foot hy the hunger-cure, ii.
  48 ; treatment of syphilitic ulceration of
  the throat and palate,  ii. 91; on the fric-
  tion-cure in syphilis, ii. 94; on the treat-
  ment of caries, ii. 118; mode of reducing
  dislocation of the humerus, ii. 224 ; me-
  thod of replacement of the dislocated fe--
  mur, ii. 239, 240; on the nature of stran-
  gulation  in ruptures, ii. 269 ; on ligature
  of the external iliac, ii. 538.
Ruyer's case of exarticulation of metatarsal
  bones,  with  the  diseased  bones  of  the
  tarsus, iii.  710.
Ruysch on the reduction of the prolapsed
  and ulcerated womb,  ii. 375,
Ryan's, Dr., case  of wound of the neck,
  involving the oesophagus, i. 479 ; on the
  treatment of haemorrhage  consecutive to
  extraction of a tooth,  ii. 143.

Sabatier advises the opening of abscesses
  at the  hip with caustic, i. 298; more
  general  application  of the trephine, i.
  454;  plan  for arresting  bleeding  from
  the intercostal artery, i. 492; apparatus
  for fracture of the neckof  the femur, i.
  623;  internal opening of rectal  fistula,
  ii. 162 ;  reduction en masse, ii. 27.4; case
  of rupture of the lungs, ii. 360; prolapse
  of the womb, ii. 368;  reduction of the
  prolapsed and ulcerated wound, ii. 375 ;
  treatment  of.  the prolapsed  pregnant
  womb, ii. 375;  excision  of joints, iii.
  727; mode of operating in excision of the
  head of the humerus, iii.,732.
Sachs on the operation for the treatment of
  ingrowing of the nail, i. 224.
Sacrum, fracture of, i. 595.
Salamon's treatment of fractured clavicle,
  i. 605 ; operation for ligature of the com-
  mon iliac, ii* 533.
Salemy's mode of amputating through  the
  leg in its lower third, iii. 706.
Salivary fistula, ii. 146.
 ■  ■  —calculus, iii. 123.
Salle, De, on the treatment of gonorrhea,
  i. 197;  on iodine in hard  swellings  of
  the testicle, ii. 101.
Salmon's operation for the extirpation of
  the degenerated  prolapse of the rectum,
  ii. 404; incautious use of enemata a cause
  of relaxed rectum, ii. 406;  seat of stric-
  ture in the rectum, iii. 46.
Sams' case of cerebral irritation preceding
  orchitis, consequent on gonorrhea, i. 201.
Sanctorius' lithotritie instruments, ii. 285.
Sandifort on congenital dislocation  of the
  hip, ii. 207.
Sanson on dressing  the  wound  after the
  operation for  rectal fistula, ii. 167; on the
  reduction en masse, ii. 274 ; on the retrac-
  tion of the tendons of the fingers, ii. 465;
  modes of'performing  the recto-vesical
  operation for  stone, iii. 344; mode of am-
  putating at the hip-joint with two flaps,
  iii.  698; at the  shoulder-joint with the
  circular cut, iii. 716; mode of operating
  in excision of the knee-joint,  iii. 740.
Sarcocele, iii. 547; syphilitic, i. 200.
Sarcomatous tumours, iii.  448.
Sartorius  on  the  section  of  the  tendo
  Achillis in club-foot, ii. 453.
Saucerotte on the operation for lacerated
  perineum, ii. 39; on the  application of
  sutures, ii. 39; case of artificial retention
  of faeces after the operation, ii. 40.
Sauter's. apparatus- for fracture of the neck
  of  the femur, i.  624; on permanent ex-
  tension in fracture of the  femur, i. 628  ;
  apparatus for permanent extension  in
  fractures of the leg, i. 637; plan of reduc-
  ing  dislocation of the humerus, ii. 225;
  d irections for the extirpation of the womb,
  iii.  570.
Saviard on mortification from spurred rye,
  i. 7.4; on the  healing the wounds of arte-
  ries, i. 330.
Scabies, scabies spuria, ii. 63, 64.
Scapula, fracture of* i. 601; resection of, iii.
  762; with the elavicle, iii. 764.
Scarification, iii.. 615.
Scarpa on the healingof wounds of arteries,
  i.  330; experiments on the ligature of
  arteries, i. 335; experiment with the liga-
  ture and cylindenoflinen, i. 335; practice
  in wounded intestine, i. 509; on the pro-
  duction of callus, n 550; on the appear- 
ANALYTICAL INDEX.
903
 ancespresented on post-mortem examina-
 tion, some time after the cure of an arti-
 ficial anus, ii. 155;  on the nature  of
 strangulation in ruptures, ii. 269 ; on the
 reduction en masse, ii. 274 ;  on dilatation
 of the  stricture  in strangulated  hernia
 without cutting, ii. 298; modification of
 the operation for femoral rupture, ii, 336;
 opposed to the radical cure of umbilical
 rupture by ligature, ii. 347; treats ischiatic
 rupture  as enlarged  pudic rupture  in
 women, and enlarged perineal rupture in
 men, ii. .351; on the causes of club-foot,
 ii. 446; machine for dub-foot, ii. 451;
 views respecting the non-expansion of all
 the arterial coats in aneurism not always
 correct, ii 477 ; on the-application of the
 ligature, ii. 492; on the  effects produced
 by the  ligature on the arterial  coats, ii.
 493; on ligature of the external iliac,
  ii. 539; on the division ofthe prostate, iii.
  312; on the diagnosis between scrofula
 and  scirrhus, iii. 503 ; on  the nature of
  scirrhus, iii. 509; case  of lacteal swell-
  ing, iii. 532.
Schaack on tapping a cold  abscess with the
  trocar, and injecting red  wine, or a solu-
  tion of bichloride of mercury or  nitrate
  of silver, i. 106.
Schallein's, von, prophylactic  treatment
  of hydrophobia, i. 412.
Schindler's artery-compressor, i. 331; on
  the  more general  application of the tre-
  phine, i. 454;  mode of  operating- in ex-
  cision of the lower jaw with the condyles,
  iii. 749;  on the previous ligature of the
  carotid artery, iii. 750*
Schmalkalden on the treatment of artificial
  anus, ii. 159.
Schmalz on the effects of electrifying pa-
  tients in doubtful cases  of mercurial dis-
  ease, ii. 112.
Schmitt's obturator  for vesico-vaginal fis-
  tula, ii. 189.
Schmucker's case of concussion, i.  452;
  case of wound of  the womb, i- 533 ; on
  ligature of the hernial sac for its-radical
  cure, ii. 283; case of spontaneous  rupture
  of the ovarian cyst, iii.  214.
Schneider's case of reduction of the con-
  secutive dislocation in hip-disease, i. 208;
  bandage for rupture of the tendoAohillis,

Schonlein on the elimination of the mole-
  cular fibrin, i. 43.
             the  lengthening of the limb
  complete rectal fistulae, ii. 169; on the use
  of the suture in vesico-vaginal fistula, ii.
  191, 192; on congenital dislocation of the
  hip, ii. 207; on the causes of congenital
  dislocations, ii. 207;  on incision of the
  hernial sac and the introduction of lint-
  tents, to  effect the radical cure, ii. 283 ;
  indications when  the operation for the
  radical cure is admissible, ii. 287; opera-
  tion for cartilaginous bodies in the shoul-
  der-joint, iii. 448; on the complication of
  nasal polypus with teleangiectasy,iii. 470;
  mode of  amputating  the penis near the
  pubic bones, iii. 544.
Schreiner's  mode of amputating, iii. 641.
Sohuh's case of partial dislocation of the
  vertebrae, i. 587.
Schumer never  found any trace of  inflam-
  mation in cartilage, i. 262.
Schurmayer's apparatus for fraeture of the
  neck  of the femur, i. 614.
Schwann's opinion on the formation of new
  vessels, i. 323.
Schwarz on the treatment of prolapse of
  the rectum, ii. 402.
Schwenke on the  lengthening of the limb
  in hip-disease, i. 285.
Schwerdt's  cleft-needle for the introduc-
  tion ofthe thread in staphyloraphy, ii. 33.
Scoliosis, ii. 430.
Scott's case of  abseesses of the hip-joint,
  i. 282;  plan of  treatment of hip-dis-
  ease, i. 293;  case of wounded stomach
  without protrusion, i. 521.
Scoutetten's operation for the destruction
  of the matrix  of the nail, i. 223;  on the
  causes of club-foot, ii.447; on the section
  of the tendo Achillis in club-foot, ii.  453;
  mode  of operating  in exarticulating a
  bone, iii. 687; mode of operating for am-
  putation at the hip-joint, iii. 698; oval cut
  in partial amputation of the foot, iii. 705;
  mode of operating in exarticulation of the
  metatarsal bones,iii. 706; in exarticulation
  of  the metatarsal  bone of the  great toe,
  iii. 709; in exarticulation of the toes, iii.
  711 ;  amputation at  the shoulder-joint
  with the oval cut, iii. 716; mode of ope-
  rating in exarticulation of the metacarpal
  bones of the  ring and  little fingers, iii.
  721;, oval cut in exarticulation  of the
  middle metacarpal bone, iii. 721.
 Scrotum, frost-bitten, i. 144;  sarcomatous,
  iii. 559; cancer of, iii. 548?
 Scultetus' artery-compressor, i. 331.
 Sebaceous tumors, iii. 434.
S7nRhip-diseU^                    of Sedillot's oblique cut in amputations, iii
the head  of  the thigh-bone  downwards
and inwards  in hip-disease, i. 286; case.
of reduction of the consecutive disloca-
tion  i. 298;  on the treatment of salivary
fistula, ii. 147; apparatus for ligaturing
  64v
Segalas'"caustic-holder for stricture ofthe
  urethra, iii. 83.
Seiler's modification  of Dupuytren's en-
  terotome, ii. 158; on the nature of stran- 
904
ANALYTICAL  INDEX.
  gulation in rupture, ii. 269; on the opera-
  tion for strangulated  ischiatic rupture, ii.
  351; on the posterior labiafrupture,ii. 355.
Selwyn's, Dr. Congreve, case of recovery
  from wound of the brain, i. 437.
Senac on the globular structure of pus, i. 51.
Senff on ligature ofthe hernial sac for its
  radical cure, ii. 283.
Sennertus on aneurismal varix, ii. 547.
Serres' case of  aneurism of  the  basilar
  artery, ii.  516.
Seton, introduction of,  iii. 618.
Se-utin on the treatment of compound frac-
  tures, i. 561;  on the starch  bandage in
  fractured ribs, i. 599; treatment of frac-
  ture of  the humerus, i, 609;  application
  of  the permanent apparatus in  fracture
  ofthe femur, i. 629 ; in fractures of the
  bones of the leg, i. 638; case of excision
  of the head of the femur, iii. 736; case of
  resection of the fibula, iii. 767.
Severinus on cauterizing the tonsils with
  red-hot  iron or caustic, i. 165.
Sharp on tying the tonsils, i. 165;  on the
  arrest of haemorrhage by nature, i. 329 ;
  on  Cheselden's  operation for stone,  iii
  315; mode of amputating at the shoulder-
  joint by the cireular cut, iii. 715.
Shaw's case of extirpation of the tonsil,
  followed by superficial slough, alarming
  haemorrhage, and ligature  of the carotid,
  i.  166;  on dissection-wounds and their
  treatment,  i. 385; case of fatal  haemor-
  rhage during  lithotomy from wound  of
  dorsal artery ofthe penis, iii. 334.
Sheldon's treatment of fractured oleoranon,!
  i. 613.                                j
Shiptqn's experiments on wounded intes-:
  tine, i. 511.
Shoulder, curvature of, ii. 463; exarticula-)
  tion of  the arm at, iii. 711;  excision of
  the head ofthe humerus at, iii. 731.     I
Shoval's  case of gastrotomy for the remo-1
  val of a knife from the stomach, iii. 106.
Siebold, von, on tying the tonsils, i. 164; I
  case of yielding of the abdominal parie-
  tes, ii. 349; of extirpation of the womb,
  iii. 570; mode of amputating", iii. 641.
Sigebert on mortification  from  spurred
  rye, i. 74.
Signoroni's modification of Gerdy's opera-
  tion for the radical cure of rupture, ii. 284.
Simpson, Dr., on cauliflower excrescence of
  the os  uteri, iih 563; on the mode of
  using the  speculum vaginae, iii. 565.
Simpson, opinions of, relative to the forma-
  tion of pus, i.  46; adaptation of Thor-
  bern's staphylotome to the extirpation of
  the tonsils, i. 164.
Sinogovitz on the  nature of strangulation
  in rupture, ii. 269.
Skin, cancer of, iii. 504.
Skoda on the formation of new vesseh, i.
  323.
Skull, fractures  of the, i. 428; fungus  of,
  iii. 419.
Smew's experiments on substances adapted
  for the immoveable  apparatus for frac-
  tures, i. 554.
Smellie, Dt., on the operation for lacerated
  perineum, ii. 39; on the application of
  the sutures, ii. 39.
Smith on morbus coxae^ senilis, i. 289;  on
  eolehicum in tetanus, i. 420; case of tre-
  panning the spine,  i. 590;  on some  of
  the signs of fracture  of  the neck of the
  femur, i. 618;  fracture-bed, i. 625; on the
  reduction of old dislocations, ii. 205, 206;
  case of congenital dislocation ofthe lower
  jaw, ii. 211; on the post-mortem appear-
  ances in congenital  subacromial disloca-
  tion, ii. 227; on the resemblance between
  the congenital subcoracoid  dislocation,
  and the partial dislocation ofthe humerus,
  and that caused by rheumatic affection of
  the shoulder-joint, or by unusual atrophy
  of the  upper arm, ii. 228; on  the  treat-
  ment  of   teleangiectasy by   inserting
  threads- dipped in  solution  of nitrate of
  silver,  ii. 565; on the statistics of  litho-
  tomy, iii. 271; case of large calculus, iii.
  272'.
Soemmering's preparation of  fracture  of
  the neck of the femur within the capsular
  ligament united  by callus, i. 621 ;  case
  of spontaneous cure of umbilical rupture,
  ii. 346.
Softening, i. 66.
Solander's, Dr., sufferings from  exposure
  to cold, i.  145.
Solera's  operation for varix by cutting
  through the vein above and below, ii. 572.
Solingen on amputating just above the
  ankle,  iii. 671.
Solly's case of gangrene, i..  73; case of
  frost-bite,  i.  145;  case of recto-vesical
  operation for stone, iii. 344.
Somme's case of relaxed rectum, with inva-
  gination of the mucous membrane,  ii.
  405.
South's  case  of cold abscess,  i. 58;  of
  lymph-abscess, i. 61; on vesications filled
  with a blueish or blueish black fluid  in
  eases of severe bruise, or when the ban-
  dages  used  in fracture  are  too tight, i.
  68;  case  of mortification of the lower
  extremity from effusion of blood causing
  distention of the limb, i. 68;  cases  of
  mortification  after fever,  i.  69; of dry
  gangrene consequent on abdominal ty-
  phus, i. 69;  of dry gangrene  from or-
  ganic disease ofthe heart, i. 69; of arte-
  ritis without gangrene, i. 73; of noma in
  the adult, i. 76;  on  the  sloughing  state 
ANALYTICAL  INDEX.
905
of stumps from want of power, i. 84;  on
inflammation ofthe cellular tissue, i. 86;
on the tendency of serous membranes to
adhesive inflammation, i. 88; case of ar-
teritis, i. 89; on phlebitis, i. 92;  on the
cause of inflammation of the absorbents,
i. 95; on  earthy deposits in the absor-
bents, i. 96 ; recommends  the early open-
ing of abscesses just beneath the skin,'
and in glandular structures, i. 103; con-
demnation of pressure and squeezing  an
abscess, i. 104 ; on opening an abscess,
i. 105; amputation  should never be per-
formed while gangrene is in progress, i.
Ill; on erysipelas and erythema, i. 115;
case of  degeneration of the cellular  tis-
sue ofthe forehead and face,i. 120; the con-
stitutional and  local treatment of simple
erysipelas, i.  123; on the treatment of
erythema symptomaticum by incisions, i.
124;  on the application of the nitrate of
silver in erysipelas, i.  124 ; on burns, i.
127;  burns  generally more  dangerous
than scalds, i. 127 ; complete immersion
of a person in boiling water, fatal in ten
or fifteen minutes, i. 127;  persons whose
entire surface  has  been  charred by fire
may live several hours, i. 127; danger
of burns and  scalds the greater, in refer-
ence to  the part injured, i. 127;  use of
flour in  the treatment of  burns, i. 133;
treatment of burns and scalds, i. 135; in-
ternal treatment of burns  and scalds, i.
138;  effects  of the contraction of cica-
trices, i. 139; case  in which the cicatrix
was dissected out, i. 140 ; parallelism of
the effects of great degrees of heat and
cold on the animal body, i. 143; mus-
tard and liniment  in the  treatment  of
chilblains, i.  150;  treatment of boils  by
free incision, i.  153; recommends the
employment  of  general   treatment  in
cases of  boils, i.  153;  rarity of car-
buncle  on the head, i. 156;  treatment
of carbuncle, i. 156; recommends the
actual cautery in cases in  which an arte-
rial branch has been wounded in scarify-
ing the  tonsils, i. 160;   directions for
opening a tonsillar abseess, i. 161 ; treat-
ment of enlarged tonsils, i. 162 ; amputa-
tion ofthe tonsils, i. 165 ; opinion against
excision ofthe uvula, i. 167; on the arrest
of the secretion of milk, and its absorp-
tion,  170;  recommends  abscess  of the
breast to be  opened freely and early, i.
170 ; advantages ofthe proceeding, i. 170;
condemns Langenbeck's plan of treating
the fistulae, i. 171; treatment of fistulae,
i. 172*-; case of chronic  abscess of the
breast, operated on by mistake for scir-
rhus, i.  173 ; on retention of urine in se-
vere gonorrhea, i. 178; on gonorrhea viru-
lenta, a constitutional disease in certain
persons, i. 183 ; frequency ofthe co-occur-
rence of chancre and gonorrhea, i. 184 ;
gonorrheal sore throat, i. 188;  treatment
of gonorrhea, i. 191 ; of painful erections
and  chordee, i. 192 ;  arrest of  haemor-
rhage  from the urethra,  i. 192;  treat-
ment of gonorrhea  in women, i. 193 ; on
gleet, i. 194; on the infectious  nature of,
i.  194; condemnation  of the practice  of
inoculating with gonorrhea to cure gleet,
i.  196; on cubebs and copaiba in gonoT-
rhea, i. 196 ; on balanitis,  i. 198 ;  treat-
mentof balanitis, i 198 ; doubts swelling
of the testicle being ever dependent on a
syphilitic origin, i. 206 ; on congestion of
the semen in the seminal tubes, as a cause
of orchitis, i.  200 ; wasting of the tes-
ticle, caused by inflammation, i.  202;
treatment  of orchitis, i. 203; of fungus
of the testicle, consecutive to abscess, i.
203 ;  of orchitis by compression, i. 203 ;
on the application of compression, i. 205 ;
results  of compression, i.  205;  case  of
metastasis  of gonorrhea and inflamma-
tion of the testicle to  the brain,  i. 206;
origin of lumbar abscess from external
violence, i. 209 ; distinctive character of
psoas abscess from femoral hernia, i. 209 ;
insidious progress  ofthe disease, i.' 210;
controverts Astley Cooper's opinion that
the abscess should be allowed to take its
course, i. 211 ; on issues in the treatment
of lumbar or psoas abscess, i. 211 ;  con-
demns  the practice of passing  a  seton
through a lumbar  abscess, and prefers
puncturing it with  a lancet, i. 212 ; treat-
ment of the abscess, i. 213; paronychia
cellulosa,  i. 216; on the tendency ofthe
tendinous  and cellular whitlows  to run
into each other, i.  217; on the free  inci-
sionand subsequent treatment of whitlow,
i. 220; directions for the treatment of the
second variety of whitlow, i. 221; of the
third  variety of whitlow, and the  neces-
sity for free and deep incisions, i. 221 ;
contravenes Cooper's statement that the
application of a blister will often  bring
away the  nail in cases of ingrowing^ i.
224;  condemns  Cooper's operations for
the removal ofthe diseased nail, i. 225;
on the  evulsion of the nail in onychia
maligna, i. 227; treatment of onychia by
the  destruction  of the nail-gland with
nitric acid, i. 228 ; absence of discrimi-
nating signs between simple acute inflam-
mation of the ligaments and rheumatism,
i.  231 ; relaxation of the  ligaments, i.
233; cases  of abscesses external to the
joint, i. 235; position ofthe limb during
disease of the  knee-joint,  i. 235;  non-
malignancy of pulpy degeneration of the 
906
ANALYTICAL INDEX.
synovial membrane, i. 243; local treat-
ment of synovial inflammation, i. 245;
if suppuration ensue, the swelling should
be punctured early, i. 246; use of blisters
in promoting the absorption of the effused
fluid, i. 246 ; on irritant applications in the
treatment of chronic synovial inflamma-
tion, i. 246; case of disease ofthe syno-
vial membrane of the knee, attended with  ■
evidence  of fluctuation,  in which  the
swelling was punctured without benefit,i.
247; considers that ulceration of cartilages
differs from common inflammation ofthe
synovial membranes, and of the spongy
ends of bones, i. 262 ; opinion that the oc-
currence of scrofulous disease in the joints
has suspended the progress of some other
and  perhaps more  serious disease else-
where, i. 266 ;  has  seen the connecting
medium in anchylosis composed partly of
ligamento-fibrous, and partly of bony mat-
ter, i. 268 ;  on  the ivory-like covering of
the joint-surfaces of bones, i.  268 ;  re-
moval of the articular cartilages in  old
age, as the result of previous ulceration,
i. 268;  views on anchylosis differ some-
what from those of Hunter, i. 269; on
soft anchylosis  from granulations, i. 269 ;
cases of fibrous anchylosis, i. 270 ; of the
complication of bony and fibrous anchy-
losis, i. 271; on the constitutional treat-
ment of hysterical affections of the joints,
i. 278 ; on the  pain on the inside of the
knee in hip disease, i. 280 ; on the short-
ening ofthe limb, i. 284; explanation of
the  lengthening of the limb, i. 286; on
the appearances after death in hip-disease,
i. 287;  on the sympathetic pain in the
hip from  disordered bowels, i. 289 ; on
the morbus coxae senilis, i. 289;  the use of
issues approved of, i. 294 ; the actual cau-
tery or burning cylinders preferable in all
cases where the limb is much lengthened,
the muscles relaxed, and where there is
great swelling  from collection of fluid, i.
294 ; Brodie's  plan of treating issues ap-
proved of,i,295; management of abscesses
at the hip, i. 299 ;  diagnostic symptoms
of the diseases of the knee, i. 302; diag-
nostic sign for vertebral caries, i% 312;
diagnosis between  curvature of the spine
from caries and that from rickets, i. 312;
meaning of," quick union," J. 321; appli-
cation ofthe tourniquet, i. 331;  treatment
of protracted oozing of blood, k 333 ; of
epistaxis, i.  334 ;  wounds of  the pudic
artery and artery of the bulb during the
lateral  operation for the  stone, i. 334;
treatment of wounded arteries in the thick
fleshy parts of the hand  or foot, i. 334 ;
experiment on  the carotid of a dog, i. 335;
on the application of the ligature, i. 337;.
ligature of large arteries above and below
the wound, i. 337 ;  necessity for cutting
down upon a wounded vessel on the sound
side of  a limb, if nearer the artery than
is the part wounded, i. 338; after-manage-
ment of the ligature, i. 339 ; opinion that
the ligature  should  be allowed to come
away, as  the  result of the  suppurating
process, i. 340; management of a long-
retained ligature, i. 340; on torsion, i.
344; treatment of bleeding ossified ves-
sels, i. 352; on venous bleeding in opera-
tions, i. 353; case of fatal venous bleed-
ing during amputation of the breast, i.
353 ; use of bandages for wounds, i. 353 ;
advantages and disadvantages of sutures,
i. 358 ;  number of sutures to be used, and
the mode of their application, i. 360 ; ob-
jections to stuffing a wound  which must
heal by granulation, i. 364; regeneration
of the nerves, and the recovery of their
function after division, i. 364; on the
tearing  or stripping down of large pieces
of skin, i. 368; on torn wounds  of the
seal p, i. 368; on the sloughing which gene-
ral ly follows extensive laceration  of the
skin of  the  limbs,  i.  368; on extensive
ecchymosis, and the means of diagnosis,
when an  artery of  any material  size is
wounded, i. 369; treatment of the swell-
ing, i. 369;  danger of gangrene when  a
large artery has been wounded, from the
distention of the soft parts, i. 369 ; cases
of severe injury from  small shot, i. 371;
objects to the application of caustic in dis-
section-wounds, i.  385;  absorption  of
poisonous matter in dissection-wounds, i.
385 ; the most dangerous punctures those
received in the examination of cases of
simple or puerperal peritonitis,i. 386; con-
sequences of dissection-wounds, i. 386; on
viper-bites, and the  requisite treatment, i.
389; doubts the disposition of hydrophobic
patients to bite, i.  406; excision  of the
bitten parts  in hydrophobia, i. 411; ex-
cision of  the scar, i. 412; on the proxi-
mate cause  of tetanus, i. 417;  on the
favourable termination of cases of tetanus
which pass over the seventh day, i. 419;
on long and free incisions on either side
ofthe spine, and cauterizing the wounds
in tetanus, i.  420; on the treatment of
tetanus, i 420; on the nonrnecessity for
sutures in wounds ofthe scalp, i. -123; on
bruises of the coverings of the skull, fol-
lowed  by collections  of  fluid  blood,  i.
423; on poultices in bruises ofthe scalp,
i. 426 ; treatment of injuries of the head
 when inflammation of the dura mater has
set in, i. 426; bleeding at the ear, a sign
of fracture at the base of  the cranium, i.
429; nonrnecessity for  the  trephine in 
ANALYTICAL  INDEX.                       907
general, i. 430; on fracture of the frontal
sinuses, i. 431; on apparent fracture and
depression ofthe skull, i. 431; treatment
of simple fracture with depression with-
out the trephine, i. 431;  importance of
caution in the prognosis of wounds of the
orbit, i. 437; propriety of opening abscess
ofthe brain, i. 439; consequences of fo-
reign bodies  remaining in the brain, i.
439; chronic inflammation of  the dura
mater, i. 441; mercury in the treatment of
inflammation of the brain, i. 443; mercury
in compression, i. 446;  removal of the ex-
travasated blood after trepanning, i. 447;
puncturing the dura mater, when the ex-
travasation lies beneath, i. 447; the opera-
tion of trepanning to remove effused  blood,
i. 448; state of the pulse in concussion, i.
449 ; treatment of concussion, i. 453 ; in-
frequency of fungus  of  the brain after
trephining, i. 454;  trepanning in  caries
and necrosis of the skull, i. 457; distinc-
tion between the trepan and the trephine,
i. 463; operation of trephining, i. 463;
trepanning the frontal sinuses, i. 464 ; re-
moval ofthe depressed and detached bone,
and of any points on the edge of the frac-
ture,  i. 464; bleeding from the middle
meningeal  artery, or  from a  sinus, i.j
465 ; after-treatment, i. 466 ; the twisted
suture or thin pins in wounds of the face, j
i. 470; wounds ofthe gristly passage of
the ear, i. 472; on position in the treat-
ment of wounds of the windpipe, i. 475 ; >
on  the treatment of such wounds, i. 476,
477 ; case of fistulous wound between the
thyroid and cricoid cartilages,  i. 477; on
secondary haemorrhage in cut-throat, i.
477;  management of fistulae  resulting'
from gun-shot wounds of the  windpipe,
with loss of substance, i. 478 ; examina-
tion with the probe, etc,  in penetrating j
wounds ofthe chest, i. 481; condition of
the lungs when  the chest is  opened, i.
481; on emphysema, i. 495; on the prac- j
tice of sucking or pumping, to extract the
air in the cavity of the chest, i. 496; case
of wounded intestine, i. 507; treatment of
wounded intestine witnout feculent dis-
charge or prolapse, i. 517; rupture of the:
liver, i. 525; rupture or laceration of the
bladder in fracture of  the pelvis, i. 528;
rupture ofthe perineum, i 534; incising
the spongy body of the penis, not always;
a cause of loss of the power of erection, i.
535; objection to amputation of the penis,
in lacerations of the cavernous bodies, l.,
535 ; treatment of rupture of the urethra,
i. 535;  case of hydrocele, which wasj
tapped, and the testicle supposed  to be,
wounded, i. 536; commends Abernethy sj
practice in wounds of joints, i. 538; cases j
of torn muscles, i. 543; causes of want of
bony union in fractures of the neck of the
femur, olecranon, patella, and os calcis, i.
551; non-necessity for bandages in frac-
tures, i. 552; immoveable apparatus for
fractures,i.553; on the position of the limb
when stiffness of a joint is anticipated, i.
555; after-treatment of the fracture,  i.
556; impropriety of  setting  a fracture
before  the  lapse of a few days, i. 556;
immediate management of fractured cla-
vicle, and of oblique fractures, i. 557 ; on
the antiphlogistic treatment in compound
fracture, i.  559;  exhibition of opium in
compound  fracture,  i. 559; enlargement
of the wound, and sawing off the project-
ing portion of bone, i. 559; removal of
splinters, i. 559 ; formation and treatment
of abscesses during  the progress of com-
pound  fractures, i.  560; treatment of
wounded vessels, i. 560; mortification,
and its treatment, general  and local, i.
560; principal points to be considered in
determining on the  necessity for imme-
diate amputation, i. 568; immediate and
remoteconsequence of compound fracture,
i. 570; sympathetic, symptomatic or irri-
tative fever, i. 570; almost invariably sub-
sides as suppuration is established, i.570;
occurrence of secondary,constitutional, or
nervous symptoms,  i. 572; amputation
must not be performed while the symp-
tomatic fever continues, i. 572; the ad-
vantages hoped for by  the  immediate
removal  of the  injured  parts, in prefer-
ence to attempting to save them, i. 573;
objects and occasional results of imme-
diate  amputation, i. 573;  bending of
bones, i. 576; case  of extensive fracture
ofthe bones of the face, i. 578; fracture
ofthe lower jaw, i.  578; fracture of the
os hyoides in  persons  who  have been
hung,  i. 581; signs and rarity of occur-
rence of  fracture of the spinous process
of the vertebrae alone, i. 582;  occurrence
of fracture of the vertebrae, without any
great violence, i. 583; causes of fractured
vertebrae, and  on the injury the  spinal
cord sustains from the accident, i. 583;
case of separation of the under surface
of the second cervical vertebra from the
inter-vertebral  substance, without  dis-
placement, i. 586;  treatment of fracture
of the spinous  processes, i. 589;  on the
attempt to set a fracture through the body
of a vertebra, i. 589; treatment of frac-
tured spine, i. 589;  operation for trepan-
ning the spine, i. 594; after-treatment, i.
594 ;  fracture of the coccyx, i. 595; frac-
tures of the  hip-bone, and their danger
from rupture of the  bladder, i. 596; diag-
nosis of fracture of the hip-bone, i. 596; 
908
ANALYTICAL INDEX.
 impropriety of any operation to raise the
 depressed  portions of bone, in fractures
 of the sternum, i. 598 ; case of wound of
 the  heart caused by a fractured rib, i.
 598 ; treatment of fractured ribs, i. 599;
 causes of fracture of the scapula, i. 600;
 symptoms of fracture of the acromion, i.
 600; doubts the occurrence of fracture
 of the neck of the scapula, i. 601; case
 of  fracture of the coracoid process, i.
 601;  fracture  of the body, spine, and
 angle of the scapula, i. 601;  treatment
 of fractured  clavicle, i. 605;  fracture of
 the  greater tubercle  of the humerus, i.
 606; cases of fracture of the anatomical
 neck, i. 606; fracture ofthe surgical neck,
 i. 607; treatment of fracture of the hu-
 merus, i. 609;  fracture of the condyles,
 i. 610; treatment of compound fracture
 of the humerus, i. 610; fracture  of  the
 neck of  the  radius, i. 611;  treatment of
 fractures of the  fore-arm, i.  613 ; of frac-
 tures ofthe olecranon, i. 614;  in-locking
 of the broken  ends of the  bone, i. 618;
 case of separation of the head of  the fe-
 mur from its neck  by external violence,
 i, 619 ; preparation of fracture within  the
 capsular ligament united by callus, i.621;
 simple and compound fractures  of  the
 femur, i. 628;  treatment, of fracture  of
 the femur, i. 628; of fractured patella, i.
 633  ; means to  be adopted  for the adap-
 tation of the rectus muscle to  the new
 condition of the patella, i. 634; compound
 fracture ofthe patella, i. 634; treatment
 of fracture of the bones of the leg, i. 638;
 case of compound fracture of the os calcis,
 i, 640; fracture of  the phalanges  of the
 toes, and treatment, i. 640; causes of the
 non-union of fractured bones, i. 642; rub-
 bing the ends of the broken bone together,
 i. 643; application of pressure* in false
joints, i. 644; objects to external irrita-
tion, i.644; remarks on Green's operation
for  an ununited fracture, ii. 21;  uncer-
tainty attending all operations  on false
joints, ii. 21; period at which the opera-
tion  for  hare-lip should  be performed,
ii. 23; removal of the projecting teeth
prior to the operation, ii. 23; position of
the child's head during the  operation, ii.
23;  preference  of  the bistoury to scis-
sors, ii. 24; the time the pins should be
left, and  their removal, ii.  26;  on tear-
ing out of the needles, ii. 26; use of ob-
turators in cleft of the hard palate, ii.
27;  application  of strips  of plaster  in
the treatment of ulcers, ii. 48; iodide of
potassium and cod-liver oil in scrofula, ii.
53;  treatment of sloughing chancre, ii.
89;  of suppurating bubo, and of the sub-
sequent ulcer, ii. 90; secondary syphilitic'
 sores, and their  treatment, ii. 92; treat-
 ment  of nodes, ii. 93; the friction-cure,
 ii. 95; proper mode of exhibiting  mer-
 cury in the treatment of syphilis, ii. 103;
 possibility  of  infection from secondary
 syphilis, ii. 106;  absorption of part of the
 dead bone  in  process  of  exfoliation, ii.
 127; consequences of caries  or necrosis
 in the mastoid process, ii. 132; necrosis of
 the vault of the skull, ii. 132; case of ex-
 tensive destruction  of the vault of the
 skull, ii. 132;  caries ofthe bones of the
 face, ii. 132; disease in bones from mer-
 cury and syphilis, ii. 133;  inflammation
 and   suppuration in   the  tooth-socket
 without caries, ii.  134; symptoms and
 treatment  of  sympathetic  disease  of
 the  antrum,  ii.  136;  epulis,  ii.  136;
 stopping a carious  tooth, ii.  137; treat-
 ment of toothacH, ii. 138; hemorrhage
 consecutive to  extraction of  a tooth  in
 cases  of hemorrhagic diathesis, and its
 treatment by the  actual cautery, ii. 141;
 case of consecutive hemorrhage, ii. 141;
 necessity  for  adopting preventive  mea-
 sures immediately after the extraction of
 a tooth, when  the hemorrhagic diathesis
 is known to exist, ii. 144;  treatment  of
 fistula of the parotid duct, ii. 149 ; biliary
 fistulae, ii.  151; case of artificial anus at
 the  navel,  ii. 157;  of flow  of colourless
 fluid from  the navel, ii.  157; operation
 for rectal fistula,  ii. 166; ligature of rec-
 tal fistula, ii.  169;  incomplete internal
 urinary fistula, ii. 175 ;  operation for the
 division of the stricture in great narrow-
 ing ofthe urethra, ii. 184;  for recto-vesi-
 cal fistula,  ii. 186; diagnosis  of disloca-
 tions, ii. 201; dislocations from muscular
 action, ii. 201;  reduction of dislocations,
 ii. 203; of old dislocations, and on the
 necessity of caution in  practising exten-
 sion, ii. 201;  recurrence of dislocations
 after reduction from exhaustion of the
 muscular power,  ii.  205; auxiliary treat-
 ment in the reduction of dislocations, ii.
 206; reduction of dislocation of the lower
jaw, ii. 210; difficulty of keeping the dis-
 located scapular  end of the clavicle re-
 duced, ii. 220;  repeated dislocation ofthe
 femurin the same person, ii. 236; English
 practice in compound dislocations of the
 ankle, u. 251; reducing the dislocation of
 the astragalus,  ii. 253; case of dislocation
 of the os calcis. ii. 255; on  certain forms
 of raptares, ii.  259; presence of the sac in
 vesical and ccecal ruptures, ii. 259; causes
 of stricture in the body of the sac, ii. 260;
 hour-glass contraction of the hernial sac,
ii. 261; occasional rupture of one side of
<he sac in femoral  hernia, ii. 262; difficulty
 of distinguishing between intestinal and 
ANALYTICAL INDEX.
909
omental  ruptures, ii. 266; the gurgling
noise in  the rupture, ii. 266;  thickening
of the intestine in the sac, ii. 267; incar-
ceration  and strangulation, ii. 270;  cos-
tiveness  as a symptom of strangulation,
ii. 270;  dilatation of a strangulated rup-
ture on coughing, ii. 270; application of
the taxis, ii. 273; danger attending vio-
lence in  the application of the  taxis, ii.
273; reduction en masse, ii. 274; objec-
tions to the use of tobacco enemata, ii.
289; case  of  mortified  intestine from
strangulation, ii. 292; the proper  time
for the  performance of the operation for
strangulated hernia, ii. 294; objection to
lifting up a fold of the skin, and incising
it, ii. 295; length of the  first incision in
scrotal and femoral hernia, ii.  295;  divi-
sion of  the coverings, and opening the
hernial sac, ii. 296; cases of internal stran-
gulation by bands from the mesentery or
by diverticula ofthe ileum, ii. 296;  divi-
sion of the stricture, ii. 297; objections to
dilatation without cutting, ii.298; return
 ofthe intestines after the division of the
 stricture, ii. 298; occasional  effusion of
 fluid from the  abdomen  after the return
 of the intestines, ii. 298; treatment of ad-
 hesions between the intestine or omentum
 and the  sac, ii.  298; objections to punc-
 turing or incising the intestine, unless dis-
 tended with solid matter, ii. 299; cases of
 removal of degenerated omentum, ii.300;
 mode of treating the protruded omentum,
 ii. 301;  secondary hemorrhage from the
 omentum, ii. 301;  dark colour of the in-
 testine caused  by venous congestion, ii.
 302; consequences of protracted constric-
 tion of  the intestine, and of  violence in
 the application of the taxis, ii. 305 ;  signs
 indicative of gangrene  of the intestine,
 ii. 306; case of gangrenous  intestine, in
 which a fetid smell was perceptible before
 the sac was opened, ii. 306; division ofthe
 stricture external to the sac, ii. 307; treat-
 ment after the operation,  ii. 307; suppura-
 tion of the sac, ii. 309 ; case  of extensive
 sloughing of the abdominal  and lumbar
 cellular Tissue  after the operation, ii. 309;
 occurrence of  gangrene in  the intestine
 some days after the operation in persons
 of an enfeebled constitution, ii.  310; de-
 scription ofthe fascia transversalis, ii. 318;
 coverings of imperfect inguinal rupture,
 ii. 320;" difficulty  of diagnosis  between
 rupture and hydrocele of the cord; ii. 322;
 cases of hydrocele of the cord  mistaken
 for rupture, ii. 322; direction of the cut in
 dividing the stricture in  inguinal rupture,
 ii. 327; anatomy of femoral rupture, n.
 330; diagnosis of femoral from inguinal
 rupture in women,  ii. 333; presence of
     Vol hi.—77
other tumors in the femoral region likely;
to be mistaken for femoral rupture, ii. 333)
coverings of femoral  rupture, ii. 333 ;
cases of femoral rupture with two sacs, ii.
339; ligature of the umbilical cord, ii.
343; case of double umbilical rupture, ii.
344; opposed to the radical cure of umbi-
lical rupture by ligature, ii. 347; cases  of
rupture of the linea alba, ii. 348; cerebral
rupture, ii. 362; accidental cerebral rup-
ture, ii. 365; irritation of the rectum  in
prolapsus uteri, ii. 371;  contents of the
sac formed  by the prolapsed  vagina, ii.
371; case of prolapse of  the bladder re-i
lieved by operation, ii. 393; treatment of
prolapse of the rectum  in children,  ii.
401; causes of high shoulder, ii. 428 ;
case of hysterical club-foot, ii. 447; cases
of club-foot from palsy ofthe muscles of
the leg, ii. 449; treatment of club-foot in
early  infancy, ii.  451;  section of  the
tendo Achillis in club foot, ii. 453; appli-
cation of the extending  power after the
operation and healing of the wound, ii.
454; division  of  the plantar fascia  ii.
455; section of the tendon of the tibialis
posticus,vand danger of  wounding  the
posterior tibial  artery, ii. 455 ; cause of
the mischief in splay foot, ii. 459; ulcera-
tion of the calf a  cause of horse foot, ii.
460 ; case of horse foot from palsy, ii.
460;  apparatus  for horse foot,  ii. 460;
distinguishingcharacters of circumscribed
true and false aneurism, ii. 472; case of
aneurism mistaken for abscess,  ii. 474 ;
relative frequency of aneurism  in the
 sexes, ii. 475; spontaneous cure  of aneu-
 rism, ii. 479 ;  size of the aneurism best
 fitted for operation, ii. 491;  importance
 of opening the sheath to the least possible
 extent in applying a ligature round an
 artery, ii. 495; return of pulsation in  the
 aneurism for a  short time, after  the liga-
 ture of  the artery, ii. 498 ;  treatment of
 secondary haemorrhage,ii. 499; objections
 to  the  operations  for  ligatures of  the
 axillary  artery, ii. 517;  ligature  of  the
 subclavian, ii. 519; aneurisms of  the
 aorta and origin of the  carotid  and sub-
 clavian liable to be mistaken for aneurism
  of  the  subclavian,  ii.   521;  results  of
  injury to  the  axillary  nerves,  ii.  525;
  compensating  collateral  branches after
  ligature of the brachial, ii. 531 ; com-
  ments on Perry's case of aneurism burst
  ing into a vein, ii. 551; application of tin
  ligature in teleangiectasy, ii. 563; causti
  in  teleangiectasy, ii. 564; case of vari
  of a deep-seated vein,  ii. 570; ligatur
  of the  saphena vein for varix, ii. 572
  spermatocele, ii. 575;   adhesion  of  th.
  tongue to the cheek, iii. 23; objection.- 
910
ANALYTICAL INDEX.
 to protrusion of the tongue prior to the
 passage of the oesophagus bougie, iii. 32;
 case of adhesion of the  two portions of
 the ileo-colic valve, causing obstruction
 to the passage of the meconium, iii, 35;
 of imperforate  anus  opening under the
 glans penis, iii. 39 ; Jewish operation of
 circumcision, iii. 55; reduction of  para-
 phimosis, iii. 61; danger  of using plaster
 bougies in stricture, iii. 73; introduction
 of the bougie, iii. 74; general treatment
 of stricture, iii. 75; practice to be adopted
 when laceration  of the  urethra by the
 bougie is suspected, iii.  77; use of the
 armed bougie, iii. 84; treatment of false
 passages, iii. 86; of closure of the vagina
 in infants, iii.  88;  case of a  piece of
 tobacco-pipe lodged in the cheek, iii. 94;
 case of foreign bodies in  the oesophagus,
 iii. 95;  case of  a fish-bone  in  the  oeso-
 phagus, iii. 96;  preference of tracheoto-
 my to cesophagotomy, iii. 100; inserting
 a tube in the larynx after laryngotomy,
 iii. 116;  case of fistulous opening in the
 larynx after  an  attempt at  suicide, iii.
 116; necessity of probing the larynx and
 rima glottidis after an operation for the
. extraction of foreign bodies,iii. 119; mode
 of operating for ranula, iii. 124;  case of
 adhesion between, and ulceration of the
 gall-bladder into the duodenum, iii. 125;
 bursting and  gangrene  of the  bladder,
 rare terminations of ischuria,  iii. 128; rare
 occurrence of re-opening of the urachus,
 iii. 128 ; obstruction to the urine by cal-
 culi  in  the urethra,  iii.  134;   removal
 of calculi from the urethra, iii. 135; case
 of retention of urine from the pressure of
 an hydatid, iii. 136;  catheterism in in-
 flammation of the prostate,  iii.  137 ;  in
 enlarged prostate, iii. 144 ;  treatment of
 complete  retention in stricture, iii.  144;
 operation  of  cutting into the urethra in
 the perineum, iii. 146; shape and thick-
 ness ofthe catheter, iii. 148;  puncturing
 the bladder, iii. 155; haematocele follow-
 ing the operation for hydrocele, iii.  176;
 dispersing the blood in haematocele of the
 vaginal tunic, iii.  176; occurrence of sup-
 puration if the effused blood be not soon
 absorbed, iii. 177; formation of bursae from
 pressure, iii. 178;  partial enlargements
 ofthe sheaths of tendons, iii. 179; house-
 maid's knee, iii. 180; treatment of drop-
 sical bursae, iii.  181;  objection to ope-
 rating in hydrarthrus, iii. 183; objects to
 injections of iodine in hydrarthrus, iii.
 184;  to opening abscess of the lung, iii.
 196; suppuration of the pericardium, iii.
 201 ;  propriety of passing the  catheter
 before tapping for dropsy, iii. 206; of as-
 certaining  the condition  of the womb
 before tapping, iii. 206; operation of tap-
 ping, iii. 206; case of wound of  the epi-
 gastric artery  in tapping, iii.  207;  of
 venous haemorrhage during tapping, iii.
 207; relative  value  of the small  and
 large operations for ovarian dropsy, iii.
 213 ; characters of hydrocele, iii. 220;
 situation of the testicle in  hydrocele, iii.
 221 ; characters  of the serum in hydro-
 cele, iii. 221; complications of hydrocele,
 iii. 221;  the spontaneous  cure  of,  iii.
 223; treatment of by punctures, iii. 224;
 impropriety of any other operation than
 tapping in hydrocele of old people,  iii.
 225; iodine injection  in hydrocele,  iii.
 228; suppuration of the tunica vaginalis
 after the operation by injection, iii. 228 ;
 treatment  when the cellular tissue of the
 scrotum is injected by mistake instead of
 the tunica vaginalis, iii. 22~4; of hydro-
 cele by seton, iii. 230; cutting away the
 vaginal tunic, iii. 230 ;  treatment of hy-
 drocele complicated  with  rupture,  iii.
 235; foreign bodies the nuclei of stones,
 iii. 248; treatment of renal calculi,  iii.
 268; sounding, iii. 277; existence of cal-
 culous symptoms without  the  presence
 of a stone  in the bladder, iii. 277 ; stimu-
 lation of calculus by vesical polypus,  iii.
 278; measuring the  calculus, iii 278;
 case of stone undetected by the sound
 during eight years, iii. 310; external  in-
 cision in lithotomy, iii. 311; use of the
cutting  gorget, iii. 321; contraction of
 the bladder during lithotomy, iii. 331 ;
 treatment of haemorrhage during and  af-
 ter the operation  for stone, iii. 334 ;  se-
condary haemorrhage, iii. 335;  case  of
 secondary haemorrhage, iii, 335 ; wound-
 ing the rectum, iii. 337;  treatment to be
adopted after the operation, iii. 337 ;  in-
continence of urine consequent on litho-
 tomy in women, iii.  353;  dilatation of
 the female urethra for  the extraction of
calculi, iii.  353;  cases in which litho-
 trity should be performed, and those in
which lithotomy  should be preferred,  iii.
 360; treatment of stone in the urethra,  iii.
 364; extraction of calculi in the urethra in
 front of the scrotum, without incising the
canal,  iii.  364;  lymphatic bronchocele
and  serous  cysts in the neck, iii. 387;
 employment of iodide of potassium,  iii.
 395;  in the form of  ointment, iii. 396;
 enlargement of the nymphae, iii. 400;  re-
 moval of  the enlarged nymphae by ope-
 ration, iii. 400;  venereal and malignant
 warts, iii.  401;  treatment of common,
 venereal, and malignant warts, iii. 402;
 case of human  horns,  iii.  404;  fatty
 tumore, iii. 426; lipoma  diffusum,  iii.
 426; extirpation of fatty tumors, iii. 429; 
ANALYTICAL INDEX.
911
removal of the  roots of the tumor, and
after-dressing,  iii.  429; cysts  forming
around  foreign  substances,  iii.  429°;
atheromatous  cysts, and their contents,
iii. 433;  cause of"  sebaceous tumors,
iii. 433;  removal  of by operation, iii.
438;  condemns the extirpation of gan-
glions, iii. 440; cases of acephalocysts,
iii. 442; composition of foreign bodies in
joints, iii. 445; mode  of operating for
foreign  bodies in joints, iii. 446;  two
kinds of  sarcomatous tumors, iii. 448;
enlargement ofthe prepuce and scrotum,
iii. 449;  removal of the sarcomatous tu-
mors  by operation, iii. 450; plugging the
nostrils, iii. 450; opening  the maxillary
sinus, iii. 483; after-treatment, iii. 483;
tumors of nerves in stumps, iii.  507;
case of long-standing scirrhus, iii. 509 ;
compression of scirrhus, iii. 511;  opera-
tion for cancer of the lip, when the dis-
ease does not extend beyond the red part,
iii. 516;   scirrhus of the breast, iii. 527;
case of  lacteal swelling, iii. 532; ques-
tion  as to the  propriety of removing a
scirrhus  breast,  iii. 539;  case of fatal
venous haemorrhage from extirpation of
the breast, iii. 541; after-treatment, iii.
541;  opinion that amputation is not pre-
ferable to extirpation of the  breast, iii.
542;  recurrence of cancer  after amputa-
tion ofthe penis, iii. 544; relative value
of the two operations for amputation of
the penis, iii.  546;  retraction  of the cord
during extirpation of the testicle, iii. 556;
ligature  of the spermatic cord, iii. 557;
treatment of  undescended  testicle, iii,
558;  extension of chimney-sweep's can-
cer to the neighboring parts, iii. 561;
case of chimney-sweep's cancer, iii. 561;
cause of recurrence of the disease after
its extirpation, iii. 561;  case  of reunion
of divided parts, iii.  582; exhibition of
opium and dietetic stimulants prior to and
after  an  operation, iii.  601; condemns
Wardrop's proposal to bleed a patient to
fainting, and operate during the syncope,
iii. 602 ; directions  for blood-letting from
a  vein, iii.  610; arteriotomy, iii. 612;
treatment ofthe after-bleeding from leech-
bites, iii.  614; substitute for cupping, iii.
616;  dangerous  haemorrhage from cup-
ping, iii.  616; relative value  of leeches
and cupping, iii. 616; preference of cup-
ping, iii. 617; use  of glass  beads for
issues, iii. 617;  of India rubber tape for
setons, iii. 618; application of blisters, in.
619; inconveniences resulting from keep-
ing a  blister too long on the part, in. 619;
on the length of time during which  a
blister should be applied,  in. 620; on
children, iii. 620;  use  of mustard poul-
tices, iii. 620 ; vesicating by friction with
croton oil, iii.  621; relative value of the
tourniquet, and  of compression  of  the
principal artery by a capable assistant in
amputation, iii. 638; retraction ofthe di-
vived muscles by the hand in amputation,
iii. 642; use ofthe saw, iii. 643 ; duties of
the assistant when the bone is being sawn
through, iii. 643;  venous haemorrhage,
and the ligature of the veins after ampu-
tation, iii. 644; exposure ofthe stump, iii.
645 ; bringing the  edges  of the  wound
together in the  horizontal  direction, iii.
645 ; application of the strips of plaster
after amputation, iii. 646; use of cradles,
and a substitute for  them, after amputa-
tion, iii.  646 ;  of sutures after flap-ampu-
tations, iii. 617 ; objects to the practice of
dressing the  amputation-wound to heal
by suppuration and granulation, iii. 647;
treatment of ligatures after amputation, iii.
648 ; of after-bleeding, iii. 648 ;  impro-
priety of tying the  main arterial trunk for
consecutive haemorrhage  after amputa-
tion, iii. 649 ;  use of the actual cautery in
after-bleeding, iii. 649 ; causes and treat-
ment of  protrusion of the bone, iii. 651;
exfoliation of  the bone after amputation,
iii. 651; fungous growth from the me-
dullary cavity, iii.  651; relative value of
the flap and circular operations, iii. 653 ;
objects to flap operations on the leg, iii.
654 ; union of an amputation-wound, iii.
655; results of amputation, iii. 655; posi-
tion  of the limb in amputation  of the
thigh, iii. 657 ; position and duties ofthe
assistants, iii. 657 ; circular cut, and ver-
tical division of the skin laterally, iii.
658 ; mode of using the knife in ampu-
tating, iii. 658; retraction of the soft parts
with the hand while sawing through the
bone, iii. 658; bandaging and dressing the
wound, iii. 659 ; reason why in Liston's
flap-operation  the   hind  flap  should be
longer than the front, iii. 660; comments
on   Syme's  objections  to  amputation
through  the shaft  of the femur, and re-
commendation to amputate through the
trochanters, or condyles, iii. 661; forma-
tion of conical stumps in flap-amputations
of the  thigh, iii. 667 ;  application of the
tourniquet in amputations ofthe leg, iii.
669  ; seat of amputation through the leg,
iii. 670 ; ligature of the retracted anterior
tibial  artery  in  amputation  high  up
through the leg, iii. 671;  treatment  of
haemorrhage from   the  nutritious  artery
ofthe tibia, iii. 671; causes of subsequent
sloughing of  the integuments, iii.  671 ;
objections to flap amputations of the leg,
iii. 672; case of amputation just above the
ankle, iii. 674 ; tabular report of amputa- 
912                       ANALYTICAL  INDEX.
  lions through the leg, iii. 676 ; propriety
  of having a long stump,  if possible, in
  amputation through  the upper arm, iii.
  679 ;  tabular report of, iii. 680 ; flap-am-
  putations through the fore-arm, iii. 682;
  tabular report of, iii. 682 ; consequences
  of  amputation through  the metatarsal
  bone ofthe great toe, iii. 684; amputation
  through the metacarpal bones, iii. 685;
  amputation at the hip-joint, iii. 688;  ex-
  cision ofthe acromion, glenoid cavity, and
  coracoid  process  in  amputation  at  the
  shoulder-joint, iii. 718; case of amputa-
  tion at the shoulder-joint, iii. 718; precau-
  tions to be  taken in the flap-operations at
  the wrist, iii. 720 ; comparative danger of
  primary and  secondary  amputation  in
  severe injuries of the thigh, iii. 724 ; con-
  clusion in favour  of primary amputation,
  iii. 724 ;  minor danger in injuries of the
  leg or upper extremities, and consequent
  propriety of  immediate amputation, iii.
  724 ; excision ofthe ankle-joint, iii. 743;
  injurious effects produced by the inhala-
  tion  of ether, iii. 769 ; impropriety of
  inhaling ether prior to the  operation for
  cataract, iii. 770.
Southam on paracentesis in ovarian dropsy,
  iii. 211; nature of ovarian  disease, iii.
  214 ; extirpation of ovarian cysts, iii. 215.
$pence on the effeets of the scorpion sting,
  i. 387.
Spermatic artery, ligature of, iii. 555.
<---- cord, wounds of,i. 536; degeneration of,
  iii. 556.
Spermatocele, ii. 576.
Speyer on the peculiar causes of death at
  different periods in wounds of the heart,
  ii. 174.
Spina bifida, iii. 185; ventosa, iii.  413.
Spine, fracture and  dislocations of, i. 582 ;
  eurvatures  of, ii. 427.
Splay-foot, ii. 456.
Spleen, wounds of the, i. 526 ; are gene-
  rally fatal,  i. 526; Astley Cooper's case
  of wound  of, i.  526 ; Astley  Cooper's
  cases of separation  of from its attach-
  ments, i. 526 ; rupture of, i.  526; protru-
  sion of, i. 526 ; Ferguson's case, i. 526.
 Stanley on inversion of the foot in fracture
  of the neck of the femur, i. 618 ;  case of
  fracture of the neck of the femur within
  the capsular ligament united by bone, i.
  621 ; of dislocation  ofthe  astragalus out-
  wards, ii. 252; of contracted knees cured
  by the subcutaneous section of the  ham-
  string tendons, ii. 444 ; pulsating tumors
  of bones, ii. 556.
Staphyloraphy, ii. 30—34.
Stark's case of wound  of the larynx and
  pharynx, i. 478.
 Starke on the phosphor, hydrarg. in the
   treatment of syphilis, ii. 93.
Steno's duct, fistula of, ii. 146.
Sternum, fracture of, i. 597.
Stevens', Dr., operation for the ligature of
  the internal  iliac, ii. 534.
Stewart's opinions relative to the forma-
  tion of pus,  i. 46.
Stiebel's  diagnostic  sign  for  vertebral
  caries, i. 312.
Stilling on the interweaving of arteries, i.
  344.
Stokes', Dr. case of displacement of the
  heart from external violence, ii. 361; cases
  of foreign bodies in the  oesophagus in-
  ducing laryngeal symptoms, iii. 114.
Stoess on the  section of the tendo Achillis
  in club-foot, ii.  453.
Stomach, wounds of the, i. 525;  symp-
  toms, i. 521; danger of such wounds, i.
  521 ; treatment, i. 521; use ofthe suture
  if the external wound be large, the wound
  of the stomach directly opposite, or if the
  wounded part protrude,  i. 521 ; Scott's
  case of wounded  stomach without pro-
  trusion, i. 522; Travers' case in which he
  applied a ligature round  the wound of a
  protruded stomach, i. 523; Dr. Cook's
  case of fistulous opening  in the stomach,
  i. 524; foreign bodies in the, iii. 103.
Stricture of the oesophagus, iii. 26; of the
  rectum, iii. 33; ofthe urethra, iii. 62.
Stromeyer on the causes of congenital dis-
  locations, ii. 208;  of wry neck, ii.  422;
  treatment of wry neck after the section
  of the sterno-cleido-mastoideus, ii. 425;
  palsy of the serratus magnus a cause of
  scoliosis or lateral curvature of the spine,
  ii. 430; case of curvature of the hip, in
  which the pectineus and  sartorius were
  divided, ii.  442;  section  of  the  tendo
  Achillis in club-foot, ii.  453; causes of
  splay-foot, ii. 457;  treatment  of aneu-
  rismal varix, ii. 550.
Struve on extirpation of  the womb, iii.
  568.
Subclavian aneurism, iii. 516.
-.---artery, ligature of, ii. 518.
Sue's case of a foreign body remaining a
  long while in the windpipe, iii.  112.
Suppuration :—a natural result of severe
  inflammation, i. 46; secretion  of pus,
  i.  46;  formation  of abscess,  i.  46;
  opinions of Simpson, De Haen, Morgan,
  Hunter, Brugmans, Pinel,  Boerhaave,
  Bell, Gotter, Quesnay, Hoffman, Gras-
  huis,  Stewart,  Pearson,  Hewson,  E.
  Home, Berzelius, Gruithuisen,  Fischer,
  Donne,  Gluge, Valentin,  Gueterbock,
  Wood, Bonnet, Mandt,  Vogel, and von
  Bibra, relative to the formation of pus, i.
  46 ; symptoms of approaching suppura-
  tion, i. 47;  occurrence and signs of fluc-
  tuation, i. 48; symptoms of deep-seated
  suppuration, i. 48;  hectic fever accom- 
ANALYTICAL  INDEX.                       91£
panies every considerable suppuration, i.
48; formation of the walls of an abscess,
and circumscription  of the pus, i. 48;
circumscription of pus does not take place
unless the inflammation  be connected
with plastic exudation, i. 48; walls of an
abscess are secreting and absorbing sur-
faces, i.  48;  resorption of pus, i. 48;
metastatic abscesses, i. 48 ;  Vogel and
Bonnet on the effects of the resorption of
pus, i. 48; Hunter on the cause and results
of suppuration,  i. 49;  Valentin on the
microscopic results of suppuration, i. 49 ;
Hunter  on suppurative inflammation, i.
49; Travers on  the  lining membrane of
abscess,  i.  49;  Hunter and Travers on
the circumstances which  terminate an
abscess to the surface, i. 50; qualities of
pure good pus, i. 50; formation of pus, i.
51; Travers  on the  purpose which the
formation of  pus serves in the economy,
i. 51; Hunter on the qualities of pus and
the pus-globules, i. 51; Hunter and Gul-
liver  on  the putrefaction of pus-, i. 51;
Senac on the globular structure of pus, i.
51 ; Gueterbock. on  the composition and
chemical analysis of  pus, i. 52; com-
 position of the serum of pus, i. 52; fatty
 vesicles discovered by Henle in the serum;
of pus, i. 52; Gueterbock's discovery of
 pyine, i. 52; characters of pus-globules, i.
 52;  Mandt on the pus-globules, i. 53;
 discovery of the difference in size of the
 pus-globules, i.  53;  Mayo describes pus-
 globules as occasionally seen in healthy
 blood, i. 53; denied by Gulliver, i. 53;
 Gerber's account of the formation of pus,
 and of  the reproductive organization in
 suppurating  wounds, i. 53; Travers on
 the constitution of pus, i. 54; varieties of
 pus,  i.  55; distinguishing characters of
 laudable pus, and ichor on sanies, i. 55;
 presence of globules in the serum proved
 by Bauer, Faraday, and' Mandt, i. 56;
 characters of the albumen in pus, i. 56;
 Grassmeyer £nd Fischer on  the  distin-
 guishing'tests for pus and mucus, i. 56;
 Gruithuisen's microscopic tests-for pus
 and  mucus, i. 56;  Gerber's description
 of ichor, puriform mucus, and serous exu-
 dations, i. 57;  pus cannot be  produced
 without inflammation,  i.  57; cold  or
 lymph abscess, i. 57; the diathesis puru-
 lenta, i. 57 ; abscess of congestion, i. 57;
 symptoms of cold abscess, i. 57 ; cold ab-
 scess not to be confounded with Hunter s
 collections of  matter without inflamma-
  tion, nor with the cold  abscess of the
 surgeons ofthe Saracen school, the chro-
 nic  abscess of modern  surgeons, i. 58 ;
 South's case of cold abscess,  l. 58; Dr.
  Riaby on puerperal abscess following con-
 tagious  or adynamic puerperal  fever, i.
 60;  Beinl, Rust, and others regard  the
 so-called lymph-swelling as being  an
 extravasation of lymph, i. 60;  Beinl's
 opinion that the  strongest  and  most
 healthy are more subject to lymph-abscess
 than the weak, and men than women, and
 that  it does not occur without external
 injury disproved by Rust, i. 61 ; Nasse's
 case of lymph-swelling  from  external
 injury, i. 61; such cases exceedingly rare,
 i. 61; opinions  of Langenbeck, Ekl, and
 Zembsch on the  lymph-swelling, i.  61;
 South's- case of lymph-abscess, i.  61;
 treatment during and after suppuration, i.
 102; attention to the general health requi-
 site  during suppuration, i. 109 ; suppura-
 tion of the testicle to be feared when the
 inflammation is active and the pain throb-
 bing, i. 201; suppuration of the testicle
 rare when the  swelling  is sympathetic,
 i. 202;  Astley Cooper on suppuration of
 the  testicle, i. 202; bursting of the  ab-
 scess sometimes followed by a fungous
 growth, i. 202; treatment of suppuration
 and  abscess of the testicle, i. 203; .treat-
 ment of suppurationexternal to the joints,
 i.  234 ;  of  suppuration internal to  the
 joints, i. 234; South's cases of abscesses
 external to the  joint, i. 235; suppuration
 of the synovial membrane, i. 239; symp-
 toms of suppuration of the hip-joint, i.
 279; Astley Cooper and Coulson on the
 bursting of abscesses of the hip-joint, i.
 282; Mackenzie and Scott's cases of ab-
 scesses of the hip-joint, i. 282; Key and
  South on suppuration of the sac, after the
  operation for strangulated hernia, ii. 309.
Surgery, definition of, i. 13; division of, i.
  16; historical  sketch of, i. 17 ;  literature
  of, i. 21.
Surgical Operations :—elementary  pro-
  ceedings, iii. 599;  steps of an operation,
  iii.  599; method of operating,  iii. 599;:
  circumstances  to be attended to in giving
  the preference  to the various methods.of
  operating, iii. 599;  many operations  sub-
  ject to certain  and  general rules, iii.  599;
  those operations most difficult which are
  not subject to rules, iii. 600; cases re-
  quiring operations, iii.600; circumstances
  necessary to be attended to in order to
  obtain the  successful result of the opera-
  tion, iii. 600;  the  patient's condition.re-
  lative to the success ofthe operation iii.
   601;  proceedings  preparatory  to an ope-
   ration, iii.  601;  South  on the exhibition
   of opium i and dietetic stimulants-prior
   to, and after an operation, iii.  601;
   time of the-year at'which  operations
   should be performed, iii. 602; Wardrop's
   proposal to bleed  the patient to fainting, 
914                         ANALYTICAL INDEX.
and operate during the syncope, iii. 603;
condemned by South, iii. 603 ; the most
serious occurrences during an operation,
iii. 603; faintings and  convulsions, iii.
603;  sudden death and its causes during
operations, iii, 603 ; entrance of air into
veins, iii. 603 ; treatment of such  an ac-
cident, according to Amussat and Magen-
die, iii. 603 ;  Bichat, Nysten, Magendie,
and Piedagnel on the cause of death from
the entrance of air into the veins, iii.603,
604;  Amussat, Warren, Mussey, and
Mercier on the treatment of the accident,
iii. 604; B.  Cooper's case, iii. 604; di-
vision of organized parts, iii. 604;  by
mechanical or chemical means, iii. 604;
four modes of effecting division by me-
chanical means, iii. 604;  two classes  of
instruments for the division of soft parts
by cutting, iii. 604; knives, bistouries,
and scalpels, iii. 604; varieties of the bis-
toury, iii. 605; description  of a regular
cut, and mode of making  it, iii. 605; va-
rieties of incisions, iii. 605;  use  of the
convex  and  button-ended bistoury, iii.
605;  mode of holding the knife, iii. 606;
mode of action of scissors  in effecting
the division of parts, iii. 606; circum-
stances under which  scissors are used,
iii. 606;  varieties  of scissors, iii. 606;
mode of using scissors, iii. 607;  division
of soft parts by stabbing, iii. 607; instru-
ments used for that purpose, iii. 607; de-
scription  of the  trocar and lancet, iii.
607;  division of parts by tearing, iii. 607;:
specially used for polypi, iii. 607; divi-
sion of parts by tying or the ligature, iii..
607;  cases in which this mode of divi-
sion should be employed,iii.607; division
of a bone,  iii. 607 ; instruments used for
the purpose, iii. 607; separation of divided
parts, iii.  607; dilatation of parts, iii.
608 ;  general surgical operations, iii. 608;
blood-letting, iii. 608; modesof operating,
iii.608; opening veins,phlebotomy, iii.608;
situation where performed, iii.608;  choice,
of  a  vein at the  bend  of the  elbow,
iii. 609; mode of opening a vein, iii. 609;
South's directions for blood  letting from
a vein,  iii.  609; dressing  the wound,
and applying the bandage, iii. 610; acci-
dents which occur during the operation,
iii- 610;  faulty stab, iii. 610; formation
of too small an opening, iii. 610; stoppage
of the  flow of blood, iii.  610;  severe
pain  from wounding  a nerve,  iii. 610;
wounding an artery, iii. 610;  wound of a
 lymphatic vessel, tendon, or aponeurotic
 expansion, iii. 610; accidents which may
 occur after the operation, iii. 610;  bleed-
 ing,  iii. 610; inflammation and suppura-
 tion, iii. 610;  inflammation of the veins.
or lymphatics, iii. 610; Abernethy on the
treatment of traumatic phlebitis, iii. 611;
severe pain and even convulsions from
partial division of a nervous twig, iii.6\\;
Abernethy on the complete section of the
nervous twig in such cases, iii.611; use of
the snapper dangerous, iii. 611; opening
the veins of the fore-arm and  hand, iii.
611; blood-letting  in  the  foot, iii. 611;
blood-letting in the neck, iii. 611;  direc-
tions  for opening  the external jugular
vein,  iii. 611; opening arteries, iii. 611;
only performed on the temporal, iii. 612;
mode of operating, iii. 612; South and
Cline jun. on arteriotomy, iii. 612; appli-
cation of leeches, iii. 612;  mode  of apply-
ing them, iii. 612; description  of the
blood-leech, iii. 612;  of  the  horse-leech
and common leech, iii. 612 ; means to in-
duce leeches to bite, iii. 613 ;  application
of leeches to the mouth, or near the anus,
iii.  613; Crampton and  Osborne on the
application of leeches to the mucous sur-
faces, iii. 613; treatment after the leeches
have dropped off, iii.  613 ; of  the after-
bleeding in children, iii. 613; Bricheteau,
Lisfranc, Green,  and  Oliver's  cases of
fatal haemorrhage  from  leech-bites, iii.
614 ; South on the  treatment ofthe after-
bleeding, iii. 615; treatment  of ecchy-
mosis, inflammation and suppuration of
leech-bites, iii. 615; scarification, iii. 615 ;
definition and employment of, iii.  615 ;
cupping, iii. 615; mode of operating, iii.
615; dry cupping,  iii. 616 ;  South on a
substitute for cupping, iii. 616  ; Dr. Os-
borne's polytome, iii. 616; South on dan-
gerous  haemorrhage  from cupping, iii.
616;  relative value of leeches and cup-
ping, iii. 616; Junod's apparatus to cause
derivation of blood, iii. 616 ; South on the
relative value of leeches  and cupping, iii.
617;  South's preference of cupping, iii.
617; putting in issues, iii. 617 ;  definition,
iii. 617 ; situation in which issues should
be made, iii. 617 ;  making an issue with
the bistoury, iii. 617; South on the use of
glass beads foT issues, iii. 617;  making an
issue by a blister, iii. 617 ; after-treatment
of the  issue, iii. 61S ; introducing a seton,
iii. 618; definition, iii. 618; mode of ope-
rating, iii. 616; South on the  use of In-
dia-rubber tape for setons, iii. 61*; pass-
ing a seton into a cavity containing fluid,
iii. 618; into a swelling not containing
fluid, iii. 619; after-treatment ofthe seton,
iii. 619 ; application of blister plaster and
mazereon bark, iii.  619 ;  mode  of applica-
tion of blister plaster, iii. 619; South  on
the application of blisters,,iii. 619; blisters
raised by boiling water, iii. 620; South on
the inconveniences resulting from keep- 
ANALYTICAL INDEX.
915
ing a blister too long on the part, iii. 620 ;
South on the length of time during which
a blister should be applied, iii. 620; on
children, iii. 620;  South on the  use  of
mustard poultices, iii. 620 ; treatment of
the blister, iii.  620 ; treatment of  severe
inflammation from a  blister, iii. 620;  of
strangury, iii. 620; employment of meze-
reon bark as a  blister, iii. 621 ; South on
vesicating by friction with croton  oil, iii.
621; vaccination or inoculation with cow
pock, iii. 621; definition, iii. 621 ; use of
the lymph, iii.  622 ; Dr. Gregory on the
origin of vaccination, iii. 622; Dr. Jenner's
discovery, iii. 622;  Cline the first experi-
menter, iii. 622; Dr.  Gregory on the pre-
servation of vaccine lymph for transmis-
sion,.iii. 622;  Gregory on the period at
which lymph should  be taken for vacci-
nation, iii. 622; vaccination an operation
without danger, iii. 623 ; mode of vacci-
nating from a fresh pustule, iii. 623 ; Dr.
Gregory on the operation of vaccination,
iii. 623 ; vaccination with dry matter, iii.
623; appearances after  effectual vaccina-
tion, iii. 623;  Gregory  on  the appear-
ances after effectual vaccination, iii. 624;
irregularities in the course of the vaccine
vesicle, iii.  624; Gregory on the insus-
ceptibility of some constitutions  to the
vaccine virus,  iii. 624; after-treatment,
iii. 625;  Gregory on the appearance  of
vaccine  lichen, iii. 625; infusion and
transfusion, iii. 625 ; definition and use
of infusion, iii. 626 ;  effects of  infusion,
iii. 626; of simple warm water used by
Magendie in hydrophobia, iii.  626; use
of infusion in tetanus,  cholera, and foreign
bodies in the  throat, iii. "626;  mode of
operating, iii. 626 ; definition of transfu-
sion, iii. 627; cases in  which it is appli-
cable, iii. 627; immediate and mediate
transfusion, iii. 627; apparatus and opera-
tion for immediate transfusion, iii. 628;
possible dangers of transfusion, iii. 628;
mode of operating in mediate transfusion,
iii. 628; Blundell's  apparatus, iii. 629;
Midler's proposal to  separate the  fibrous
parts of the blood prior to transfusion, iii.
629 ; cauterization, iii. 630 ; employment |
of escharotics, iii. 630;  of fire  by the j
actual cautery and by moxas, iii. 630; the
object of cauterization, iii. 630 ;  the effect
of cauterization by escharotics and by fire,
iii. 630;  various degrees of heat at which
the actual cautery is applied, iii. 630; the
various forms  of cautery irons, iii. 630 ;
application of the actual cautery, iii. 631 ;
parts to which the actual cautery should
not be applied, iii. 631 ; after-treatment,
iii. 631; description and application ofthe
moxa, iii. 631  ; Larrey's moxa of rotten
phosphorescent wood, iii. 631; Percy's
moxa made with  the  pitch of the sun-
flower, iii. 631; moxas made with English
blotting-paper and  chromate of potash, iii.
632; treatment of the slough from a moxa,
iii.  632 ; difference between the effect of
a moxa and ofthe actual cautery, iii. 632;
division of nerves in neuralgia, iii. 632 ;
cases in which the operation is required,
iii.  632; the result ofthe operation doubt-
ful, iii. 633 ; excision of a portion of the
nerve, and  cauterization recommended,
when the disease returns after the section,
iii. 633 ; subcutaneous division of nerves,
iii.  633 ; symptoms of frontal neuralgia,
iii.  633; division ofthe nerve and subse-
quent treatment, iii. 633;  the  operation
for the subcutaneous division of the inner
and outer branches of the frontal nerve,
iii.  633 ; the operation for infra-orbitar
neuralgia, iii. 633;   the  operation for
the subcutaneous  division of  the  infra-
orbitar nerve, iii.   633 ; Klein's  opera-
tion for the  division of the nriddle bran-
ches of the  facial  and of the infra-orbi-
tar  nerves,  iii.  633 ;  Klein's  operation
for  dividing the facial nerve, iii. 634;
Klein's operation for dividing the inferior
maxillary nerve, iii. 634;  Dieffenbach's
operation for the subcutaneous division of
the nerves of the  cheek,  iii. 634; Bon-
net's  operation for the subcutaneous di-
vision of the  nerve in mental neuralgia,
iii.  634; Klein's operation for destroying
the trunk of the facial nerve at its exit
from the stylo-mastoid  foramen, iii. 634;
the operation performed  in two cases,
without a permanent cure, iii. 634; Klein
considers the  operation to be entirely free
from  danger, iii.  635;  Langenbeck's
operation for  the  division or excision of
the facial nerve at the stylo-mastoid fora-
men, iii. 635; comparison of the subcu-
taneous division of the nerves  with the
ordinary operation, iii. 635; Bonnet on
the nature  of the uniting  medium  be-
tween the two ends of the dividing nerve,
iii. 636; Delpech, Earle,  Astley Coop-
er,  Abernethy, Wilson, Malagodi,Swan,
Manovy, and  Bujalsky's cases of nerves
divided for neuralgia, iii. 636; Lentin on
neuralgia of the heel, iii. 636 ; amputa-
tion of the  limbs, iii. 636 ;  amputations
divided  into  those which are performed
in the continuity of the limbs  and those
at joints, iii. 638;  points to be considered
in performing amputations, iii. 638; pre-
cautions against haemorrhage, iii. 638; in-
conveniences  of the  application  of the
tourniquet, iii. 638; compression of the
principal artery by a capable  assistant
preferable,  iii.  638;  Briinninghausen's 
916
ANALYTICAL  INDEX.
recommendation to swathe the  limb in
flannel, to diminish the loss of blood, iii.
638 ;  South oh the relative value of the
tourniquet, and of  compression of the
principal  artery by a capable  assistant
in amputation, iii. 638; formation of such
wound  that  the  bone can  be properly
covered by soft parts, iii. 639; by the cir-
cular incision, iii. 639; the Celsian opera-
tion, iii. 639; objections to this operation,
iii. 639; Petit, Mynors, Brunninghausen,
Louis, Alanson, Gooch, Bell,  Desault,
Richter, Boyer, Graefe, Dupuytren, Wil-
hel m, Valentin, and Portal's modes of ope-
rating, iii. 640; flap amputations, iii. 641;
Pott, Siebold, and Schreiner's operations,
iii. 641 ; Langenbeck  and Scoutetten's
operations  for disarticulations,  iii.  642;
the oblique cut of Sedillot and Baudens,
iii. 642; the sloping cut of  Blasius, iii.
642; retraction of the divided muscles and
sawing of the bone, iii. 642;  scraping
off the periosteum superfluous, iii. 642 ;
Walther  and   Brunninghausen's  man-
agement of  the  periosteum,  iii.  642;
South  on the  retraction  of  the divided
muscles by the hand, iii. 642; South and
Liston on the use  of the saw, iii. 643;
South  on  the  duties  of the  assistant,
when  the bone is being sawn  through,
iii. 643; ligature  of the divided vessels,
iii. 643; historical sketch  of the  treat-
ment of haemorrhage after amputation, iii.
644;  South on venous haemorrhage, and
the ligature of the veins after amputation,
iii. 644;  subsequent  dressing of  the
wound, iii. 644 ; leaving the wound open
for some  hours after the operation, to
guard  against  after-bleeding*  iii.  644;
Dupuytren's practice, iii. 644;  South on
the exposure of the stump, iii. 645;  mode
of dressing to promote quick union, iii.
645; South on the bringing the edges of
the wound together in the horizontal di-
rection, iii. 645; South on the application
of the plaster straps after amputation, iii.
646; use of cradles after amputation, iii.
646 ; South on the use of cradles, and of
a substitute for them, after  amputation,
iii. 646; dressing after flap-amputations,
iii. 647 ; South on the use of sutures af-
ter flap-amputations, iii.'647;  dressing
the stump, when intended to heal by sup-
puration and granulation, iii. 647; South's
objections to  the practice, iii. 648; acci-
dents which may ensue after amputation,
iii. 648; renewal of the dressing  underi
ordinary circumstances,  iii. 648;  mode
of changing the dressings, iii. 648; with-
drawal of the ligature, iii. 648  ; general
treatment after amputation, iii. 648;  Be-
nedict's stimulant treatment of stumps,
iii. 648; South on the treatment of liga-
tures after amputation, iii.  648; after-
bleeding, and its treatment, iii. 648; liga-
ture of the principal  arterial  trunk for
consecutive haemorrhage, iii. 648; causes
and treatment  of parenchymatous bleed-
ing, iii.  648;  treatment of consecutive
haemorrhage, from  ossification or carti-
laginous thickening of the arteries, iii.
649;  South on  the  treatment  of after-
bleeding, iii. 649 ; South  on the impro-
priety  of tying  the  main arterial trunk
for consecutive haemorrhage after ampu-
tation, iii. 649; South  on  the use of the
actual cautery  in after-bleeding, iii. 649;
violent inflammation ofthe stump, and its
treatment, iii. 649; erythetic condition of
the stump, iii. 649; inflammation of the
arteries or veins, a not unfreq uent cause of
death after amputation, iii. 650; symp-
toms and treatment, iii. 650;  insufficient
degree of inflammation, or torpid condi-
tion of the stump, iii.  650; treatment of
sloughing, iii. 650; of too copious sup-
puration, iii. 650; causes and treatment
of  protrusion  of the  bone, iii. 650;
South  on the causes  and treatment of
protrusion  of the  bone,  651;  necro-
sis of the  bone, iii. 651; South  on the
exfoliation of  bone after amputation, iii.
651; ulceration of the bone or soft parts,
iii. 651;  South  on  the fungus growth
from the medullary cavity, iii. 651;  the
relative value  of the  several modes of
proceeding in amputation of the limbs in
their continuity, iii. 652; objections to
the flap-operation, iii. 653; cases in "which
the flap-operation is  suitable, iii. 653;
Liston's preference of  the flap-operation,
and objections to the circular operation,
iii. 653; South and Fergusson on the rela-
tive value of the flap and circular opera-
tions, iii. 653; Fergusson on  amputation
through  the calf of the leg and at the
shoulder-joint, iii. 653;  South's objections
to flap-operations  on  the leg,  iii. 654;
the propriety of quick  union  of stumps,
or ofthe cure by suppuration and granu-
lation, iii.  654;  Dupuytren's  mode of
dressing stumps, iii. 655; South  on the
union of an amputation-wound, iii. 655;
results of amputation, iii. 655;  Phillips,
Lawrie, Potter, and South on the results
of amputation, iii.  656 ; Amputation in
the continuity of the several limbs.——am-
putation through  the thigh, iii. 657;  pre-
paratory steps of the operation, iii. 657;
compression of the artery, iii. 657; South
on the position of  the limb,  iii 657;
South on the position  and duties of the
assistants, iii. 657; the circular operation,
iii. 657;  division and   retraction of the 
ANALYTICAL  INDEX.
917
skin and cellular tissue, iii. 657; South
on  the circular cut and vertical division
of the skin laterally, iii. 658;  section of
the muscles, iii. 658;  of the periosteum,
iii, 658; sawing the bone, iii. 658; cutting
through the muscles on the outside of the
thigh, iii. 658; South on  the mode of
using the knife in amputating, iii. 6o8;
South on the retraction of the soft parts
with the hand,  while sawing through the
bone, iii. 658; bandaging and dressing the
wound, iii. 658; South on bandaging and
dressing the wound, iii. 659; amputation
through the thigh, with twoflaps, iii. 659;
mode of operating, iii. 659; Langenbeck's
mode of amputating, iii. 659; Liston's
mode of amputating the  thigh  by the
flap-operation,  iii. 660;  preferred  by
Syme and Fergusson, iii. 660;  Fergus-
son and South's  reasons why the  hind
flap should be longer than  the front,  iii.
 660; amputation through the  thigh with
 a single flap, iii. 660; Benedict, Textor,
 and Jaeger's plan of amputating, with a
 flap from the outer side, iii. 660; Zang
 and Textor's  plan with a flap from the
 inner side, iii. 660; Hey's mode with the
 flap  from behind, iii. 660; B. Bell, Le
 Gras, and Foulliay's plan with a  flap
 from before, iii. 660; mode of operating,
 iii. 660; Dr. Little's  case of amputation
 with a  flap from behind, iii. 660; Fer-
 gusson's recommendation  to excise a
 considerable portion  of the sciatic nerve
 in that operation,  iii. 660; Syme's objec-
 tions to amputation through the shaft of
 the thigh-bone, and  recommendation to
 amputate  through the  condyles or tro-
 chanters,  iii.  660;  commented on by
 South,  iii. 661;  Liston's  account  of
 eighteen amputations through the thigh
 iii. 661; report of twenty-eight amputa-
 tions through  the thigh, iii.  662;  Syme
 and  South on  the formation of conical
 stumps, iii. 667;  Syme on  amputation
 through the epiphyses, iii. 668; amputa-
 tion through the  leg, iii. 668; directions
 for the  operation, iii. 669 ; application of
 the  tourniquet, iii.  669; South on the
 application  of the  tourniquet,  iii. 669;
 modes  of operating in amputation with
 the  circular  cut, iii.  669;  amputation
 through the leg in its lower third, in. 670;
  Salemi, Lenoir, and Baudens' modes of
  operating, iii. 670; disjointing the head ot
  the fibula, iii. 670;  Larrey's amputation
  through the  head of the tibia, in. 670;
  South on the  seat of amputation through
  the leg, iii. 671; ligature of the_ vesseIs
  Ui.  671; after-dressing, m. 671;  South
  on the ligature of the retracted anterior
  tibial   artery, in amputation   high up
through the leg, iii. 671;  South on the
treatment of hemorrhage from the nutri-
tious artery of the tibia, iii.  671; South on
the bringing the edges of  the wound to-
gether horizontally, iii. 671;  South on
the causes of subsequent sloughing of the
integuments, iii. 672; amputation through
the leg with a single flap, iii. 672; mode
of operating, iii. 672; South's objections
to flap-operations on the leg, iii. 672; am-
putation through the leg with two flaps,
iii. 672; mode of operating, iii. 673;  Lis-
ton's and Fergusson's mode of operating,
iii. 673; amputation just above the ankle,
iii. 674; Solingen, Dionis, White, Brom-
field, Wright, Alanson, and Hey on this
operation, iii. 674; Lawrence and South's
cases, iii. 675; Liston's statistics of ampu-
tation through the leg, iii.  675; Lawrie's
objection to amputation below the knee,
iii. 675 ; South's tabular report of ampu-
tations through the leg, iii. 679 ; ampu-
tation through  the  upper-arm, iii. 679 ;
steps preliminary to the operation, iii. 679;
Liston's statistics  of the operation, ii.
679 ; South on the propriety of having a
long stump if possible,  iii. 679; South's
tabular report of  amputations  through
the  upper arm,  iii.  680;  amputation
through the fore-arm, iii. 681; directions
for  the  operation, iii.  681; amputation
with a single flap, iii. 681; with two flaps,
iii. 681; South on flap amputations through
the fore-arm,  iii. 681; South's  tabular
 report of amputations  through the fore-
 arm, iii. 682; Liston's cases, iii. 682; am-
 putation through the metatarsal and me-
 tacarpal bones, iii.  682; application of the
 tourniquet, iii. 683 ;  amputation through
 the metatarsal bone of the great  toe, iii.
 683 ; mode of operating when the flap is
 formed from the sole, iii. 683; when the
 flap is made from the  inner side of the
 metatarsal bone, iii. 683  ;  the bone best
 sawn through obliquely from within out-
 wards, iii. 684; mode of  operating  when
 the flap is made from  the  dorsal surface
  of the metatarsal bone, iii. 684; South on
  the consequences of amputation through
  the  metatarsal bone of the great toe, iii.
  684; amputation  through  the interme-
  diate metatarsal bones, iii. 685; mode of
  operating, iii. 685; amputation through
  the metacarpal bones, iii. 685; amputa-
  tion through the metacarpal bone  of the
  thumb, iii. 686;  South  and Liston on
  amputation through the metacarpal bones,
  iii.  686;  amputation through the fingers
  and toes, iii. 686;  amputation through
  the phalanges of the fingers, iii. 686;
  mode of operating, iii.  686; cutting off
  the finger with a chisel, iii. 686; Mayor 
918                         ANALYTICAL INDEX.
on the amputation of the phalanges with
the tachytome, iii. 686; exarticulation or
amputation through the joints, iii. 686 ;
cases in which exarticulation is required,
iii.  687;  Scoutetten's mode of operating,
iii.  687; general  directions, iii. 687; con-
dition  of the parts around the joint, iii.
687;  exarticulation of the thigh  at the
hip, iii. 688; danger and statistics of the
operation,  iii.  688;  Jaeger,  Krimer,
and  South on  the operation, iii. 688;
cases requiring  the operation, iii. 688;
La  Croix  d'Orleans,  Perrault, and H.
Thomson's cases, iii. 689;  the mode of
operating, iii. 689; by the circular cut, iii.
689;  Abernethy, Veitch, Cole, Jaeger,
Kerr, and Graefe's modes of operating,
iii.  689; by the flap-cut with a single flap,
iii.  691; Puthod, Hunczorsky,  Bryce,
L'Alouette, Langenbeck, Delpech, Le-
noir,  Plantade,  and Manec's modes of
operating, iii. 691; with two flaps, iii. 691;
Blandin, Larrey, Mott, Dupuytren, Lis-
franc,  von Walther,  Vohler, Bell, Be-
clard, Liston, Begin, and Sanson's modes
of operating, iii. 692;  the oval cut, iii.
696;  Sanson, Guthrie, Scoutetten, and
Cornuau's modes of operating, iii, 698;
the preference given  to Larrey's  opera-
tion, iii. 698; after dressing, iii. 698; exar-
ticulation of the  leg at  the knee, iii. 699;
opinions respecting the propriety  of the
operation, iii.  699; Jaeger's statistics  of
the operation, iii. 699; modes of operating,
iii. 699; amputation with the flap-cut, iii.
699;   Blandin,  Rossi, Maingault, and
Kern's operations, iii. 699;  the circular
cut, iii. 700; Velpeau, Cornuau, and Bau-
dens'  operations, iii. 700; the operation
when the knee-cap is  diseased, iii. 700;
exarticulation at the ankle-joint an infe-
rior operation to amputation through the
leg, iii. 700;  exarticulation  of the foot at
the' ankle, iii. 700; Velpeau,  Baudens,
Syme, and Handyside's modes of opera-
ting, iii. 702;  Syme on the advantages of |
this operation, iii. 702;  exarticulation of
the tarsal bones, iii. 703; the operation
restricted to  the removal of astragalus
and navicular bones, iii. 703; Hammond's
caseofexarticulationofthe astragal us, iii.
703; Green's case, iii. 703 ; general di-
rections for the operation, iii. 703; am-
putation of the foot between the astragalus
and navicular bones,  and the  heel and
cuboid bones,iii. 703; Chopart's operation,
iii. 703; cases requiring the operation, iii.
703;  mode of operating, iii. 704;  when
an under  flap only is formed, iii. 704;
when an under and upper flap are formed,
 iii. 704; Maingault's operation, iii. 705;
 Langenbeck,  Klein, and Richerand's ob-
jections to the upper flap, iii. 705; Wal-
ther's operation preferred, iii. 705; Scou-
tetten's oval cut, iii. 705; Blasius' oblique
cut, iii. 705 ;  exarticulation of the  meta-
tarsal bones, iii. 706; advantages and dis-
advantages ofthe operation, iii. 706; Hey,
Scoutetten, Lisfranc, and Munzenthaler's
modes of operating, iii. 706; exarticulation
of single metatarsal bones,  iii. 708 ; pre-
servation of the great toe important, iii.
708; mode of operating, iii.  708 ; exarti-
culation  ofthe metatarsal bone of the great
toe, iii. 709; mode of operating, iii. 709;
Langenbeck and Scoutetten's operations,
iii. 709 ; exarticulation of the metatarsal
bone of the little toe, iii. 709;  of the middle
metatarsal  bones,  iii. 710; consentaneous
removal of the diseased tarsal bones, iii.
710;  Key, Dieffenbach,  and  Ruyer's
cases, iii. 710 ; exarticulation ofthe toes,
iii. 710;  mode of operating with an under
flap, iii.  710;  with a flap on  the  dorsal
surface, iii. 710;  with an outer or  inner
flap, iii. 710; exarticulation of the second
from the first phalanx, iii. 710; of all the
toes at once, iii. 711; Scoutetten's opera-
tion, iii. 711; exarticulation  ofthe  arm at
the shoulder, iii.  711 ; various modes of
operating,  iii.  712; compression  of  the
subclavian artery by an  assistant safer
than with  an instrument, iii.  712; Wal-
ther's operation by an upper and an under
flap, iii. 712; dressing  the wound, iii.
712;  Le Dran, Garengeot, Dupuytren,
Onsenoort, Lisfranc, and Champesme's
modes of operating, iii. 712; the operation
on the left arm, iii. 713; Astley Cooper's
amputation at the  shoulder-joint  with a
single flap, iii. 713; Hesselbach, Desault,
Larrey,  Langenbeck, and Dupuytren's
modes of operating, iii.  714; exarticula-
tion with the  circular cut, iii. 715; Mo-
rand, Sharp, Nannoni, Bertrandi, Alan-
son,  Graefe,  Cornuau,  Sanson, and  B.
Bell's operations, iii. 716; Scoutetten's
operation with the oval cut,  iii. 716 ; Du-
puytren, Beclard,  Bonfils, and Blasius'
operations, iii. 716 ; circumstances which
guide  the  choice  of either of these
methods, iii. 716;  removal  of the  injured
acromion or glenoid cavity, iii. 717; prac-
tised by Brown, iii.  717; recommended
by Robinson and  Fraser, iii.  717; Lis-
franc's modification of the operation when
performed prior to the age  of fifteen, iii.
717 ; gun-shot wounds of the head of the
 humerus, iii. 717 ; excision of the head of
 the bone, or removal of the broken pieces
 requisite,  iii. 717; Larrey's operation for
 the excision of the head of the humerus
 in such cases, iii.  717 ; Guthrie on gun-
 shot wounds causing fracture of  the hu- 
ANALYTICAL INDEX.
919
merus  beneath and exterior to the cap-
sular ligament, iii. 718;  South  on the
excision of the acromion, glenoid  cavity,
or coracoid process in amputation at the
shoulder-joint, iii. 718;  Liston,  South,
and Astley Cooper's cases, iii. 718; exar-
ticulation of the fore-arm at the elbow, iii.
718;  mode of operating according  to
Textor, iii. 719 ; Brasdor, Jaeger,  Hager,
Rodgers, Dupuytren, Velpeau, Cornuau,
Textor, and Baudens' modes ofoperating,
iii.  719; exarticulation of the hand at the
wrist, iii.  720; modes of operating, iii.
720; Lisfranc's mode, iii. 720; South on
the precautions to be  taken  in the flap-'
amputation at  the wrist, iii. 720;  exarti-
culation of the metacarpal bones at their
junction with the carpus, i ii. 721; mode of
operating in exarticulating the metacar-
pal bone ofthe thumb, iii. 721; formation
ofthe upper or under flap, iii. 721; exar-(
ticulation of the metacarpal bones of the
ring and middle fingers, iii. 721; Langen-
beck and Scoutetten's modes ofoperating, I
iii.  721;  Scoutetten's oval cut in exarti-
culation of the middle metacarpal bone,
iii.  721 ; mode of operating,  iii. 721; in
the exarticulation  of both middle meta-
carpal  bones, iii.  722 ; von Walther and (
Astley Cooper's modes of operating, iii.1
722;  Riadore, Guthrie, von  Graefe, von
Walther, Jaeger, Astley Cooper, Larrey,]
Tyrrell, and Bennaben's cases of excision,
of part of the hand,iii  722 ; mode of ope-j
rating in exarticulation of the four meta-
carpal  bones, iii. 722; Troccon's mode of j
operating, iii. 722 ; when one metacarpal:
or  metatarsal  bone is  diseased alone, it
should be alone removed, iii. 723; exci-
sion of the first metacarpal bone, iii. 723;]
of the other metacarpal bones, iii.  723 ; of >.
the first metatarsal bone, iii. 723  ; of thej
other metatarsal bones, iii. 723; exarticu- j
lation of ihe fingers, at their junction with
the  metacarpal bones,  and at their own]
joints, iii. 723; Dupuytren and Lisfrancj
on  exarticulation  of the middle and ring|
fingers, iii. 723 ; Barthelemy on the sec-
tion ofthe palmar aponeurosis after exar-
ticulation  of the fingers from the meta-
carpal bones, iii. 723 ;  mode of operating!
in exarticulation of the joints of  the fin-j
gers from each other, iii. 723; with two
flaps, iii, 721; Lisfranc's flap operation,
iii.  724: statistics of amputations, iii. 724;
Immediate Amputation, iii- 724; im-
portance of the question, iii. 724 ; South
on  the comparative danger  of primary
and secondary amputation in severe  in-
juries ofthe thigh, iii. 724; South's con-
clusion in  favour of primary amputation,
iii  724; South  on the minor danger in
injuries of the leg or upper extremities,
and the consequent  propriety of  imme-
diate amputation, iii. 724; John Hunter's
preference  of secondary amputation, iii.
725 ; John Hunter's objections to primary
amputation in severe injuries of the ex-
tremities, iii. 725; Astley Cooper's opinion
in favour  of immediate  amputation  in
such cases, the constitution then having
but one shock to sustain, iii. 725 ; RutheT-
ford Alcock on the difference ofthe shock
to the  constitution in such  cases, when
occurring in  civil  life, and  on the  field
of battle, iii. 725; excision of the joints,
iii. 726;  first  performed on  the knee-
joint, iii. 726; afterwards extended to the
other joints,  iii, 726; Filkin,  Vigaroux,
David, White,  Bent, Orred, Park, Mo-
reau, Graefe, and Davie's cases, iii. 726;
Sabatier, Percy, Roux,  Moreau, Larrey,
Guthrie, Syme, Textor, and  Jaeger  on
the excision of joints, iii. 726; Wachter,
Vermandois, Kohler, and Chaussier's ex-
periments,  iii.  727;  objections to this
operation as compared with amputation,
iii. 727;  advantages  of the operation
principally referable  to the joints  of the
upper extremities, iii. 727 ; not so great
in operations on the other joints, iii.  727;
statistics of Jaeger, Syme, and Moreau's
cases,  iii.  727;  Crampton on the  ex-
cision of joints, iii 728; cases in which
excision  of the ends of  bones  is  pre-
ferable to amputation, iii. 728; contra-
indications to the operation, iii. 729; mode
ofoperating, iii. 729 ; direction and extent
of the incision in the skin, iii. 729; ex-
cision of the  diseased bone, iii. 729; ex-
tent of bone required to be removed, iii.
729 ; instruments for excising the ends of
bones, iii. 730; arrest ofthe subsequent
haemorrhage,iii. 730; dressingthe wound,
iii. 730; after-treatment, iii. 730; untoward
occurrences during the after-treatment, iii.
731; after-bleeding, iii. 731; abscesses, iii.
731; fistulous passages, iii. 731; necrosis
of rare occurrence after this operation, iii.
731; after-treatment of the sawn ends of
the bone, iii.  731; excision at the shoulder-
joint, iii. 731; mode of operating in ex-
cision ofthe head of the humerus, iii.732;
C.White, Orred, Bent, Sabatier, Moreau,
and Syme's modes of operating, iii. 732;
motions of the arm subsequent to the ope-
ration, iii. 732; excision of the elbow-joint,
iii. 732;  Moreau's mode of operating, iii.
733; Dupuytren and  Syme's modes of
operating, iii.733;  Moreau on the division
of the ulnar  nerve in  this operation, iii.
733; Dupuytren, Crampton, Jaeger, and
Syme recommend its  preservation, iii.
734;  Jaeger's mode of operating, iii. 734; 
920
ANALYTICAL INDEX.
condition of the arm after excision of the
elbow-joint,iii.734;Cramptonand Syme's
cases, iii. 734 ; excision of the wrist-joint,
iii.  734; Roux and  Jaeger's  modes of
operating in excision of the lower ends of
the radius and ulna, iii. 734;  dressing the
wound and after-treatment, iii. 735; Du-
bled and Velpeau's operations, iii. 735;
Butt's case of excision of part of the ne-
crosed ulna, iii. 735 ;  excision of the hip-
joint, iii. 735; mode of operating, iii. 735;
by a simple longitudinal cut, iii. 736; by
the formation of a flap, iii. 736 ;  by Tex-
tor's oval cut,iii.736; dressing the wound,
iii.736; White, Carmichael,  Oppenheim,
Hewson, Seutin, and Textor's cases, iii.
737; C. White on excision of the head of
the femur, iii. 737; A. White and Fer-
gusson's cases of excision of the head of
the femur,  iii. 738; excision of the knee-
jaint, iii. 740; Moreau, Park,  Mulder,
Sanson, Begin, Jaeger,and Syme's modes
of operating, iii. 740; Jaeger's operation
preferred,  iii. 740;  Moreau, Park,  and
Jaeger on  the  mode  of union after the
operation, iii. 740; Syme on the treatment
after the operation, iii. 741; A.  White's
case of compound dislocation of the femur
behind the leg, iii. 741 ; excision of the
ankle-joint, iii. 742; Moreau,   Jaeger,
Mulder, and Kerst's modes ofoperating,
iii. 743;  South on excision of the ankle-
joint, iii. 743;  dressing the wound, and
after-treatment, iii. 743; excision of the
joints of the metacarpus and metatarsus,
iii. 744 ; mode of operating, iii.  744 ; af-
ter-treatment, iii. 744 ; Textor,  Kramer,
Roux, and Fricke's cases, iii.744; excision
of the lower jaw, iii. 745; cases requiring
the  operation,  iii. 745;  circumstances
admitting  a favourable result, iii.  745;
priority of claim as  originator of the
operation,  iii. 745; Tyrrell's case of ne-
crosis of the lower jaw, iii. 745; excision
if  the middle of the lower jaw,  iii. 746;
mode of operating, iii. 746 ;  retraction of
the tongue, iii. 746 ;  Dupuytren, Graefe,
and Astley Cooper's  cases, iii.  747; re-
moving a portion of the side of the lower
jaw without the condyle, iii.  747; mode of
operating,  iii. 748 ;  Deadrick, Mott and
Wardrop's cases, iii. 748; excision ofthe
lower jaw  withitscondyles,i\i.lAS; Mott,
Schindler, von Graefe, Syme, Jaeger, and
Cusack's  modes of  operating,  iii. 749;
Mott, von  Graefe, Dzondi, Jaeger, and
 Schindler  on the previous ligature of the
carotid artery,  iii. 750;  White's case of
 excision of the lower jaw, iii. 750; Graefe
 and Mott's cases of exarticulation of one
 side of the lower jaw, iii. 751; Cusack on
 the non-necessity of tying the carotid
artery  prior to the  operation,  iii.  752;
Cusack's cases of  exarticulation of the
lower jaw, iii. 752; Liston's mode of ope-
rating, iii. 753; Perry's case of necrosis of
the lower jaw, iii. 753 ; resection of the
upper jaw, iii. 753; cases in which the
operation is indicated, iii. 753; Dupuy-
tren's cases of extirpation of the upper
jaw doubted by Gensoul, iii. 754;  Ako-
luthus' case, iii.754; Dr.T. White's case of
almost complete extirpation ofthe upper
jaw, iii. 754; mode of operating, iii. 755;
section of the skin and  muscles, ac-
cording to Gensoul and Dieffenbach, iii.
755; Lizars the first to recommend the
entire removal of the upper jaw, iii. 755;
his description of the proposed operation,
iii. 755; Lizars'  cases in  which he at-
tempted  to  perform the  operation, but
failed on account of the hemorrhage, iii.
756; Lizars' cases in which he performed
the operation, iii. 756; Gensoul's case of
extirpation  of the  superior  maxillary
bone, iii. 756; cutting away the diseased
jaw, iii. 757; Heyfelder's operation for the
resection of both  jaws, iii. 758 ; Syme,
Liston, and Fergusson's modes  of ope-
rating, iii. 758; O'Shaugnessy's case of
removal  ofthe upper jaw, iii. 759; Het-
ling's case of osteosarcoma of the jaws, in
which he removed part of the upper, and
part of the lower jaw,  iii. 760; Liston
on the prospect of ultimate success in this
operation in cases of malignant disease,
iii. 761;  dressing the  wound, and  after-
treatment, iii. 761;  dangerous symptoms
which may occur after the operation, iii.
761; recurrence of the disease, iii. 761;
resection of the scapula (blade-bone,) iii.
762; von Walther's mode of operating,
iii. 762;  Haymann's operation, iii. 762;
Liston, Janson, Luke, Syme, and Travers'
cases, inwhich resection ofthe scapulawas
performed, iii. 762; James' case of tear-
ing away the arm  and scapula by ma-
chinery,  iii.  763;  resection  of clavicle
 (collar-bone,) iii. 763; cases requiring the
 operation, iii. 763; mode of operating, iii.
 763;  Cuming, Meyer, Roux, Warren,
 Mott, Travers, and  Chaumet's cases  in
 which resection of  the clavicle was per-
 formed, iii. 764;  resection ofthe scapula
 and  clavicle  together, iii. 764 ; Mussey,
 M'Clellan,Gilbert,and Fergusson's cases
 iii. 765; Fergusson's  mode of  operating,
 iii. 765; Gaetani Bey's case of resection
 of the scapula, and of the acromial end of
 the clavicle, iii. 766;  resection  of the ribs,
 iii.  766;  mode of operating, iii. 766;
 in compound comminuted fracture, iii.
 766;  Textor and Warren's  cases of  re-
 section  of a rib, iii. 766; Dixon's resec- 
ANALYTICAL INDEX.                        921
  tion of the cartilage of a  rib, iii. 767;
  Roux's case of resection of rib on account
  of necrosis,  iii.  767;  resection of the
 fibula, iii. 767;  Seutin  and Malgaigne's
  cases, iii. 767; resection  of other bones,
  iii. 767.
Sutcliffe's performance  of the Taliacotian
  operation, iii. 577.
Sutton's, Dr. case of a foreign body re-
  maininga long while in the windpipe, iii.
  112;  case  of ovarian dropsy, with dis-
 , charge of hair by the wound made in tap-
  ping, iii. 215.
Swan's case of fracture of the neck of the
  femur within the capsule united by bone,
  i. 621; case  of division  of the peroneal
  nerve, iii. 636.
Swediaur proposes the word Menorrhagia
  in lieu of gonorrhea, i. 174; objections to
  the use of corrosive sublimate in cases of
  syphilis in infants, ii. 106.
Synovial membrane, inflammation of.  See
  Inflammation of the joints.
Syme on inversion of the  foot in  fracture of
  the neck of the femur, i. 618; distinguish
  ing character of caries,ii. 115; characters of
  caries, ii. 115; treatment of caries, ii. 119;
  case of destruction of the bones of the face,
  ii. 133; salivary calculi,ii. 150; prolapsus
  ani, ii. 398; characters of prolapsus ani,
  ii. 399; diagnosis between prolapsed rec-
  tum, and haemorrhoids and intus-suscep-
  tion, ii. 399 ; case of wry-neck, ii. 422 ;
  distorted  position  of  the  head  caused
  by caries  between the  occiput and atlas
  liable to be mistaken for wry-neck from
  muscular contraction, ii. 422 ;  wry-neck
  a cause of  lateral curvature, ii. 431; sec-
  tion of muscles in spinal  curvature, ii.
  439; carotid aneurism, ii. 507; removal
  of internal piles by ligature, ii. 583; seat
  of stricture in the rectum, iii. 46; case of j
  subcutaneous section for foreign bodies in J
  joints, iii. 447; prefers Liston's flap-opera- j
  tion for the thigh, iii. 660; objects to am-
  putation through  the shaft of the femur,
  and  recommends  amputation  through
  the condyles, or trochanters, iii. 660; for-
  mation of conical stumps in flap-amputa-
  tions of the thigh, iii. 667 ; amputation
  through the  epiphyses of the femur,  iii.
  668; mode of amputating at the ankle-
  joint, iii. 702; advantages of this opera-
  tion, iii. 702; excision of joints, iii. 726;
  statistics of cases, iii. 727;  mode ofopera-
  ting in excision  of the  head of the  hu-
  merus, iii. 732; in excision ofthe elbow-
  joint, iii. 733; recommends the non-divi-
  sion  of the ulnar nerve in that operation,
  iii. 734; cases of excision of the elbow-
  ioint, iii. 734; mode of operating in ex-
  cision of the knee-joint, iii. 740;  treat-
      Vol. in.—78
  ment after the operation, iii. 741; mode of
  operating  in  excision of the lower jaw
  with the condyles, iii. 749; in resection of
  the upper jaw, iii. 758; case of resection
  of the scapula, iii. 762.
Symond's, Dr.  case of removal of the in-
  verted womb by ligature, ii. 388.
Symphysiotomy, iii. 165.
Syphilis ;—question of its identity with go-
  norrhea, i. 183;  observations and experi-
  ments of Hernandez and Ricord, i. 183;
  Hunter on the identity ofthe two poisons,
  i.  184;  accounts for the different effects
  of the same poison by the gonorrhea pro-
  ceeding from a secreting surface, and the
  chancre being formed on a non-secreting
  surface, i. 184; South on the frequency of
  the co-occurrence of chancre and gonor-
  rhea, i. 184; Benjamin  Bell denies the
  identity  of gonorrhea  and  syphilis,  i.
  185;  Hernandez' experiments on the
  subject, i. 185;  ulcers produced  by in-
  oculating   with   gonorrheal  virus  not
  syphilitic, i.  186; Ricord's  observations
  and  experiments, i.  186;  Ricord's in-
  ferences  from the results of the inocu-
  lation  with  gonorrheal  matter, i.  186;
  venereal ulcers, ii. 70 ;  distinguished as
  primary and  secondary, ii. 71; causes, ii.
  71; South on the inappropriate use of the
  terms "venereal ulcer" and "chancre"
  as synonymous, ii. 71; John Hunter on
  the  two modes  in which the venereal
  poison affects the system, ii. 71 ;  Law-
  rence on the progress of syphilis from one
  part ofthe body to another, ii. 72; the ope
  ration of the venereal contagion requires a
  peculiar delicate structure of the part af-
  fected, or a deprivation of its cuticle, i. 72;
  symptoms of chancre, ii. 72; characters of
  the pus secreted  by venereal  ulcers, ii. 72;
  John Hunter and Ricord on the period at
  which chancres  appear after infection, ii.
  72;  John  Hunter, on the symptoms  of
  chancre,  ii.  72; Lawrence  on the pro-
  gress of ulceration in a syphilitic  sore,
  ii. 72; Lawrence on  the five kinds  of
  syphilitic  sores, ii.  73; the pus  of the
  ulcer the  special vehicle of the venereal
  contagion, ii. 73 ; Hunter's experiments
  by inoculating with the matter of gonor-
  rhea  and  chancre,  ii.  73; Ricord  on
  inoculation for  the  purpose of distin-
  guishing  syphilitic sores, whether  pri-
  mary or  secondary, ii.  74 ; buboes the
  first symptoms  of general  syphilis, ii.
  75; may  be idiopathic, or  sympathetic,
  ii. 75; symptoms, progress, and termina-
  tions,  ii.  75; John  Hunter  on the true
   venereal  buboes, ii. 75; Ricord on the
  seven kinds of buboes, ii. 75 ; Hunter
  and Ricord on the existence of syphilitic 
922                      ANALYTICAL  INDEX.
 buboes without  primary  sore, ii.  76;'■
 general syphilis attacks  specially either,
 the skin, mucous membranes, or bones,
 ii.  77; John  Hunter on the continu-
 ance of the constitutional irritation from
 lues,  independent of continued absorp-
 tion, ii. 77; inflammation of the mucous
 membrane of the throat, ii.  77; symp-
 toms,  appearances, and  results, ii.  78;
 venereal eruptions,  ii.  78;  symptoms,
 ii.  78; Lawrence  on  the  four  kinds
 of  syphilitic eruptions,  ii. 78; herpetic)
 eruptions,  rhagades,  verrucae,  and con-
 dylomata,  ii. 79; John Hunter and  Ri-j
 cord on the non-infectious character of
 the pus from a  secondary syphilitic sore,
 ii. 79; symptoms and results  of syphilis j
 in the bones, ii. 80;  modifications  of the!
 symptoms  of syphilis,  ii. 80; primary1
 syphilitic   ulcers  no decided  external
 character, ii. 81;  Abernethy on pseudo-
 syphilis, ii. 81; Abernethy on the means
 of distinguishing between true  and false
 syphilis, ii. 82; Carmichael's objections
 to the terms, syphilis, syphiloidal, and
 pseudo-syphilis, ii. 82; Carmichael bases
 his arrangement of venereal  complaints]
 on the character of  the  eruption, ii. 82;
 Ricord on  the  causes of the varied  ap-
 pearances of chancre or  primary syphi-J
 tide sore,  ii. 82; differences in  secon-
 dary syphilis, ii.  84; prognosis, ii. 84;
 John Hunter on the relative rapidity of i
 cure of gonorrhea, chancre, and lues ve-|
 nerea,  ii.  85;  Abernethy on the. occa-
 sional  spontaneous  healing of  chancre,
 ii.  85; John  Hunter on the  relapse
 of ulcers after  chancres have cicatrized,
 ii. 85; treatment of syphilis with  mercury,
 ii. 86; in  treating chancre, an especial
indication  to prevent general syphilis, ii.
 86; local  treatment,  ii.  86;  Ricord on
 the destruction of the ulcer by the nitrate
 of silver,  ii. 86,  internal exhibition  of
 mercury, ii. 86; Lawrence on the  exhi-
 bition  of mercury in  cases of  chancre,
 and on the rarity of the occurrence  of
 secondary symptoms  when mercury has
 been used, ii. 86; Lawrence on the ex-
 tent to which the  use of mercury may be
 pushed, ii.  87; Green on  the use of mer-
cury in syphilis, and  on  the  forms  in
which it should be employed, ii. 87; cir-
cumstances requiring the  local exhibition
 of corrosive sublimate;  ii. 88;  Delpech
 on frictions with the ung. hyd. cin.  in
primary syphilis, ii. 89;  iSouth on  the
treatment  of sloughing chancre, ii. 89 ;
mercury not to  be used either internally
 or externally under  such  circumstances,
 ii. 89; mercury should be exhibited for
some   time  in  smaller  doses  after  the
 chancre has cicatrized, ii. 89;  treatment
 of buboes, ii. 89;  tendency of idiopathic
 buboes to suppurate, ii. 90; treatment of
 tfie remaining ulcer, ii. 90; treatment of
 the indurated bubo, ii.  90; mode of open-
 ing  suppurating  buboes,  ii.  905  Fer-
 guson, Fricke, Reynaud, and Ricord on
 the treatment of buboes, ii. 90;  South on
 the treatment of suppurating bubo, and of
 the subsequent ulcer, ii. 90; treatment of
 general syphilis by mercury, ii. 91; ex-
 ternal employment of mercury,  when re-
 quired, ii.  91;  sublimate baths, ii. 91;
 the  internal exhibition of  mercury pre-
 ferable in ordinary syphilis, ii.  91; local
 symptoms  require special  treatment, ii.
 91;  Rust's treatment of syphilitic ulce-
 ration  of the  throat and palate, ii. 91;
 treatment of syphilitic eruptions, ii. 92;
 treatment of the granulations by caustic
 or the knife, ii. 92; of syphilitic diseases
 of the bones, ii. 92; mercurial fumiga-
 tion  in syphilitic ulceration of the tonsils
 and  pharynx, ii. 92;  South on  secon-
 dary  syphilitic  sores   and  their  treat-
 ment, ii.  92; South  on the treatment of
 nodes, ii. 92; necessary to vary the mer-
 curial preparations  in  use  according to
 constitution, and other  circumstances, ii.
 93;  >'tarke on  the phosphor,  hydrarg.
 von Graefe on the iodide and bromide of
mercury, and  Mendaga and Parent on
the hydrarg. cyan., ii. 93; salivation not
necessary for the  cure of  the  venereal
disease, ii. 93;  treatment of salivation,
ii. 94; treatment of old cases  of vene-
real  disease, ii. 94;  Louvrier and Rust
 on the friction-cure, ii. 95; cases in which
 the friction-cure  is indicated,  ii. 95;
cases in which it is contra-indicated, ii.95;
 South on the friction-cure,  ii. 95;  mode
 of em ploy ing it, ii. 95; Wedemeyer, Rust,
and South  on  the  number  of times the
frictions may require to be  practised, ii.
 96;  the order in which the rubbings-in
are to be conducted, ii. 96; symptoms
 which  occur during this  treatment, ii.
 97;  the Montpellier modification of the
 friction-cure condemned,  ii. 97;  treat-
ment to be adopted, if the  salivation or
 critical sweating be suddenly suspended,
 ii. 97; occurrence of spasmodic or ner-
 vous symptoms, ii. 97; subsequent treat-
 ment, ii.  97; Weinhold's mercurial cure,
 ii. 97;  mode of employing it, ii. 98;
 Zittmann's decoction,  ii. 98;  mode of
 exhibiting  it, ii. 98:  formula  for  Zitt-
 mann's  decoction,  ii.  99 ;  the Arabian
 treatment,  ii.  99;  Dzondi's treatment,
 ii. 100; the preference given to the use of
 Zittmann's decoction, ii. 100; treatment
 of syphilis  without mercury,  ii. 100; 
ANALYTICAL INDEX.                        923
various  modes  of  treating  secondary
symptoms without mercury, ii. 100; Pit-
cairn, Chrestien, and Niel on gold and
its preparations inprimaryand secondary
syphilis, ii. 101; Ricord, Eusebede Salle,
Lallemand, Biett,Pailland, Wallace, Dr.
Williams,  Judd,  Tyrrell,  Ebers, von
Hasselberg, and Hacker  on iodine and
hydriodate  of potash  in  gonorrhea and
general syphilis, ii. 101;  Forster on the
cure of syphilis by the chloride of  gold
and soda, ii. 102; treatment of syphilis
without  mercury in  England, ii. 102;
Hill, Hennen, Rose, Guthrie, and  Thom-
son on the duration of the disease under
this  treatment, and  on the  subsequent
occurrence  of secondary  symptoms,  ii.
103; South  on the  proper mode of exhi-
biting  mercury in  the treatment  of sy-
philis, ii. 103 ; objections to the treatment
withoutand with mercury, ii. 103; syphilis
in infants, ii. 103 ; causes of infection, ii.
104; Evanson and  Maunsell on the com-
munication of syphilis to the foetus in the
womb, ii. 104; Huguier on the period at
which syphilis shows itself after birth, ii.
104;  infection  of a  child by a  syphi-
litic nurse, ii. 105; Dycktnan's assertion
that  the  child may be infected by milk
of a diseased nurse, ii. 105; Hunter, Law-
rence, and Todd's cases of diseased chil-
dren infecting the nurses, ii.  105;  Colles
doubts whether the  child  can infect the
nurse, unless she have ulceration  of the
nipple, ii. 105; Evanson and Maunsell on
the symptoms  of syphilis in infants,  ii.
106; Lawrence on  syphilitic iritis, and
ulceration about the anus in infants,  ii.
106;  prognosis, ii. 106;  Evanson and
Maunsell on the treatment of syphilis in
infants, ii. 106; Swediaur and Bacot ob-
ject to the use of corrrosive sublimate in
such cases, ii.  106;  Hey,  Lawrence,
Hunter, Ricord, and  South on the possi-
bility of infection from secondary syphilis,
ii. 106.
Taylor on the rarity of carbonate of  lime
   calcoli, iii. 242; on calculi of children, iii.
   248; hour-glass calculi, iii. 272.
Teeth, caries of, ii.  133;  extraction of, ii.
   138; replacement of, iii. 596;  supernu-
   merary, iii. 597.
Telangiectasy, ii.  559; congenital,  ii.
   559; characters, ii. 559; fungous growths
   after rupture of the swelling, ii. 559; na-
   ture ofthe disease, ii. 559; complications,
   ii.  560;   telangiectasis   lipomatodes,  ii.
   560; causes,  ii.  560;  always a  local
   disease, ii. 561 ; prognosis, ii. 561; treat-
   ment, 561; ii. by compression, ii.  561;
   Abernethy on  compression, ii.  561; by
   extirpation with the knife, ii, 561;  with
   the ligature, ii. 562; advantages of the
   ligature, ii. 562; Lawrence, Brodie, and
   South on the application of the ligature,
   ii. 562; destruction of teleangiectasy by
   caustic, ii. 563 ; South  on caustic in te-
   leangiectasy, ii. 564 ; various remedies to
   induce inflammation and suppuration  in
   the diseased  growth, ii. 565;  Pattison,
   Smith, and Tyrrell's cases, ii. 565; tying
   the principal trunk supplying the diseased
   growth, ii. 566; if the teleangiectasy be
   seated on the extremities, and incurable,
   amputation must be performed, ii. 566;
   Pauli on the tattooing of moles on the
   skin, ii. 566.
Temporal artery, ligature of, ii. 515.
Tessier proves that animals are subject to
   gangrene from the use of spurred rye, i.
   75.
Testicle,  inflammation of,  orchitis,
   hernia  humoralis:—Benjamin Bell on
   alternate swelling of the testicle, i.  199 ;
   causes—gonorrhea  as a cause, i.  199;
   epididymitis,  i.  129;  Hunter on  the
   period when swelled testicle supervenes,
   i.  199; may be a  symptom of general
   syphilis, i. 199; Hunter says swelling of
   the testicle is  from sympathy, and not
   from syphilis, i. 199 ; Astley Cooper and
   Ricord describe syphilitic swelling ofthe
   testicle, i. 200; external  injury,  cold, and
   violent exertions may induce orchitis, i.
   200; Hunter on gout as a cause, i. 200 ;
   Astley Cooper mentions enlargement of
   the prostate in old  age, inflammation of
   the neck of the bladder, a stone passing
   through  the  ureter, or  pressing on the
   commencement of the urethra, as causes
   of swelled  testicle, i. 200; South on con-
   gestion of semen in the  seminal tubes as
   a cause of orchitis, i. 200; symptoms and
   terminations of orchitis,  i. 201; suppura-
   tion to be feared when the pain is throb-
   bing, i. 201 ;  induration not an uncorn:
   mon termination, i. 201; gangrene  rare,
   i. 201;  Astley Cooper on the symptoms
   and  progress  of orchitis, i. 201; occa-
Tait's case of ligature of both the external
  itiacs, ii. 537.
Taliacotian operation, iii. 577.
Tanchou's caustic-holder for stricture of
  the urethra, iii. 83.
Taramelli's  case of  hernia of the vermi-
  form appendix, ii. 260.
Tarsal bones, exarticulation of, iii. 703.
Tarsus, fracture of, i. 639; dislocation of
  the bones of, ii, 251.
Tavignot  on the  use  of oil varnish  on
  starch bandages  in fractures   in young
  children, i. 554; subcutaneous ligature ot
  the superficial arteries, ii. 503 ;  treatment
  of spina bifida by closure  of the sac, in.
  190. 
924
ANALYTICAL INDEX.
 sionally  preceded by great irritation of
 the brain, i. 201; Sam's case of cerebral
 irritation preceding an attack of orchitis,
 consequent on  gonorrhea, i. 201; subsi-
 dence of orchitis generally followed by a
 return  of gonorrhea,  i.  202;  Astley
 Cooper on adhesion and thickening of the
 tunica vaginalis,!. 202 ; suppurative rare
 when the inflammation is  sympathetic, i.
 202;  Astley Cooper on suppuration of the
 testicle, i. 202; bursting  of the abscess
 sometimes followed by a fungous growth,
 i. 202; symptoms and progress of orchitis
 serve to  distinguish it from any  other
 disease, i. 202; S. Cooper's case of or-
 chitis, simulating strangulated rupture, i.
 202; swelling ofthe testicle from blows
 takes place very rapidly,  i. 202.; Astley
 Cooper and South on wasting of the tes-
 ticle,  caused  by  inflammation, i.  202;
 Astley Cooper on the more frequent seat
 of the disease in the globus major, i. 202;
 treatment of orchitis, i. 203; South on the
 treatment, i. 203 ; treatment of suppura-
 tion and abscess of the testicle, i. 203;
 South on the treatment of fungus of the
 testicle, consecutive to abscess, i. 203;
 treatment of induration, i. 203; occasional
 termination of induration  in sarcoma and
 scirrhus, i. 204; treatment of orchitis
 from  cold  or external  injury, i.  204;
 Fricke on compression in  orchitis,!. 204;
  South on the treatment by compression,
 i. 204; mode of application of compres
  sion, i. 204; South  on the application of
  compression  i. 205; subsequent  treat-
  ment, i. 205; South on the results of com-
  pression,!.205; South's case of metastasis
  of gonorrhea and inflammation of the tes-
  ticle to the brain, i. 206; great care re-
  quired in the  application  of the plasters
  for compression, i. 207;  the advantages
  of compression, according to  Fripke, i.
  207; wounds of, and of the spermatic cord,
  i. 536;  treatment of the accompanying
  inflammation,  i. 536; if  the testicle be
  destroyed, either by the injury or the sub-
  sequent suppuration, it must be removed,
  i. 536; wounds  ofthe oord, involving the
  nerves and  vessels of the testicle,  cause
  its shrivelling or deeay, i. 536 ; South's
  case of tapping a hydrocele, with sup-
  posed wound ofthe testicle, i. 536.
Testicle, cancer of, iii. 547; sarcocele, iii.
  547;  cystie swelling of,  iii. 553;  hyda-
  tids  of,  iii. 553; fungus of,  iii. 554;
  scrofulous swellings of, iii. 554 ; syphi-
  litic swellings of,  iii. 554; medullary
  fungus  of, iii. 554; extirpation  of, iii.
  556 ;  undescended testicle, and its treat-
  ment, iii. 557.
Tetanus, i. 414 ;  varieties,  i. 415; Travers
  on traumatic tetanus, i. 415; Travers on
  the period of accession ofthe disease after
  the receipt of the injury, i. 415 ; Dr. Ro-
  bison's case,  i. 415; Brodie, Sir  James
  M'Grigor, and  Blane on  the period of
  accession of tetanus after  the receipt of
  the injury, i. 415; three stages of tetanus,
  i. 416; symptoms, i. 416; Lawrence and
  Abernethy on a costive state of the sys-
  tem preceding tetanus, i. 416; Hunter on
  the cause of death in, i. 416; state of the
  intellect in, i. 417; Samuel Cooper's case
  of chronic tetahus of five weeks'duration,
  i. 417; proximate cause, i. 417; Froriep,
  Friedrich, Curling, South, and Lawrence
  on the proximate cause, i, 417;  remote
  oauses, i. 417 ;  John Hunter, Travers,
  arid Samuel Cooper on the causes, i. 418;
  Dr. Bardsley  on the diagnosis of tetanus
  from  hydrophobia,  i. 418;  prognosis
  always extremely unfavourable, i. 418;
  Dr. O'Beirne and   Hennen on its fatal
  character, i. 419; South on the favourable
  termination of cases which  pass over the
  seventh day, i.,419; treatment,  i. 419;
  Larrey and Dupuytren on amputation in,
  i. 419 ; general treatment, i. 419; Klein
  and Treswart on the use of prussic acid
  in, i. 419; Smith on colchicum in, i. 419;
  South on long and free incisions on either
  side of the spine,  and cauterizing the
  wounds,  i.  420; exhibition of opium in,
  i. 420; South on the treatment of, i. 420.
Textor on dislocation of the head  of the
  thigh-bone  downwards  and inwards in
  hip-disease, i. 287; case of reduction of
  the consecutive dislocation^ i. 297; on the
  arrest of haemorrhage by nature, i. 329;
  effects of torsion, i.  343; dressing the
  wound after the operation for rectal fistula,
  ii. 167;  ligature of the femoral  below
  Poupart's ligament, ii. 539; cutting away
  the tunica  vaginalis, iii. 230;  mode  of
  amputating the thigh with a flap from the
  outer side,  iii. 660;  from the inner side,
  iii. 660; mode of operating in exarticu-
  lation  of the fore-arm at  the elbow, iii.
  719;  excision of joints, iii. 726; case of
  excision  of the head of the femur, iii.
  737;  of  excision of the head of a meta-
  carpal bone, and of the os magnum, iii.
  744 ;  of  resection of a rib, iii. 766.
Theden's apparatus for fracture of the neck
  of the femur, i. 623; ligature of the her-
  nial sac for its radical cure, ii. 283*
Thevenin  on dilatation of the stricture in
  strangulated hernia without cutting,ii.298
Thierry on  torsion of arteries, i. 341, ii.
  501; mode of practising torsion, i. 342.
Thigh,   artificial,  iii.  594;  amputating
  through, iii. 656; exarticulation of at the
  hip-joint, iii.  688. 
ANALYTICAL  INDEX.                        925
Thilenius' case of reduction of the con-
  secutive  dislocation in  hip disease, i.
  297;  division of the tendo Achillis in
  club-foot, ii. 457.
Thomson's, Dr., observations on the varia-
  tion of the current of the  blood  through
  the capillaries, resulting from the appli-
  cation of different substances, i. 38; mor-
  tification from the use  of spurred rye, i.
  74; objections  to John  Hunter's views
  on " quick union," i. 319; splitting ofthe
  ball  in gun-shot wounds  by  the sharp
  edge of a  bone, i. 374;  sabre-wounds of
  the head, i. 427;  sabre-cuts of the head
  and neck,  and the infrequenpy of hernia
  cerebri, i. 428; amaurosis and inflamma-
  tion of the eye caused by the passage of
  a ball through or near the organ, i. 470;
  duration of  syphilis under the non-mer-
  curial  treatment,  and subsequent occur-
  rence of secondary symptoms, ii. 103.
Thomson, H., on  the protraction  of the
  period of incubation in hydrophobia, i.
  404;  case of amputation at the hip-joint,
  iii. 689.
Throat, polypus of, iii. 477.
Thumb, exarticulation of  the metacarpal
  bone  of, iii. 721.
Thune on the causes of splay-foot, ii. 457;
  primitive and  secondary valgus, ii. 457.
Thyroid rupture, ii. 353.
—----gland, inflammation of, iii. 385.
------artery, superior, ligature of, iii. 389.
------------inferior, ligature of, iii. 393.
Tibia, fracture of, i. 636.
Tibial ariery, anterior, aneurism  of, ii. 543;
  ligature of,  ii. 544; posterior, aneurism
  of, ii. 544; ligature of, ii. 544.
Tiedkmann on  the high bifurcation  of the
  brachial artery, ii. 529.
Tinea capitis and its varieties, ii. 60.
Titley's, Dr.,  case of sarcomatous tumor
  of the scrotum, iii. 449.
Todd, Dr.,  considers there is a difference
  between temporary  and  articular  carti-
  lage, i. 250.
Todd's  case of a syphilitic child infecting
  its grandmother, i. 105.
Toes, union of, ii. 509 ; supernumerary, in.
  597; amputation of, iii.  686;  exarticula-
  tion of, iii. 709.                .,.
Tongue, unnatural adherence of,  in. &*$
  enlargement of, iii.  382; cancer of,  m.
  520; removal of by ligature, in. 520; ex-
  tirpation of, iii. 521.
Tooth-ache, ii. 134.
Tonsils,inflammation of, quinsy:—symp-
  toms, i. 158; causes and terminations, i.
  159; abscess, i. 159;  Dr. Tweedie on
  enlargement of, i. 159; Guersent's cases
  of gangrene of, i. 159; treatment, ,.159;
  Drf W'atson on the local  treatment, u
160;  Hercy's inhaler, i. 160; scarifica-
tions, i.  160; danger of wounding the
carotid, or a branch, i.  160;  Watson's
cases, i. 160; South's recommendation of
the actual cautery in case an  arterial
branch were wounded, i. 160; astringent
gargles to be used on the subsidence of
the inflammation, i.  160; opening the
abscess with a guarded  bistoury or the
pharyngotome, i. 160; treatment after the
pus has  been evacuated, i. 160;  in rare
cases the abscess becomes external under
the jaw,  i. 160 ; Allan Burns on the spon-
taneous bursting  of the abscess, i.  161 ;
attended with much  danger, i. 161; de-
tails of a case in which  the trachea was
deluged  with purulent matter, and death
by  suffocation ensued,  i.  161;   Burns'
advice in such cases  to  tap the  abscess
with  trocar and canula,  i. 161; in  most
cases of  tonsillar abscess  the action of
emetics will cause its rupture; if not, it
must be opened, i. 161; Burns' directions
for  opening a tonsillar abscess,  i.  161;
South's, i. 161; cases of fatal haemorrhage
consecutive to opening  a tonsillar ab-
scess, mentioned by Portal, Allan Burns,
Tyrrell, and Brodie, i. 162; Lawrence's
case of alarming haemorrhage from punc-
turing an immature  tonsillar abscess, i.
162;  hardening of the  tonsils,!.  162;
Else denies the existence of the so-called
scirrhus  ofthe throat,!.  162; Dr. Twee-
die ascribes  suoh  cases  to hypertrophy
and induration alone, i.  162;  roughness
of the voice and deafness caused by en-
larged tonsils, i. 162; South on the treat-
ment of  enlarged  tonsils, i. 163;  Allan
Burns on the formation of  calculi in the
tonsils, i. 163; partial extirpation of en-
larged tonsils, i. 163; description ofthe
operation, i. 163;  ligature ofthe tonsils*
or the application of caustic not to be
preferred to their  removal by the knife,
i. 164; various modes of effecting their
removal by  cutting,  tearing  out, tying,
or by destroying with caustic, i. 164; the
operation by cutting  performed  by Cel-
sus, Richter, and  Moscati, i.  164;  that
of tearing out the tonsils by Celsus and
Fabricius ab Aquapendente, i. 164 ; tying
the tonsils  by Guillemeau, Sharp,  Che-
selden,  Bibrach, Siebold,  Bell, Cheva-
lier, and  Hard,  i. 164;  cauterizing the
tonsils  with red-hot  iron or  caustic by
Severinus and Wieseman, i. 165; Else's
objection to excision, especially in chil-
dren, on account  of the  haemorrhage, i.
165; prefers Cheselden's operation, i.
165;  Physick's  guillotine  instrument
for  amputating  the  tonsils,  i.   165;
Simpson's adaptation of Thorbern's sta- 
926
ANALYTICAL INDEX.
  phylotome for  the  same operation, i.
  165;  the  operation performed in  the
  United  States  with scissors  in  prefer-
  ence  to the knife, i. 165; Gibson's  for-
  ceps,  i. 165;  South  on  this operation, i.
  165;  means of stopping  the  haemor-
  rhage,!. 166: Lawrence and  Callaway
  on the haemorrhage following extirpation,
  i. 166; Shaw's case of extirpation follow-
  ed by superficial slough, alarming haemor-
  rhage, and ligature ofthe carotid, i. 166;
  relaxation of the uvula, i. 166; extirpa-
  tion ofthe uvula, i. 166; Bennati recom-
  mends cauterization with nitrate of silver,
  i.  167; Paulus iEgineta cauterizing it
  with the aid  of the staphylokauston, i.
  167; Pare used the ligature, i. 167; Ast-
  ley Cooper and  South's opinion against
  the operation, i. 167.
Torsion of arteries, i. 341.
Tournel's case of dislocation ofthe scapu-
  lar end of the  clavicle downwards, ii.
  219.
Toynbee  on the  synovial membrane, i.
  236; non-vascularity of cartilage,  i. 250;
  development  of, i. 250; supply of nutri-
  ent fluid to articular  cartilages, i. 250;
  vessels by which articular cartilages are
  nourished, i.  251;  description  of  the
  canals in  adult  cartilage,  i.  252;  re-
  moval of the articular cartilage  in old
  age, i. 268.
Trachea, foreign bodies in, iii. 109,
Tracheotomy, iii. 177,
Transfusion, iii, 625.
Travers on the cause of pain  in inflamma-
  tion, i. 36; remarks that pain is not neces-
  sarily an  attendant  on inflammation, i.:
  37; redness  in  inflammation,  i. 37; in-
  crease of  heat  in  inflammation,  i.  37;
  experiments  of Dr. John Thomson re-
  peated by, i. 40; oscillation attending the |
  recovery of the circulation in  inflamma-
  tion,  i. 41;  effusion  of serum, i.  45;
  lining membrane of an abscess, i.  49; i
  the circumstances which determine  anj
  abscess  to the  surface, i. 49; purpose,
  which the formation of  pus serves in the
  economy, i. 51; constitution  of pus, i. 54;'
  process of ulceration, i. 64; objection to!
  the terms mortification  and  sphacelus, i.J
  66; acute gangrene, i. 67; deep and ex-
  tensive effusions and injuries of nerves j
  causes  of mortification, i.  68; chronic I
  gangrene, i, 72; severe  phlebitis, i. 93;
  primary symptoms of gonorrhea, i. 176 ;
  gonorrheal sores, and their consequences,
  i.  187; secondary symptoms  of  gonor-
  rheal sores, i. 187; paronychia affecting
  the tendons,  i. 216;  the blood  as  a  me-
  dium of organized adhesion in wounds,
  i,  320; formation of new vessels, i. 323;
  filling up a  gaping wound, i. 324;  case
  of wound of the posterior tibial artery, i.
  338; traumatic tetanus, i 415 ;  period of
  the  accession of  the  disease after the re-
  ceipt  of the injury, i.  415;  causes  of
  tetanus, i. 418; case of suicidal wound
  of the lingual or facial artery near its
  origin, with unsuccessful ligature of the
  common carotid, i. 474; effects  of injury
  of the abdomen,  i. 502; wounds  of the
  abdomen, i. 503;  case of wounded intes-
  tine, i,  507;  wounds of  the  intestines
  communicating directly with the surface,
  i. 508 ; varieties  of wounds of the intes-
  tines, i. 508;  experiments on wounded
  intestine, i. 511;  objections to returning
  a wounded  intestine without suture  into
  the  abdomen, i. 514; withdrawal of the
  suture after union has taken place, i. 514;
  directions for stitching a wounded intes-
  tine, i. 514; reparation by artificial con-
  nexion of the divided parts of a wounded
  intestine, i. 516 ;  treatment of wounded
  intestine, without feculent discharge or
  prolapse, i. 517 ;  spontaneous reparation
  in wounded intestine,  i. 517; effusion
  into the cavity of {he abdomen in cases
  of penetrating wounds,  i. 518 ;  impedi-
  ments to effusion of the intestinal  con-
  tents  in wounds  of  the bowels, i. 518;
  case in which  he applied a ligature round
  the  wound  of a  protruded  stomach, i.
  522; combined effects of mercury and
  syphilis in the production of the mercu-
  rial  disease, ii. 109; cachexia mercurialis,
  ii. 110; nature of strangulation in  rup-
  tures, ii. 269; effects  produced  by the
  ligature on the arterial coats, ii. 492;  case
  of ligature of the carotid, ii. 508 ; treat-
  ment of branching aneurism,  ii. 554;
  case of suppuration  of the bursa of the
  knee-cap, iii. 181; treatment of hydrocele
  by puncture, iii. 224; case of impaction
  of calculus in  the ureter, iii. 270; of se-
  condary haemorrhage after lithotomy, iii.
  335 ; of calculus in the urethra, iii. 362;
  of stone broken  up under  the  use  of a
  constitutional  stone-solvent, iii. 367 ; on
  the  genus carcinoma, iii. 455; occasional
  inertness of scirrhus during life, iii.  509;
  resemblance of chimney-sweep's cancer
  to lupus, iii. 560; case of resection of the
  scapula, iii. 762; of resection ofthe cla-
  vicle, iii. 761.
Travers', jun., case of dislocation into the
  ischiatic notch in a boy five years old, ii.
  202; case of a foreign body in the wind-
  pipe for a long time, iii. 112.
Trepanning, ) the   operations   of.    See
Trephining, )   Wounds ofthe Head.
Treswart on the exhibition of prussic acid
  in tetanus,  i. 419, 
ANALYTICAL  INDEX.
927
Troccon's  mode of operating in exarticu-1-
  lation of the four metacarpal bones, iii.
  722.
Troja on incipient production of new bone
  after necrosis, ii. 127.
Trolliet considers the mucus  from  the
  inflamed mucous membrane ofthe bronchi
  in hydrophobia to be the vehicle of the
  poison, i. 401.
Trousseau  on  tracheotomy in croup, iii.
  115.
Tubercle in bone, iii. 416.
Tumours, adipose, iii. 426 ; encysted, iii.
   429; atheromatous, iii. 433; sebaceous,iii.
   434; sarcomatous, iii. 448; lardaceous, iii.
   450.
 Tunaley's case of a bristle in the oesopha-
   gus, iii. 98.
Turchetti's  cases of malignant pustule,
   described by him as anthrax, i. 80.
Tweedie,  Dr. on enlargement of the ton-
   sils, i. 159; ascribes cases of the so-called
   scirrhus of the tonsils to hypertrophy and
   induration alone, i.  162.
 Tympanitis, iii. 218.
 Tyrrell's  case of fatal haemorrhage  con-
   secutive to opening  a tonsillar abscess, i.
   162; of  protracted gleet, i. 195; distinc-
   tion between gonorrheal gleet, and gl eet
   from stricture, i. 195; diagnosis between
   inflammation and  hysterical affections of
   the joints, i. 277; adhesive plaster, i. 361;
   case of wounded intestine, i. 507; of tre-
   panning the spine, i. 590; hydriodate of
   potash in general syphilis, ii. 101; case of
   compound dislocation of the sternal end
   ofthe clavicle backwards.ii. 218; of hook-
   foot, arising from an accident, ii. 461;  of
   the existence of several  aneurisms in the
   same  person, ii. 477;  of  teleangiectasy
   treated by injecting  a solution of alum, ii.
   565; of a broken piece of  catheter in the
   bladder,  iii. 135; section  of the prostate
   in the operation for  stone, iii. 320; case of
   inhealing of a metallic frame to remedy a
    sunken nose, iii. 592; of excision of part
   of the hand,  iii. 722; of  necrosis of the
   lower jaw, iii. 745.

  Ulceration:—causes, i. 61;  Hunter on
   ulcerative inflammation, i. 61; ulcerative j
   absorption, or absorption  with  suppura-
   tion,  i.  63;  progressive  absorption, i.
   63;  Travers  on  the process  of ulcera-
   tion,  i.  64;  ulceration of  the  synovial
   membrane, i. 339.                 _
  Ulcers in general:—definition of, n. 41;
   causes,   internal  and   external,  n. 41 ?j
   division of ulcers into  simple and com-
   plicated, ii. 41; subdivisions  of compli-
   cated ulcers, ii. 41; reaction of ulcers on
   the organism, ii. 41;  prognosis, n. 41 ;|
treatment, ii. 42; three stages of the pro-
gress of ulcers towards healing, ii. 42;
symptoms and  treatment of an inflamed
ulcer, ii. 42; of the erethetic ulcer, ii. 43;
of the torpid  ulcer, ii. 43 ; symptoms,
appearances, and treatment  of the  foul
or gangrenous ulcer, ii. 43  ; Percy, La-
barraque,  Lisfranc,  Lemaire, Ekl,  Kli-
matis, Biett, Cloquet, Cullerier, Boulay,
and  Pigne on the solution  of the chlo-
ride  of lime in foul, gangrenous, and tor-
pid ulcers, ii. 44; symptoms and treat-
ment of .the callous  ulcer, ii. 44 ;  of the
cedematous ulcer, ii. 44; of the fungous
ulcer, ii.  44; of varicose  ulcer, ii. 45;
issues required if the ulcers are of long
standing, ii. 46;  atonic  ulcers, ii. 46;
causes,  situation, and  symptoms, ii. 46;
prognosis,  ii. 47; treatment, ii. 47 ; ap-
plication of sticking-plaster, ii.  47 ;  Un-
derwood and Boyer allow the patient to
walk while wearing the sticking-plaster,
ii. 47;  local application of  aromatic and
astringent remedies, ii. 47;  Rust's treat-
ment of chronic ulcers of the foot by the
hunger-cure, ii. 48;  South on  the appli-
cations  of strips of  plaster  in the  treat-
ment of ulcers, ii. 48; general treatment,
ii. 48;  prevention  of  relapses, ii. 48;
scorbutic ulcers, ii. 48; causes and symp-
toms, ii. 49;  characters,  ii. 49;  occa-
sional causes of scurvy, ii. 49;  Bateman
on purpura  haemorrhagic, or land scurvy,
ii. 49;  general and local treatment,  ii.
50;  scrofulous  ulcers,  ii. 50;  causes,  ii.
50;  indications of the  scrofulous dispo-
sition, ii. 51; diseases dependant on scro-
fula, ii.  51;   characters  of  scrofulous
sores, ii. 51; treatment of the sores must
be constitutional, ii. 51; occasional dis-
appearance of scrofula at puberty,  or
during  the  first pregnancy, ii. 51; gene-
ral  treatment of scrofula, ii. 51 ;  local
treatment   of glandular swellings  and
scrofulous ulcers, ii. 52; local treatment
of the ulcers when torpid, ii. 52; use of
iodine and cod-liver oil, ii. 52; Lugol  on
iodine in scrofula, ii. 52; Lugol's formulae
for the  exhibition of iodine, ii. 52;  exhi-
bition of cod-liver oil, ii. 52;  Negrier  on
fresh walnut leaves and their decoction
 in scrofula, ii. 53; Pollini's decoction, ii.
 53; Russell and Burns on  the treatment
 of scrofulous  ulcers, ii. 53;  South on the
 iodide  of postassium and cod-liver oil in
 scrofula, ii. 53 ; scrofulous inflammation
 of the upper lip, nose, and cheeks, and  its
 treatment,  ii.  54; gouty ulcers, ii. 54;
 causes and characters, ii. 54;  situation
 and  diagnosis, ii.  54; the  treatment of
 these ulcers, requires greatcare, for fearof
 metastasis, ii. 55; general treatment, ii. 
928                        ANALYTICAL INDEX.
55;  wine of colchicum seeds the most
efficacious remedy in gouty and rheumatic
affections, ii.  55; Lewin's experiments
on colchicum  as a cause of an increased
production of uric acid in  the urine, ii.
55;  local treatment,  ii. 55 ; earthy mat-
ters  deposited  in gout, ii. 55 ;  impeti-
ginous ulcers,  ii. 56; varieties, ii.  56 ; to
be considered as  symptoms  of  chronic
eruption of the  skin,  ii.  56;  causes of
chronic eruptions, ii. 56; subdivisons of
impetiginous  ulcers, ii. 56; treatment,
general and local, ii. 56; herpetic ulcers,
ii. 57; characters, ii.  57; varieties  of
herpes, ii. 57 ; characters of herpes exe-
dens or lupus, ii. 58; proximate cause, ii.
58 ;  hereditary disposition to herpes, ii.
58 ;  remote causes, ii. 58; complications
with scrofula, syphilis  and  gout, ii. 58;
danger of the  repulsion  or imperfect
development of herpes, ii. 58;  Veiel's
division of  herpes, ii. 58;  treatment of
herpetic  ulcers,  ii.  59;   anti-herpetic
medicines, ii. 59; external treatment, ii.
59;  scalled head or tinea capitis, ii. 60;
symptoms and characters of scalled head,
ii. 60;  characters of tinea favosa, ii. 60;
of tinea granulata, ii. 61;  of tinea fur-
furacea, ii. 61;  of tinea  asbestina, ii.  61;
of tinea muciflua, ii. 61; consequences
of long-cpntinued scalled  head,  ii. 61  ;
proximate and  occasional causes, ii. 61;
sudden suppression of sealled head some-j
times  dangerous, ii.  62; treatment, ii. j
62;  local treatment,  ii. 62; milk  crust
or crusla lactea, ii. 62; characters, ii. 62;
of crusta serpiginosa, ii. 63 ; causes of
crusta  lactea,  ii. 63;  crusta serpiginosa
always consequent on  complication of
crusta  lactea with  syphilis or  herpes,
ii. 63 ;  Autenrieth's opinion that crusta
serpiginosa  is  connected with itch,  ii.
63;  local  and  general  treatment  of
crusta  lactea,  ii.  63;  of  crusta  serpi-
ginosa, ii. 63;  von Wedekind  on the
treatment of crusta  lactea,  ii. 63; itch,
scabies or psora, ii.  64;  characters,  ii.
64; characters and causes of itch  ulcers,
ii. 64;  Krause on the  existence  of itch
without  eruption, ii. 64; cause of itch,
ii. 64; the itch-mite, ii. 65; symptoms
of scabies spuria,  ii. 65;  Wichmann,
Bateman, Baker, Canton, Alibert,  Lugol,
Renucci, Albin Gras, and Eble on the ex-
istence of the itch-mite or acarus scabiei,
ii. 65;  Eble's observations on the acarus, |
ii. 65; Emery and Aube on the contagion
of itch, dependent on  the itch-mite, ii.
65, 66; the inoculation of itch by trans-
planting the acarus, ii.  66;  Mouffet,
Avenzoar, Joubert, Linnaeus, Dr. Adams,
and Hyacinth Cestoni on the acarus sca-
 biei, ii. 66;  Gale's  experiment with the
 itch-mite, ii. 66; consequences of neglect-
 ed itch, ii. 66 ;  simple and complicated
 itch, ii. 66;  treatment of simple itch, ii.
 66; objections to greasy applications in
 the treatment of itch, ii. 67; Horn's lini-
 ment, ii. 67;  Fischer  on the applica-
 tion of smear,  black, or green soap, ii.
 67; mode of using it, ii. 67; symptoms,
 which  occur during  this treatment, ii.
 68 ; treatmeht of itch by Graf, Vezin,
 and Pentzlin, ii. 68 ;  treatment  of itch
 by liquid sulphuret of Jime in the Bel-
 gian army,  ii.  69; treatment  of  com-
 plicated  itch, ii. 69;  of itch-ulcers, ii.
 69; of suppressed  itch, ii. 70; venereal
 ulcers, ii. 70; distinguished as primary
 and secondary, ii. 70;  causes,  ii. 70;
 South on  the inappropriate  use of the
 terms  "venereal ulcer," and "chancre"
 as synonymous, ii. 71; John Hunter on
 the  two modes in  which the  venereal
 poison affects the system, ii. 71;  Law-
 rence on  the progress of syphilis  from
 one part of  the body to another, ii. 71;
 the operation of the venereal contagion
 requires  a peculiar  delicate structure of
 the part affected, or  a  deprivation of  its
 cuticle, ii. 71; symptoms of chancre, ii.
 71;  characters of the pus  secreted  by
 venereal ulcers, ii. 72; John Hunter and
 Ricord on the period at which chancres
 appear  after  infection,  ii.  72;   John
 Hunter on the symptoms of chancre, ii.
 72 ;  Lawrence on the progress of ulcera-
 tion in a syphilitic sore, ii. 72; Lawrence
 on  the Ave  kinds  of syphilitic sores, ii.
 73;  the  pus of the  ulcer the  special
 vehicle of the venereal contagion, ii. 73 ;
 Hunter's experiments by inoculating with
 the matter of gonorrhea and chancre, ii.
 73 ;  Ricord  on  inoculation for the pur-
 pose of distinguishing syphilitic sores,
whether primary or secondary, ii. 74;
buboes  the first  symptoms  of general
 syphilis, ii.  75;  may be idiopathic, or
 sympathetic, ii. 75; symptoms, progress,
and terminations, ii. 75; John  Hunter on
 the true venereal buboes, ii. 75 ;  Ricord
 on  the seven kinds of buboes,  ii. 75;
 Hunter and Ricord on the existence of
 syphilitic  buboes, without primary  sore,
 ii. 76;  general syphilis attacks specially
either the skin, mucous membranes, or
bones, ii. 77; John Hunter on the con-
 tinuance  of  the constitutional irritation
from lues, independent of continued ab-
sorption, ii. 77; inflammation of the mu-
cous membrane of  the  throat, ii. 77;
symptoms, appearances, and results, ii.
78;  venereal eruptions, ii. 78 ; symp-
toms, ii. 78;  Lawrence on the four kinds 
ANALYTICAL INDEX.                        929
of syphilitic eruptions,  ii. 78;  herpetic
eruptions, rhagades, veruccae, and  con-
dylomata, ii. 79; John Hunter and Ricord
on the non-infectious character of the pus
from a secondary syphilitic sore, ii.79, 80;
symptoms and results of syphilis in the
bones, ii. 80; modifications of the symp-
toms  of syphilis, ii. 81; primary syphi-
litic ulcers no decided external character,
ii. 81; Abernethy on pseudo-syphilis, ii.
81;  Abernethy  on the  means  of dis-
tinguishing between true and false syphi-
lis, ii. 82; Carmichael's objections to the
terms syphilis, syphiloidal, and  pseudo-
syphilis, ii. 82;  Carmichael  bases his
arrangement of  venereal complaints  on
the character  of the  eruption,  ii. 82 ;
Ricord  on  the  causes of the varied ap-
pearances of chancre or primary syphi-
litic sore, ii. 82;  differences  in secon-
dary syphilis, ii. 84; prognosis, ii. 85 ;
John  Hunter on the relative rapidity of
cure of gonorrhea, chancre, and  lues ve-
nerea, ii.  85;  Abernethy on  the  occa-
sional spontaneous healing of chancre, ii.
85; John Hunter on the relapse of ulcers
after  chancres  have cicatrized, ii.  85;
treatment of syphilis with mercury, ii, 86;
in treating chancre, an especial indication
to prevent general  syphilis, ii. 86 ;  local
treatment, iL 86; Ricord on the  destruc-
tion of the ulcer by the nitrate of silver,
ii. 86 ; internal exhibition of mercury, ii.
86; Lawrence on the exhibition  of  mer-
cury in cases of chancre, and on the rarity
of the occurrence of secondary symptoms
when  mercury has been used, ii. 86 ;
Lawrence on the extent to which the use
of mercury may be pushed, ii. 87 ; Green
on the use of mercury in syphilis, and on
the forms in which it should be employed,
ii. 87 ; circumstances requiring the  local
exhibition of corrosive sublimate, ii. 88;
Delpech on frictions with the  ung.  hyd.
cin. in  primary  syphilis, ii. 89; South
on the treatment of sloughing chancre, ii.
89 ; mercury not to be used either inter-
nally  or externally under such  circum-j
stances, ii. 89;  mercury should be ex-i
hibited  for some time in smaller doses
after the chancre has cicatrized, ii. 89;
treatment of buboes, ii. 89;  tendency of
idiopathic buboes  to  suppurate, ii. 90  ;
treatment of the remaining ulcer, ii. 90; |
treatment of the indurated bubo, ii. 90  ;j
mode of opening suppurating buboes, n.j
90;  Ferguson,  Fricke, Reynaud, and
Ricord on the treatment of buboes, ii. 90  ;
South on  the  treatment of  suppurating
bubo, and of the subsequent ulcer, ii. 90;
treatment of general syphilis by mercury,
ii. 91; external employment of mercury, i
 when required, ii. 91;  sublimate  baths,
 ii. 91; the internal exhibition of mercury
 preferable  in ordinary  syphilis, ii.  91 ;
 local symptoms require special treatment,
 ii.  91 ;  Rust's treatment  of syphilitic
 ulceration of the throat and palate, ii. 91 ;
 treatment of syphilitic eruptions, ii. 92 ;
 treatment of the granulations  by caustic
 or the knife, ii. 92 ;  of syphilitic disease
 of the  bones, ii. 92; mercurial  fumiga-
 tion in syphilitic ulceration of the tonsils
and pharynx, ii. 92 ;  South on secondary
syphilitic sores and  their  treatment, ii.
92 ; South on the treatment of nodes, ii.
93;  necessary to  vary  the  mercurial
preparations  in use according to consti-
tution and other circumstances, ii.  93 ;
Starke on  the phosphor, hydrarg.,  von
Graefe on the iodide and bromide of mer-
cury, and Mendaga  and Parent on  the
hydrarg. cyan., ii.  93;  salivation  not
necessary for the  cure  of the  venereal
disease,  ii.  94 ; treatment of salivation,
ii. 94 ; treatment of old cases of venereal
disease, ii. 94 ; Louvrierand Rust on the
friction-cure, ii. 94 ;  cases in which the
friction-cure is indicated, ii. 95 ;  cases in
which it is contra-indicated, ii. 95 ; South
on the friction-cure, ii. 95; mode of em-
ploying  it, ii. 95;  Wedemeyer,  Rust,
and South on the  number of times the
frictions may require to  be practised, ii.
96; the order in which the rubbings-in
are to be conducted, ii. 96; symptoms
which  occur during  this treatment, ii.
97 ; the Montpellier  modification of the
friction-cure  condemned, ii.  97;  treat-
ment to be adopted, if  the salivation or
critical sweating b§ suddenly suspended,
ii. 97; occurrence of spasmodic or ner-
vous symptoms, ii. 97 ; subsequent treat-
ment, ii. 97 ; Weinhold's mercurial cure,
ii.  97;  mode of  employing it,  ii.  98;
 Zittmann's  decoction, ii. 98;  mode of
 exhibiting it, ii. 98  ; formula for Zitt-
 mann's   decoction, ii.  98;  the  Arabian
 treatment, ii. 99; Dzondi's treatment, ii.
 99;  the preference given to the use of
 Zittmann's  decoction, ii. 100; treatment
 of syphilis without mercury, ii. 100; va-
 rious modes of treating  secondary symp-
 toms without mercury, ii. 100 ; Pitcairn,
 Chrestien, and Niel  on  gold and its pre-
 parations in primary and secondary sy-
 philis, ii. 101; Ricord, Eusebe de Salle,
 Lallemand, Biett, Paillaud, Wallace, Dr.
 Williams, Judd, Tyrrell, Ebers, von Has-
 selberg, and Hacker on iodine  and  hy-
 riodate of potash in gonorrhea and general
 syphilis, ii. 101;  Forster on the cure of
 syphilis by the chloride  of gold and soda,
 ii.  102;  treatment  of  syphilis  without 
930
ANALYTICAL  INDEX.
  mercury in England, ii. 102 ; Hill, Hen-
  nen, Rose, Guthrie,and Thomson on the
  duration of the disease under this treat-
  ment, and on the subsequent occurrence
  of secondary symptoms, ii. 103; South on
  the  proper mode of exhibiting mercury in
  the  treatment of syphilis, ii. 103 ; objec-
  tions to the treatment without and with
  mercury, ii. 103; syphilis in infants, ii.
  104; causes of infection, ii. 104 ; Evan-
  son and  Maunsell on  the communica-
  tion of  syphilis  to  the foetus  in the
  womb,ii.  104 ; Huguier on the period at
  which syphilis shows itself after birth, ii.
  104; infection  of the  child by  a syphi-
  litic nurse, ii. 105; Dyckman's assertion
  that the child  may be  infected by the
  milk of a diseased nurse, ii. 105 ; Hunter,
  Lawrence, and Todd's cases of diseased
  children  infecting the nurses,  ii. 105;
  Colles doubts whether the child can infect
  the  nurse, unless she have ulceration of
  the  nipple,ii. 105; Evansonand Maunsell
  on the symptoms of syphilis in infants, ii.
  106; Lawrence on syphilitic iritis, and
  ulceration about the anus in infants, ii.
  106; prognosis, ii. 106;  Evanson  and
  Maunsell on the treatment of syphilis in
  infants, ii. 106; Swediaurand Bacot ob-
  ject to  the use of corrosive sublimate in
  such cases, ii.106; Hey, Lawrence, Hun-
  ter, Ricord, and South on the possibility
  of infection from secondary syphilis, ii.
  106.
Ulna, fracture  of, i. 612;  dislocation  of,
  ii. 229.
Ulnar artery, ligature of, ii. 530.
Ullsamer on endemic prolapse ofthe womb
  from the use of the labour-chair,  ii. 375.
  Umbilical rupture, ii. 343.
Underwood on the treatment of ulcers by
  sticking-plaster, ii. 48.
Urban's  opinion  that there is a circlet of
  small vesicles round the wound  or scar
  in hydrophobia, i. 405.
Ureter, stone in the, iii. 269.
Urethra,Inflammation of:—Gonorrhea;
  causes, i.  174;  symptoms and progress,
  i. 175; chordee, i. 175;  balanitis, i. 176;
  phymosis, i.  176;  paraphymosis, i. 176;
  Hunter and Astley Cooper on the period
  when gonorrhea first  shows itself after
  infection, i. 176; Astley Cooper, Hunter,
  and Travers on the primary symptoms,
  i. 176; Hunter on the specific extent of
  the  inflammation, i. 176;  Hunter  and
  Astley Cooper on the  actual seat of the
  discharge,  i. 177; Cooper on the post-
  mortem appearances, i 177; Hunter on
  the  small swellings which are noticed ex-
  ternally near the urethra, i. 177;  Hunter
on the size and form  of  the stream of
urine,  177; Hunter and  Cooper on the
occurrence of haemorrhage in severe go-
norrhea, i. 177;  in rare cases the corpus
spongiosum is ruptured, i. 178; Macmur-
do's case  of rupture of a vessel  in the
penis during coition, i. 178; Hunter on
inflammatory and spasmodic chordee, i.
178; Abernethy on permanent chordee
from the inflammation  having extended
to the corpus spongiosum, i. 178; Hunter
on the extent of local  irritation, i. 178;
South  on  retention of urine in severe
gonorrhea, i. 178;  Hunter on the exten-
sion of the inflammation to the bladder,
and the consequent inability of that viscus
to retain its contents, i. 178; the consti-
tution  rarely primarily affected, i. 179;
Hunter's case of fever  preceding gonor-
rhea, i. 179; continuance  of the symp-
toms, i. 179; gleet, i. 179; Astley Cooper
on the influence of constitutional causes
on gonorrhea, i.  179;  consequences of
gonorrhea, i. 179 ;  seat of, in the female,
i. 179; its propagation to the rectum, i.
180; distinguishing characters from leu-
eorrhea, i. 180; Ricord on acute urethritis
in the female, i. 180;  Ricord  on  utero-
vaginal gonorrhea, i. 180;  Hunter on the
extension   of  the  inflammation to the
bladder in the female, i. 180; doubts its
extension  to  the ovaries,  i. 180; Ricord
regards ovaritis as a complication of go-
norrhea, i. 180; swelling and infiltration
of the  external parts, considered by Ri-
cord  a kind of phymosis or paraphymosis,
i.180; abscesses in the labia or nymphae,
i. 180; Hunter and Ricord on abscesses
complicating gonorrhea, i. 180; distinc-
tion  between gonorrhea and  leucorrhea
not easy, i. 180; Dr. Locock on leucor-
rhea, i. 180 ; characters of the secretion,
i. 180; Locock and Jewel on the distin-
guishing signs between leucorrhea and
gonorrhea, i. 181; pudendal discharges in
female infants, i.  181; Locock on the
pudendal discharges during  dentition, i.
181;  Dr. Percival, Dr. Ferriar, Dr. Mack-
intosh, Kinder Wood, and Capuron on an
epidemic vaginal catarrh, i. 182;  varieties
of gonorrhea, i. 182;  Lawrence's divi-
sion  into gonorrhea benigna and gonor-
rhea  virulenta, i. 182 ;   Hunter oh gonor-
rhea  from simple causes, i.  182; Sir
Fverard Home on the internal use of ar-
senic and  ginger as a cause of gonorrhea,
i. 182; simple gonorrhea  originating in
leucorrhea in  the female, i. 182; Hun-
ter's case, i. 182;  South on gonorrhea
virulenta a constitutional disease in cer-
tain  persons, i. 183; Lawrence's opinion,
i.  183; Abernethy on gonorrhea  viru- 
ANALYTICAL INDEX.
931
lenta, i.  183; question of identity  be-
tween gonorrhea and syphilis, i. 183;  ob-
servations and experiments of Hernandez
and Ricord, i. 183; Becket's memoran-
dum respecting gonorrhea, i.  183; John
of Gatesden's Rosa  Anglicana,  i. 183;
John  of  Arden mentions  the  chaudi-
pisse, i. 184 ; the supposed origin of  sy-
philis on the discovery of America, or at
the siege  of Naples, i. 184;  South's
opinion that syphilis was known  to John
of Arden, and perhaps to John of Gates-
den, i. 184; Hunter  on the  identity of
the two poisons, i. 184; accounts for  the
two different effects of the same poison,
by the gonorrhea preceding from  a secre-
ting surface, while the chancre is formed
on a  non-secreting  surface, i.  184 ;
South on the frequency of the co-occur-
rence of chancre and gonorrhea, i. 184 ;
Bell  denies  the identity of gonorrhea
and syphilis, i. 185; Hernandez's expe-
riments on the subject, i. 185 ; the ulcers
produced by inoculating with gonorrheal
virus are not syphilitic, i. 186; Ricord's
observations  and experiments,  i.  186;
Ricord's inferences from the results, of
the inoculation with  gonorrheal  matter,
i. 186; the opinion that gonorrhea is  un-
attended by ulceration contraverted  by
Ricord, i.  186;  Travers on  gonorrheal
sores and  their consequences,  i. 187;
Travers on the secondary symptoms of
the gonorrheal sore, i. 187; South on  the
gonorrheal sore throat, i. 188; diagnosis
of the  several kinds  of  gonorrhea, i,
188; the swelling  of the testicle, and of
the inguinal glands and prostate, sympa-
thetic not syphilitic, i. 188;  Hunter on
the sympathetic  swellings in gonorrhea,
i. 188; Cooper on  the sympathetic bubo
of gonorrhea, i. 188;  in all suspicious
cases of  discharge from the male  or fe-
male genitals, if the disease be syphilitic,
the speculum will show it in the female,
and inoculation with the matter will indi-
cate it in the male, i.  189; Ricord on the
examination of public prostitutes, i. 189;
treatment,  189 ;  Hunter on the duration
and spontaneous cure  of gonorrhea,  i.
190;  treatment, i. 190; employment of
stimulating injections, i.  190;  John of
Arden's  prescription, i. 190; Beckett's
prescription, i. 190; Abernethy's objec-
tion to any attempt to check gonorrhea, i.
191; recommends a  soothing practice, i.
191; South's  treatment, i. 191; Carmi-
chael's  injection of a strong solution of
nitrate of silver, i. 191; Ricord's treat-
ment by the  direct  application of  the
nitrate of silver, i. 191; Astley Cooper s
treatment, i. 191 ; observes  that gonor-
 rhea is difficult to cure in strumous sub-
jects, i.  192; treatment  of  hordee,  i.
192; means to check haemorrhage, if it
occur, i. 192; South's treatment of pain-
ful erections and chordee, i. 192; Astley
Cooper, Ricord, and Hunter on the reme-
dies for chordee, i. 192 ;  South, Hunter,
and Ricord on the treatment and arrest
of haemorrhage from  the urethra, i. 192 ;
subsequent treatment of gonorrhea,  i.
193 ; treatment of the syphilitic form  of
gonorrhea, i. 193; treatment  of  gonor-
rhea in women, i. 193; South and Ricord
on its  treatment in women, i. 193; use
of stimulating injections in  some  cases
objectionable,  i. 193; Home's cases  in
which the use of stimulating  injections
caused the sides of  the vagina to unite
together by the adhesive inflammation, i.
193; Ricord's treatment of severe  cases
by the introduction of a plug of lint dip-
ped in an emollient narcotic  liquid,  i.
193;  his treatment of obstinate cases by
filling  the vagina with  dry lint, i. 193;
ulcerations and  papulous granulations
to be cauterized, i. 193; Ricord on ulce-
rations of the mucous membrane of the
womb, i. 193; vegetations in the interior
of the urethra to be destroyed by incision
or cauterization, i. 194; Ricord  on gonor-
rhea in the female urethra, i. 194; treat-
ment of gleet, i. 191; South and Astley
Cooper on gleet, i. 194 ;  Astley Cooper,
Hunter and  South on the infectious na-
ture of gleet, i. 194; Tyrrell's case  of
protracted gleet, i. 195;  Tyrrell on the
distinction between gonorrheal gleet, and
gleet   from   stricture,  i. 195; Astley
Cooper on the distinction between gonor-
rhea and  gleet, and abscess of the la-
cunae, i. 195 ; Astley Cooper on the treat-
ment of gleet, i.  195; constitutional treat-
ment,  i.  195;  Ricord  on inoculation
with  gonorrhea  to cure gleet,  i.  195;
South's condemnation of that practice, i.
 196;  use  of cubebs, i. 196;  Delpech's
condemnation of cubebs, i.  196; symp-
toms produced by the exhibition of cu-
bebs, i. 196; Delpech  has shown that
cubebs do not cause  inflammation of the
 testicles, i. 197;  Delpech's treatment  of
 gonorrhea, i.  197; Velpeau,  Michaelis,
 Richon, and De Salle on the treatment of
 gonorrhea, i. 197; Astley Cooper on the
 use of cubebs in gonorrhea, i. 197 ; South
 on cubebs and  copaiba  in gonorrhea, i.
 198;  external  gonorrhea,  balanitis,  i.
 198; causes and symptoms, i.  198; Hun-
 ter and South on balanitis, i. 198; treat-
 ment,  i. 198; Ricord and South on the
 treatment, i.  199 ; gonorrhea ofthe nose,
 i. 199; Benjamin Bell's cases, i. 199; 
932                         ANALYTICAL INDEX.
  treatment of gonorrhea, dependent on a
  gouty or herpetic disease, i. 199.
Urethra, rupture of, i. 535.   See Wounds
  ofthe Penis.
Urethra, Stricture  of, iii. 63; stricture
  of the urethra of more frequent  occur-
  rence than in any other outlet, iii.  63;
  symptoms,  iii.  63;  Brodie  on  incon-
  tinence  of  urine  in stricture,  iii.  64;
  extravasation  of urine from  rupture or
  sloughing of the urethra behind the stric-
  ture, iii.  64; Brodie on extravasation of
  urine from ruptured urethra in stricture,
  iii.  64; Brodie  on abscesses  communi-
  cating with the bladder in  old cases of,
  stricture, iii. 64; changes in the urethra
  in old strictures, and the attendant symp-
  toms, iii 64; Brodie on the complication
  of stricture with  enlarged prostate,  iii. j
  65; Brodie's case of enlargement of the
  urethra from stricture, iii, 65; Brodie on
  the formation of cysts of the urethral mu-
  cous membrane in stricture, iii. 65; Bro-
  die on the occurrence of rigors and fever;
  in cases of stricture, iii.  66;  causes of
  stricture, iii. 66 ; Brodie on the existence!
  in old  strictures of an indurated  mass1
  at the lower portion of the penis, iii. 66;
  seat and  characters  of  stricture, iii. 67;
  Hunter's description of three  forms of
  stricture, iii. 67; Brodie on the original!
  seat of  stricture, iii.  68;  diseases liable)
  to be confounded with stricture, iii. 68;
  diagnosis,  iii.  68;  prognosis, iii.  68;
  treatment, iii. 69; mode of  determining
  the seat  of  the stricture, iii. 69; Brodie
  on the use of a full-sized bougie  on de-
  termining  the  seat  of the stricture, iii.
  70; preparation of common bougies, iii.
  70;  Astley Cooper, Abernethy and Bro-
  die  on  passing  the  bougie, iii.  73;
  Astley Cooper and Abernethy on the use
  of metallic  bougies, iii. 73;  Brodie on
  the treatment of stricture with bougies,
  and on  their applicability to the respec-
  tive kinds  of  stricture, ii. 74; Brodie's
  directions  for  the  introduction of the1
  bougie, iii.  74; South  on the  danger of i
  using plaster bougies, iii. 74;  South onj
  the introduction  of the bougie, iii. 74;
  South on the general treatment of stric-
  ture, iii. 75 ; the time the bougie should '
  be left in the urethra, and ihe frequency
  of its introduction, iii. 75 ; precautions to
  be taken when the instrument  is left in
  the urethra, iii.  76; gradual increase  in
  the size  of the instrument used, iii. 76;
  Arnott's oil-silk tube,  iii. 76;  action of
  the bougie, iii. 77;  symptoms occasion-
  ally produced  by  it,  iii.  77;  Astley
  Cooper and Abernethy on  haemorrhage
  from the urethra after passing the bougie,
  iii. 77; Astley Cooper and South on the
  practice to be adopted when a laceration of
  the urethra by the bougie is suspected, iii.
  77; destruction of the stricture by caustic,
  iii. 78; by ulceration to be rejected as
  dangerous, iii. 78; Brodie on the destruc-
  tion  of stricture by ulceration, iii. 78;
  cauterizing a stricture from before back-
  wards,  iii. 78;  preparation of  armed
  bougies, iii. 78;  Hunter,  Home, and
  Whately on the use of the armed bougie,
  iii. 79; objections to this mode of cauteri-
  zation, iii.  79; cauterizing the walls of
  the stricture, iii. 79; Whately and  Arnott
  on cauterizing the walls of the stricture,
  iii. 79; use of bougies armed with caus-
  tic potash, iii. 80; Whately and Lawrence
  on the use of bougies armed with caustic
  potash, iii.  80;   Ducamp's mode of
  cauterizing the  urethra,  iii.  81;  subse-
  quent treatment, iii. 81; Ducamp's mode
  of dilating the urethra after cauterization,
  iii. 81 ; Ducamp's caution respecting the
  use of caustic, iii. 82; Lallemand, Sega-
  bas, and Tanchou's causlic-holders, iii.
  83 ;  relative advantages of the treatment
  by bougies and by caustic, iii. 83;  Ast-
  ley Cooper, Brodie, Lawrence and South
  on the use of the  armed  bougie, iii. 84;
  cutting into the stricture,  and subsequent
  dilatation,  iii. 85;  Jameson's treatment
  of stricture, iii. 85 ;  formation  of  false
  passages,  iii.  86;  treatment,  iii.  86;
  South on the treatment of false passages,
  iii. 86; congenital closure of the urethra.
  iii. 86; treatment, iii. 86.
Urethra, calculus in  the, iii. 363.
Urinary fistula, ii. 174.
Urine, retention of, iii. 125.
Urethroplasty, ii. 179.
  Uvula, relaxation  of, i. 166; extirpation
  of, i.  167.

Vaccination or  inoculation with  cow
  pock, iii. 621 ;  definition, iii. 621 ; use of
  the lymph, iii. 622; Dr.  Gregory on the
  origin of vaccination, iii. 622 ;  Dr. Jen-
  ner's  discovery, iii. 622;  Cline, the first
  experimenter, iii. 622; Dr. Gregory on
  the preservation  of vaccine lymph for
  transmission, iii. 622 ;  Gregory on the pe-
  riod at which lymph should be taken for
  vaccination, iii. 623 ; vaccination an ope-
  ration without  danger, iii. 623 ; mode of
  vaccinating from a fresh pustule, iii. 623 ;
  Dr. Gregory on the operation of vacci-
  nation, iii. 623 ;  vaccination with dry
  matter, iii. 623 ; appearances after effec-
  tual vaccination, iii. 623 ; Gregory on the
  appearances  after  effectual vaccination,
  iii. 624;  irregularities in the course of
  the vaccine vesicle, iii.  624;  Gregory 
ANALYTICAL INDEX.
933
  on the insusceptibility of  some  consti-
  tutions  to  the vaccine virus, iii. 624;
  after-treatment, iii. 625 ;  Gregory on the
  appearance of vaccine lichen, iii. 625.
Vagina, wounds of, i. 533; prolapse of, ii.
  389 ;  closure, and narrowing of, iii. 87;
  polypus of, iii. 494.
Vaginal rupture, ii.  353.
Valentin on  the exudation-corpuscles, i.
  45 ; microscopic characters of pus, i. 46;
  microscopic results of suppuration, i. 49;
  mode of amputating by the circular in-
  cision, iii. 640.
Valgus, ii. 456.
Valsalva on the lengthening of the limb
  in hip-disease, i. 285.
Varicose aneurism,  ii. 549.
Varix, aneurismal, ii. 546.
Varices:—definition, ii. 567; characters,
  ii. 567; Brodie on the effects of inflam-
  mation on the blood  in veins,' ii. 568;
  Hodgson and Petit on the coagula in vari-
  cose veins, ii. 568 ;  causes, ii. 568; Dr.
  Baillie's case of obliterated vena cava in-
  ferior, ii. 569 ; Brodie's case of varicose
  veins ofthe fore-arm, ii. 569 ; Cline'scase
  of obliteration of  the inferior vena cava,
  ii. 569; Brodie's  cases of varicose veins
  ofthe arm and chest from compression of
  the subclavian veins, ii. 569 ; Petit and
  Velpeau's cases of varices in the upper
  extremities,  ii. 570;  South  and Cline's
  eases of varix of the deep-seated veins, ii
  570;  treatment,  ii.  570; Brodie  on  the
  application of adhesive  plasters in the
  treatment, ii. 570  ; radical cure, ii. 571 ;
  Gottschalk on the treatment of varix, ii.
  571;  puncture with a lancet, ii. 571; in-
  cision, ii. 571; extirpation, ii. 571; ap-
  plication of  the ligature, ii. 572;  Ricord
  on the application of the ligature, ii. 572;
  Sir E. Home and South on the ligature
  of the saphena for varix, ii. 572; Solera's
  operation  by cutting through  the vein
  above and below, ii. 572;  Brodie on the
  subcutaneous division of the vein, ii. 572;
  application  of  the   actual  or  potential
  cautery, ii.  573;  Bonnet,  von  Froriep,
  Mayo, and Brodie on the application of
  caustic, ii. 573;  introduction of needles
  through  the walls of a  vein,  ii. 573  ;
  modes of operating,  ii. 573; Velpeau on
  the introduction  of needles, ii. 574 ^la-
  teral  compression of the  vein,  ii. 574;
  occasional consequences of operations on
  varicose  veins,  ii.   575;  varicocele  or
  cirsocele,  ii.  575; definition and  charac-
  ters ofthe disease, ii. 575; Breschet and
  South on spermatocele, ii.  575 ; causes
  of,  ii. 575; Morgagni, Astley  Cooper
  and  Lenoir  on the  causes  of, ii. 577;
     Vol iii.—79
  consequences, ii. 577; treatment, ii. 577;
  operations  for the radical cure, ii. 577;
  Charles Bell and Delpech on the ligature
  of the  spermatic veins, ii. 578; Maunoir
  on the ligature of the spermatic artery, ii.
  578; Fricke, Kuh, Davat,  Franc, Ray-
  naud,  Wormald, A. Cooper,  Lehmann,
  and Breschet's operations, ii.  578;  esti-
  mate ofthe relative value of these opera-
  tions, ii. 579; mode of performing Bres-
  chet's  operation, ii. 579;  after-treatment,
  ii. 580;  haemorrhoids or piles, ii. 581;
  definition and varieties, ii. 581; situation
  and  consequences, ii.  581; Bushe  on
  the local  symptoms  of  piles, ii. 582;
  Bushe on  the  effects  of  the  loss of
  blood from piles, ii. 582 ; causes, ii. 582;
  treatment,  ii. 582; extirpation, ii. 583 ;
  Rousseau  and  Delpech's mode of extir-
  pating piles, ii. 583,584; Copeland, Bro-
  die, Bushe, and  Syme on the removal of
  internal piles by ligature, ii. 584; Petit,
  Kirby, and Brodie's cases  in  which se-
  vere symptoms  followed  the  use of the
  ligature for piles,  ii.  584;  Copeland
  and  Brodie on  the  application  of the
  ligature, ii. 584 ; extirpation of degene-
  rated piles, ii. 585; consecutive haemor-
  rhage,  symptoms and treatment, ii. 585;
  Bushe on the treatment ofthe consecutive
  haemorrhage, ii.  585; Cline, Cooper, and
  Brodie on excision of piles, ii. 586.
Varus, ii. 445.
Veiel's division of herpes, ii.  58.
Veitch's mode of amputating at the hip-
  joint by the circular cut,  iii. 689.
Velpeau's treatmentof erysipelas by mode-
  rate compression, i. 125; on pressure in
  the treatment of burns, i. 134 ; considers
  it best adapted  to cases of burn in the
  third and  fourth degrees, but  also appli-
  cable to those ofthe second, i.  135: mode
  of applying compression, i.  135;  advan-
  tages  of this plan  of treatment, i.  135  ;
  treatment  of gonorrhea, i.  197; of com-
  plete anchylosis, i. 275; on the three ope-
  rations for the relief of bony anchylosis, i.
  275; consequences of the adhesion ofthe
  knee-pan to the  condyles ofthe femur, i.
  275; objections  to the use of  Louvrier's
  apparatus, i. 276;  torsion of  arteries, i.
  276; treatment of artificial anus connected
  with the caecum, ii. 161;  case of simple
  dislocation of the sternal end  of the cla-
  vicle  inwards and  backwards, ii.  218;
  primitive direction of dislocation of the
  humerus, ii. 221; operation  for prolapsus
  uteri,  ii. 379; modification of Hey's opt-
  ration for prolapse of the rectum, ii.  40c;
  acupuncture of the artery in aneurism, ii.
  503;  ligature of the external maxillary 
934
ANALYTICAL INDEX.
  or  facial, ii. 514; case of varix in the
  upper extremity, ii. 570; introduction of
  needles in the treatment of varix, ii. 574;
  injections  of  iodine  in hydrarthrus, iii.
  183; hydrocele caused  by gonorrhea, iii.
  222; mode of  amputating at the knee
  with the circular  cut, iii. 700;  at the
  ankle-joint, iii. 700; mode of operating in
  exarticulation of the fore-arm at the elbow,
  iii. 719; operation in excision ofthe wrist,
  iii. 735.
Venesection, iii. 608.
Ventral rupture, ii. 348.
Verdier's artery-compressor, i. 331.
Vering's objection to the union of pene-
  trating wound ofthe chest, i. 493.
Vermandois on the lengthening  of the limb
  in hip-disease, i. 285; excision  of  the
  carious head of the femur in hip-disease,
  i.  300; experiments on the  excision of
  joints, iii. 727.
Vertebral artery, ligature of,  ii.  526.
Vertebrae, fractures and  dislocations of,  i.
  582; dislocations of, ii. 111.
Vesico-vaginal  fistula, ii. 188.
Vezin on the treatment of itch, ii. 68.
Viborg on the treatment of salivary  fistula,
  ii. 147.
Vidal's  proposal  to occlude the vulva in
  complete destruction  of the vagina  and
  wall of the bladder, ii. 197; surgical treat-
  ment of dislocation of the thumb from the
  metacarpal bone, ii. 235; cause of the
  difficulty experienced in reducing  this
  dislocation, ii. 235 ; operation for the di-
  vision ofthe inner fold of the prepuce, iii.
  58.
 Vigaroux's case of excision of a joint, iii.
  726.
 Vignolo on simultaneous dislocation of the
   radius forwards, and of the ulna back-
  wards, ii. 232.
 Viguerin's mode of treating congenital hy-
   drocele, iii. 231.
 Villaume on dislocation of the upper end
   ofthe radius forwards, ii. 231.
 Villerme  on the reunion  of fractures, i.
   548 ; double formation of bony substance
   in fracture, i.  549;  production of callus,
   i. 549.
 Vincent's fatal case of viper-bite, i. 389;
   case of calculi in the perineum, iii. 365;
   of calculi between the prepuce and glans
   penis, iii. 366.
 Voelter on the use of the suture in vesico-
  vaginal fistula, ii. 190.
 Vogel on  the phenomena of inflammation
   under the microscope, i. 41; formation of
   pus, i. 46;  effects  of the resorption  of
   pus, i. 48; noma, i. 75 ; essential  element
  of medullary fungns, iii. 460; blood-fun-
  gus, iii. 460.
Vohler's mode of amputating at  the hip-
  joint with two flaps, iii. 696.
Voillemier's case of dislocation  of the
  wrist, ii. 233; diagnostic signs of disloca-
  tion of the wrist,  and fracture  of the
  lower end  ofthe radius, ii. 233.
Volpi has not found benefit from the actual
  cautery, when the first symptoms of hip-
  disease occurred at the knee and not at
  the hip, i.  294 ;  case of reduction of the
  consecutive dislocation in hip-disease, i.
  297; apparatus for fracture of the  neck of
  the femur, i. 624.
Wachter's experiments on the excision of
  joints, iii. 727.
Wagner's Dr., cases of malignant pustule,
  produced  by contact  and  by eating the
  flesh of diseased animals,  i. 80.
Wallace, Dr., on hydriodate of potash in
  syphilis, iii. 201.
Wallner's treatment  of fracture  of the
  lower jaw, i. 580.
Walshe, Dr., on the genus carcinoma, iii.
  455.
Walther's, von, plan  of opening  a cold
  abscess with a seton, i. 105; treatment of
  fistulous  passages, i. 108; seat of boils
  originally in the sebaceous glands of the
  skin,  i. 150; incisions in  carbuncle, i.
  155; after-management  of ligatures on
  arteries, i. 338; symptoms  of laceration
  of the brain, i. 451; employs trepanning
  in injuries  of  the  head  only  when
  secondary  symptoms of  irritation and
  pressure  require it, i. 454;  objection to
  dressing  the wound  after the  operation
   for  rectal fistula, ii. 167;  simultaneous
  dislocation of both inferior oblique pro-
   cesses of one of the cervical vertebrae, ii.
   212;  nature of strangulation in ruptures,
   ii. 269; incision of  the hernial sac, and
   the introduction of lint-tents for its radi-
   cal cure, ii. 283;  formation of urinary
   calculi, iii. 237; origin of oxalic acid in
   the urine, iii. 244;  fungus of the dura
   mater, iii. 420; objections to operating for
   fungus of the dura  mater,  iii. 424;  dif-
   ference between fungus  haematodes  and
   sarcoma medullare, iii. 459;  ligature  of
   the spermatic artery  in sarcocele, iii. 555;
   case of excision of the  cervix uteri pre-
   ceded by excising  the  pubic  arch, iii.
   567; management of the  periosteum  in
   amputations, iii.  642;  mode  of ampu-
   tating at the hip-joint with  two flaps, iii.
   692; mode of operating in partial ampu-
   tation of the foot preferred, iii. 705;  in
   am, ul.i tion at  the  shoulder-joint by  an 
ANALYTICAL INDEX.
935
   upper and an  under flap, iii. 712;  in ex-
   articulation of both middle  met acarpal
   bones, iii. 722;  case  of excision of part
   of the hand, iii. 722; mode of operating
   in resection of the scapula, iii. 762.
 Wantzel  on the causes of club-foot, ii.
   446.
 Ward's,  Dr., application of flour in the
   treatment of burns, i. 132; mode of appli-
   cation, i. 132 ; objection to  liquid appli-
   cations,  i.  132; modus operandi of the
   flour, i. 133.
 Wardenburg's  apparatus for fractures of
   the olecranon, i. 614.
 Wardrop on ingrowing ofthe nail, i. 222;
   on onychia maligna, i. 226; evulsion of
   the nail in  the treatment of that disease,
   i. 227;  internal treatment in onychia
   maligna, i.  227; Brasdor's operation, ii.
   504;  treatment  of  branching aneurism,
   ii. 554; proposal to bleed a  patient to
   fainting, and operate during the syncope,
   iii. 603; case of excision of part of the
   lower jaw without  the condyle, iii. 748.
 Warner's case  of  abscess mistaken for
   aneurism, ii. 474.
 Warren's, Dr., plan for bringing the edges
   of the cleft together in staphyloraphy, ii.
   32;  operation when  the  cleft is  very
   large and complicated, ii. 33;  treatment
   to be adopted  when  air  enters a vein
   during an operation, iii. 604; case of re-
   section of the clavicle, iii. 764 ; of a rib,
   iii. 766; employment of ether by inha-
   lation prior to  the  performance of  im-
   portant surgical operations, iii. 767.
 Warts,  iii. 400.
 Wasserfuhr's operation and apparatus for
   re-breaking a badly-united bone, i. 576.
 Watson,  Dr., on  the local treatment of
   quinsy, i. 160; cases in which the carotid
   artery or a branch was wounded in scari-
   fying the tonsils, i. 160;  difference be-
   tween synovial inflammation and inflam-
   mation of the ligaments,  i. 241; objec-
   tions  to  Marochetti's views respecting
   hydrophobia, i.  414; cases  of hemor-
   rhage during the operation of tapping, iii.
   208.
 Wattmann's treatment of fractured clavicle,
   i. 603; method of replacement of the dis-
   located femur, ii. 239; operation on the
   humerus in anchylosis of  the elbow, iii.
    19.
 Weber's experiments show that the head
  of the thigh-bone is retained in its socket
  by atmospheric pressure, i. 285; of great
  importance in reference to  diseases of the
  hip-joint, i. 285; on  the  production of
  callus, i. 550.
Webster's case of dislocation of the ribs,
  ii. 216.
 Weckert's apparatus for fracture of the
   neck of the femur, i. 624,
 Wkdekind, von, on the treatment of crusta
   lactea, ii. 63.
 Wedemeyer  on the number of times fric-
   tions with ung. hydrarg. may require to
   be  practised in  syphilis, ii.  96;  case in
   which the aneurism  burst  after the liga-
   ture of the  femoral, and amputation was
   performed, ii. 497.
 Weidmann's apparatus for ligaturing com-
   plete rectal  fistula, ii. 169.
 Weilinger on the use of caustic to de-
   stroy the ends  of broken  bone in false
  joints, ii. 17.
 Weinhold on the introduction of the seton
   in false  joints, ii. 20; mercurial  cure in
   syphilis, ii. 98;  cloacae in necrosis, ii.
   127; case of old dislocation of the hu-
   merus, to reduce which the tendon of the
   pectoralis major was divided, ii 226;
   operations  in diseases of the maxillary
  cavity, iii. 485.
Welbank  on  sloughing phagedena, i. 84;
  case of part of a vertebra and rib in  the
  rectum, iii.  108.
Wells', Dr. case of epilepsy consequent on
  fissure of the skull, relieved  by the  tre-
  phine, i. 458; of an  aneurism bursting
  into another artery, ii. 471.
Wend on the treatment of abscesses at the
  hip, i. 298.
Wenzel's  diagnostic  sign  for vertebral
  caries, i. 311; on extirpation ofthe womb,
  iii.  568.
Wernecke's plan for bringing the edges of
  the cleft together  in  staphyloraphy, ii.
  32;  instrument for drawing  the  knots.
  ii.32; operation for considerable narrow-
  ing ofthe mouth, iii. 24.
Wernherr on morbus coxae senilis, i. 289.
West on the  extirpation of the ovary, iii.
  210;  case of extirpation of ovarian cyst,
  iii.  211.
Wetzlar on the formation of urinary cal-
  culi, iii. 237 ; treatment of  uric acid gra-
  vel, iii.  259.
Whately on the use of the armed  bougie
  in stricture  of the urethra, iii. 79 ; cau-
  terizing the  walls of the stricture,  iii. 80;
  use  of bougies armed with caustic pot-
  ash, iii. 80.
White's operation for resection of the ca-
  rious head of the femur in hip disease, i.
  300; case of cure of ununited  fraeture, ii.
   18; compensating collateral branches af-
  ter ligature of the brachial, ii. 532; ope-
  ration for ligature of the internal iliac, ii.
  534 ; seat of stricture in the  rectum, iii.
  46;  case of foreign body in  the vagina, 
936                       ANALYTICAL INDEX.
  the bladder injured, and formation  of a
  calculus, iii. 249; amputation just above
  the ankle, iii. 674; operations for the ex-
  cision of joints, iii. 726; case of excision
  of the  head of the femur, iii. 737; of
  compound dislocation ofthe femur behind
  the leg, iii. 741; of excision ofthe lower
  jaw, iii. 750.
White, C. on sawing off the ends of the
  broken bone in false joint, ii. 18; mode
  ofoperating in excision ofthe head of the
  humerus, iii. 732;  excision of the head
  of the femur, iii. 737.
------'s, Dr. case of almost complete ex-
  tirpation ofthe upper jaw, iii. 754,
White swelling, i. 304.
Whitlow, i. 215.
Wickham on  inflammation ofthe ligaments,
  i. 231; disease ofthe cellular membrane
  of the joints, i. 234; case of synovial in-
  flammation terminating in  ulceration, i.
  239; of trepanning  the spine, i. 590 ; of
  urinary  calculus enclosed  in  a  bag of
  lymph encrusted with calcareous matter,
  iii. 274; of bronchocele, which ultimately
  enlarged, after the ligature ofthe superior
  thyroid, iii. 393.
Wickmann on the existence of the acarus
  scabiei, ii.  67.
Wieseman on cauterizing the tonsils with
  the red-hot iron or caustic, i. 165,
Willan, Dr.  on  eczema rubrum, ii. 109.
Wilhelm on the nature of strangulation in
  rupture, ii. 629; mode of amputating by
  the circular incision, iii. 640.
Williams', Dr.  stimulant  plan of treat-
  ment in simple erysipelas, i. 123; on
  hydriodate  of potash in syphilis, ii.  101.
Williams' experiments and conclusions on
  the condition of the lungs when the chest
  is opened,  i. 482.
Willis,  Dr. on the formation of  urinary
  calculi, iii. "237.
Wilson  on   inflammation  of  cartilage, i.
  254; the ulcerative absorption of carti-
  lage, i.  254;  on  sebaceous tumors, iii,
  436; case of division of a nerve wounded
  in bleeding, iii. 636.
Wilson's, Erasmus, statistical account of
  human  horns, iii. 404; growth of horns
  from a previously obstructed follicle, iii.
  405.
Winslow on increased pressure  and  the
  supine  posture in  the  radical cure of
  hernia, ii. 282.
Winter's, von, case  of reduction  of the
  consecutive dislocation  in  hip-disease,
  i. 297; directions for wounded arteries,
  i. 333.
Wiseman on  incisions  in  carbuncle, i.
   156; immediate amputation in gun-shot
  wounds, i. 380; spina ventosa, iii. 414.
Wolf on twisting round of the patella, ii.
  246.
Wolf's Laud, case of extirpation of  the
  cancerous womb, iii. 569.
Wolff's case of imperforate anus, iii. 34.
Womb, abscess of, i. 532 ; prolapse of, ii.
  369; closure and narrowing of the mouth
  of,  iii. 90;  polypus of, iii. 486 ; cancer
  of, iii, 561 ; extirpation of the neck  of,
  iii. 566;  ofthe whole organ, iii. 569.
Womb,  Changed  direction of,  ii.  406;
  changes of direction to which the womb is
  subject, ii. 407 ; retroversion, ii. 407 ; Dr.
  Rigby on retroversion  in  the unimpreg-
  nated state, ii. 407 ; Dr. Blundell on the
  local  symptoms caused by retroversion,
  ii. 407;  predisposing and  occasional
  causes, ii, 407 ; symptoms of the chronic
  inflammation which precedes retrover-
  sion, ii. 407 ; symptoms of retroversion,
  ii. 408;  Mende on the seeming  retro-
  version at the later periods of pregnancy,
  ii. 408 ; Blundell on partial retention of
  urine  in retroversion, ii. 408 ; Lacroix on
  the nervous symptoms attending sudden
  retroversion,  ii. 409 ;  situation of  the
  womb as ascertained by vaginal examina-
  tion, ii. 409; Rigby on examination by
  the vagina and rectum, and by the uterine
  sound in retroflexion, ii. 409 ; symptoms
  of retroversion,  ii.  410 ;  Rigby on  the
  symptoms of, ii. 410; prognosis, ii. 411;
  Blundell on the prognosis in,  ii.  411;
  treatment, ii. 411; catheterism, ii.  411  ;
  exhibition of enemata, ii.  411; reduction
  of the retroverted  womb, ii. 411;  Bell-
  anger and  Hal pin  on  the  reduction,
  ii. 412; Jourel  and Baynham's cases
  of puncturing the womb in, ii. 412 ;  the
  replacement of the retroverted womb per
  vaginvm  preferable, ii. 413 ; treatment in
  women not pregnant, ii. 413 ; after-treat-
  ment, ii. 414 ; Rigby on  the mechanical
  support to the  womb requisite after re-
  duction, ii. 414; anteversion ofthe womb,
  ii. 414; causes and symptoms, ii.  414;
  Blundell, John  Burns, Boivin, Duges,
  and Gray on anteversion, ii.  415; treat-
  ment, ii. 416 ; Boivin  and Duges' cases
  of spontaneous cure, ii. 416; Godefrey's
  cases cured by  position, ii.  416; antro-
  version of the womb in the unimpregnated
  state, ii.  416; causes, ii. 417; reduction,
  ii. 417 ; Gray on Hull's'utero-abdbminal
  supporter, ii. 417.
Wtomb,  wounds of, i.  529 :—the unimpreg-
  nated womb not easily wounded, i. 529 ;
  danger  of  injury  to  the impregnated
  womb, i. 529; if the wound in the womb
  be so large, that the foetus is partially or 
ANALYTICAL  INDEX.                       937
 wholly in the abdomen, it must be  ex-
 tracted, i. 529 ; Duparque on the fibrous
 and cartilaginous resistance ofthe tissue
 of the womb, i. 529;  Latour and  Du-
 parcque's cases of accumulation of blood
 in the womb, i. 530; Duparcque on rup-
 ture ofthe womb during pregnancy, i. 530;
 Duparcque on the danger and immediate
 treatment of rupture,  i. 530;  Powell's
 case  of  rupture  not fatal, i,  531;   Dr.
 Rigby and Dr. Merrem on wounds ofthe
 uterus as predisposing  to rupture in sub-
 sequent labours, i. 531 ; Birch's case- of
 fatal rupture, subsequently to one previ-
 ously recovered from, i. 531 ;  Merrem's
 explanation of this, i.  531 ; Duparcque
 on partial rupture of, from a collection of
 fluid  in its parietes, i. 532;  Morere and
 Duparcque's cases of abscessof the womb,
 i. 532 ; rupture of the impregnated womb
 from  external violence,  i. 532;  Naegele's
 jun.  case of womb in  the eighth month
 of pregnancy  ruptured  by external  vio-
 lence, i.  532 ; Duparcque on punctures or
 narrow lacerations ofthe  womb, i. 533;
 Planchon's case of fatal  punctured wound,
 i. 533 ; Deneux and Schmucker's cases
 of wounds, i. 533 ; wounds and ruptures
 ofthe vagina, i. 533 ; causes, i. 533 ; con^-
 sequences, i. 533 ; South on rupture of the
 perineum, i. 533.
Wood,  Dr. on  the chemical and microscopie
 characters of pus, i. 46.
Wood,  Kinder, on an  epidemic  vaginal
 catarrh,  i.  182; operation of excising a
 portion of the tunica vaginalis in hydro-
 cele, iii. 225.
Woolaston's, Dr.  C. cases of  gangrene,
 i. 75.
Wormald's operation for varicocele, ii. 329;
Wounds :—definition of, i. 317; varieties of,
 i. 317 ; South on the German distinction
 between incised wounds, i. 318; wounds
 distinguished as simple and'complicated,
 i. 318 ; also according to their direction
 and depth, i. 318; also by the nature of
 the divided parts, i. 318; symptoms, i.
 318 ; consequences of,  i. 318; inflamma-
 tion and sympathetic fever, i. 319;  ner-
 vous symptoms  attending wounds,  and
 their causes, i. 319 ; Hunter and Meckel
 on the three kinds of  union  of divided'
  parts,—quick union, by adhesion, and by
 granulation, i..319;   Hunter on  quick.
 union, i. 319; objected to by  Dr. John
 Thomson, i. 320 ; Astley Cooper on the
 union of wounds, i. 320 ;  Travers on the
 blood as a medium of organized adhesion.
 in, i.  320 ; quick union, i. 320 ; South on
 the meaning of  " quick union,  1.321,
 Hunter on the  adhesive inflammation in
                                      79
connexion with wounds, i. 321 ;. Astley
Cooper on adhesive inflammation, i. 321;
Dr. Bennett and Wharton Jones on  the
process of union by adhesion, i. 321,322 £
Lawrence's objection to the term "inflam-
mation" in reference to  union by adhe-
sion, i. 323; Bennett on the formation of
new vessels, i. 323;  opinions of John
Hunter, Schwann,  Doellinger,. Kalten-
brunner, Pockels, Liston, Travers, Hasse,
Henle, Skoda, and Kolletschka, i. 323;
union by  granulation, i.. 323; nature of
the cicatrix, i. 323 ;  Jbhn Hunter on sup-
puration and. granulation as leading to
cicatrization, i.  324;  Travers  on  the
filling- up a  gaping wound, i. 324;
Bennett on  the process  of  granulation
and cicatrization, i. 325; Wharton Jones
on  healing  by the second intention or
granulation,  i. 326 ; points to be noticed
in the prognosis,  i.  326;  treatment i.
327;  examination  of  wounds,  i. 327;
treatment  of the bleeding, i. 327; mode
of arresting haemorrhage adopted by na-
ture, i. 327; changes in the blood-clot
in the canal  of the artery, i. 327 ; Petit,
Morand, Sharp, Gooch,  Kirkland, Pou-
teau, John Bell, Textor, and Hummel on
the arrest of haemorrhage by nature, i.
329; wounds of arteries  and  their conse-
quences, 329; closure of slight and lon-
gitudinal wounds, i. 329 ; Saviard, Petit,
and Scarpa on the healing of wounds of,
i. 330 ; means of arresting haemorrhage, i.
330; compression, i. 330 ; Ehrlich's com-
pressor, i. 330; the tourniquet,  i.  330;;
different  kinds of  tourniquets,  i.  330;
mode of applying the  tourniquet, i. 331  ;
South on  the application of, i. 331; the
artery-compressors of  Langenbeck, Ver-
dier, Mohrenheim, Dahl, Wegenhausen,
Moore,Graefe, Scultetus, Heister, Dionis,
Plattnen  Brambilla,  Desault, Liber,
Ayres, Bell,Chabert, Lampe, Faulquier,
Schindler, Hesselbach,  and Joachim, i.
331 ; Carlisle's tourniquet, and its mode
of  application, i- 332;  the ring tourni-
quet, i. 332;  Oke's arch tourniquet, i„
332; use  of the compressor cannot  be
persisted in sufficiently long, i. 332 ; treat-
ment of  wounds  after the bleeding has
ceased, i. 332; von Winter's directioi s
for wounded arteries, i.  333; immediate
or direct compression, i.  333; South on
the  treatment of  protracted  oozing of
blood; ii 333 ; pressure on the meningeal
artery inadmissible and  not  requisite, i.
333; Abernethy's case of  wounded me-
ningeal artery*, i. 333; South on the treat-
ment of  epistaxis, i. 334; South  on
wounds-of  the pudic artery, and artery 
93 S
ANALYTICAL  INDEX.
 of the bulb during the lateral operation
 for the stone, i  334 ; South on the treat-
 ment of wounded  arteries  in  the thick
 fleshy parts of  the  hand or foot, i, 334;
 ligature of arteries, i. 335; experiments
 of Jones, Crampton, and  Scarpa on the
 ligature of, i. 335; South's experiment on
 the carotid of a  dog, i. 335 ; difference of
 opinion, as to the action of the ligature, i.
 335; English surgeons so apply the liga-
 ture, as to divide the inner arterial coat, i.
 336 ; Cline's experiment with the broad
 ligature, i. 336; Scarpa's experiment with
 the ligature and cylinder of linen, i. 336;
 Manec, Dupuytren, and Roux on the in-
 troduction of  a  piece of bougie into an
 ossified artery after amputation, i.  336;
 experience in favour of the simple pound
 ligature, i. 336; application of the liga-
 ture, i. 336 ; varieties of forceps for hold-
 ing the artery, i. 336; South on the appli-.
 cation of the ligature, i. 337; treatment of
 a  retracted artery, i* 337 ;  South on the
 ligature of large arteries above and below
 the wound, i. 337; South on the necessity
 for cutting down upon a wounded vessel
 on the sound side of a limb, if nearer the
 3rtery than is the part wounded, i. 338;
 Travers' case of wound of  the posterior
 tibial, i. 338; after-management of the
 ligature, i. 338;  Lawrence, Hennen, Del-
 pech, Walther, Haire, Guthrie, and South
 on the after-management of, i. 338, 339 ;
 Dr.  M'Sweeny on  the  silk-worm  gut
 ligature, i. 339; Physick on the animal
 ligature, i, 339; Astley Cooper on the
 catgut ligature, i. 339; length of time be-
 fore the separation  of a ligature, i. 340;
 Callaway  a^id Guthrie's cases, i.  340;
 severe  pain caused  by attempts to take
 away the ligature, a nerve being included
 in the noose, i.  340;  Chopart's case, i.
 340; Lord Nelson's case, i. 340; second-.
 ary haemorrhage on  the separation ofthe
 ligature,  i.  340;  Green's  case of  se-
 condary-haemorrhage  after ligature of
 the  subclavian,  i. 340; South's opinion
 that the ligature should  be allowed to
 come away, as the result of the suppu-
 tingprocess, i. 340; Seuth on the manage-
 ment of a long-retained  ligature, i. 340;
 torsion or twisting of arteries, i.  341;
 Galen, Amussat,Thierry, Liber,Velpeau,
 Fricke, and  Dieffenbach  on   torsion, i.
 341; changes produced by, i. 341 ; John
 Hunter on the suppression of haemorrhage,
 i. 341; Palmer on torsion, i. 342; Amus-
 sat, Thierry, and Fricke on the mode of
 practising torsion, i. 342; Dieffenbach's
 torsion-forceps, i.  342;  Kluge's torsion-
. apparatus,,i.  342;  advantages  of torsion,
i. 343; Dupuytren, Loreh, Textor, Fricke,
Elston, and Bramberger on the effects of,
i. 343, 344; Dieffenbach, Dupuytren, and
Chelius' objections to, i. 344 ; South on,
i. 344; Feme and Astley Cooper's cases
of accidental torsion, i. 344;  cases in
which torsion is preferable, i. 344; Kohler
and Fricke on the torsion of bony vessels,
i. 344; Stilling  on the interweaving of
arteries, i. 344 ;  use of astringent styp-
tics, i. 345;  effects of  cauterization on
wounded vessels, i. 346; occurrence and
management  of  secondary  haemorrhage,
i. 346; circumstance  favouring  the  oc-
currence  of  secondary haemorrhage, i.
346; Cline's, jun. cases of after-bleeding,
in which the actual cautery was employed,
i. 347; Cline's, jun. clinical observations,
on after-haemorrhage, and on the use of
the actual cautery in such cases, i. 347;
Cline's, jun.  experiments  on arteries, i.
351; South on the treatment of bleeding
ossified  arteries,  i.  352; bleeding from
wounded  veins,  i.  352; indications of
venous  haemorrhage,  i.  352; bleeding
from the smaller veins usually stops of
itself, from the large ones, such as  the
internal jugular, the subclavian, and  the
femoral,is soon fatal, i. 352; compression
usually  employed to  arrest venous hae-
morrhage, the ligature rarely, i. 352; dis-
advantages of the ligature, i. 352; South
on venous bleeding in operations, i. 353;
South's case of  fetal venous  bleeding
during amputation of the breast, i. 353;
Green's case  of ligature of the external
jugular vein,  i. 353; use of the  ligature
by  Celsus, i. 353; Thomas  Gale and
Pare on the use of the ligature for wound-
ed vessels, i. 354, 355; invention ofthe
tenaculum by Bromfield, i. 355; removal
of foreign bodies from wounds, i. 355;
great care required- in doing, so, i. 356;
condition ofthe wound a guide as to the
treatment, whether for quick union, or by
suppuration and- granulation, i. 356;  the
cleaner the wound, the more is it disposed
for quick union, i. 356; slight bruises may
admit of quick union, but those with the
greatest degree of-  bruising and  tearing
do not, i.356; simultaneous injury of the
bone-does not counter-indicate union, i.
356;. deleterious matter in  the wound
counter-indicates union* i. 356; treatment
of-a wound to induce  union, i. 357; Hun-
ter, on the means for  keeping the lips of
a  wound  in  apposition, k 357; position
of the  wounded parts, i.  357;  uniting
bandages, i. 357; application of the band-
age, i. 358; South on the use of bandages
 for wounds,  i. 358; application of stick- 
ANALYTICAL  INDEX.
939
ing-plaster to keep  the lips of wounds
in apposition, i. 358;  Gale on dressing
wounds, i. 358; John Hunter on the use
of sticking-plaster or  the dry suture for
wounds,  i. 359;  Tyrrell  and Liston's
plasters, i. 359; cases in which the suture
should be used, i. 359; J'ohn Hunter on
the use of sutures, i. 360; South on the
advantages and disadvantages of sutures,
i. 360; South on the number of sutures
to be used, and the mode of their applica-
tion^.361; Dieffenbach's thin insect-pins
and the twisted suture, i. 361; varieties
of suture, i. 361; application of the in-
terrupted  suture,  i. 361;  Gale on  the
application of the interrupted suture, i.
362;  the quill suture, i.  362; dressing
the wound after the application of  su-
tures, i.  362;  subsequent treatment, i,
362;  treatment  of a wound  healing by
suppuration and  granulation,  i.  363;
South's objections to  stuffing a wound
which must heal by suppuration, i. 364;
incised wounds, i. 364 ;  longitudinal  and
transverse wound* of tendons,  i. 364;
mode of union of transverse wounds, i.
364;  treatment  of wounded  tendons, i.
364;  Ever's apparatus for  divided  and
ruptured tendons of the hand and fingers,
i. 364 ; effects of the division of a large
nerve, i. 361; South on the regeneration
of nerves, and- the recovery of their funo-
tion after division,  i.  364;  Haighton's
experiments on  the division  of both
pneumo-gastric nerves, i. 365; Meyer on
the application of nitric acid to the  scar
of nerves, i. 365;  Larrey on the  union
of the nerves of a stump in loops, i. 365;
treatment of  flap wounds, i.  365"; re-
union of separated parts, i.,365; punctured
wounds, i. 366; definition, i. 366; treat-
ment, i. 366;  punctured wounds of parts
of tough structure, or surrounded by un-
yielding aponeuroses, i. 367; punctures
of tendons, ii 367; of nerves, i. 367;
treatment of punctured wounds of nerves,
i. 367;  of punctured vessels* i. 367; en-
largement of a  punctured  wound  only
necessary for the removal of"foreign bo-
dies, to arrest hemorrhage, or to relieve
strangulation in parts of an unyielding
texture, i. 367; the introduction of a seton
to be practised  only  when  the walls of
this fistulous-passage are callous, i. 367;
lacerated  and contused wounds, i.  367;
definition and  character, i, 367;  union
to be attempted only  in wounds without
much bruising or tearing, i. 368; gene-
rally heal by suppuration  and granula-
tion, i. 368; treatment, i. 368; removal
of foreign bodies, i. 368;  South  on the
tearing or stripping down of large pieces
of skin, i. 368;  South on torn  wounds
of the scalp, i. 368; South on the slough-
ing which  generally follows extensive
laceration of the skin of the limbs, i.
368; bruises with-extravasationof blood,
i.  369; treatment,  i.  369;  if  a large
artery be wounded, it may be necessary
to expose it, and take it up, i. 369; if
suppuration  take plaee in the swelling,
it must be treated as an abscess, i. 369;
South on extensive ecchymosis, and the
means  of diagnosis, when an artery of
any material  size is wounded, i.  369;
treatment of the swelling, i. 369; danger
of gangrene  when  a   large artery has
been wounded, from the distention of the
soft  parts,  i. 369; gun-shot wounds, i.
369; definition,  L  370; John Hunter
on gun-shot wounds, i. 370; Dupuytren
on the  effects of gun-shot, i.  370;  Du-
puytren's case of a person killed  by a
gun  loaded  with powder only, i.  371;
South's cases of severe injury from small
shot, i. 371; pain  and haemorrhage at-
tendant on a gun-shot-wound, i. 371; form
of the  wound, i, 372; shock from the
wound, i. 372; subsequent symptoms, i.
372; Guthrie on  the pain  attending gun-
shot wounds, i. 372; Guthrie  on the at-
tendant haemorrhage, i. 372; Guthrie and
Hennen on tire shock caused by a gun-
shot wound, i. 372, 373^;  Hunter on the
character of gun-shot wounds, i. 373; H.
Larrey's cases of regular-shaped'gun-shot
wounds, i. 373;  direction of the shot, i.
373; general kinds of injury from shot
wounds, i. 374;  division  of shot wounds
into simple and complicated, i. 374; Rust
and' Busch*s explanation of wounds from
the wind of the  ball, i. 374; Hennen on
severe bruising from shot, i. 374; Guthrie
on the appearances caused by the passage
of a ball, i. 374; Dr. Thompson and Du-
puytren on the splitting of the ball by the
sharp edge of a bone, i. 374,375; Guthrie
 on the resistance offered to the passage of
the ball by bone or an  elastic body, L 375;
 shot wounds generally  complicated by
 foreign  bodies  in their  cavity. i.  375;
 prognosis, i. 375; indications of treatment,
 i. 375-;  circumstances under which the
 enlargement- of the wound1 may be neces-
 sary, i. 375*; Hennenon the treatment  of
 wounds by a ball in the fleshy part of the
 arm, thigh,  or  buttock,  i.  376; general
 and'local treatment, i. 376; occurrence  of
 suppuration, l 376; of secondary haemor-
 rhage, i. 376; Guthrie, Samuel Cooper,
 and1 Dupuytren on. secondary haemor-
 rhage, i. 376, 377; local and general treat- 
940
ANALYTICAL INDEX.
 mentduring the suppuration, i. 377; Hen-
 nen and Dr. Arthur on the use of the seton
 to bring away separated pieces of bone, i.
 377; Staff-Surgeon Boggie's cases,i. 377;
 treatment of shot wound complicated with j
 fracture, i. 377;  Hennen  on the occur-)
 rence of necrosis -in gun-shot injuries of |
 bones, i. 378; bleeding from the whole!
 surface of the wound in long-continued |
 suppuration, i. 378; the circumstances in
 gun-shot wounds requiring amputation on
 the spot, i. 378; Hennen on the nature of
 the injuries in gun-shot wounds requiring
 amputation, i. 379; amputation,under the
 circumstances mentioned, should be per-
 formed early, i 380; Wiseman, Le Dran, I
 and Ranby on immediate  amputation, i.|
 380;  Faure  on  the  propriety of delay-j
 ing the operation, i. 381; Bilguer's  ob-
jections to amputation altogether, i. 381;
 Hunter's objections to primary amputa-
 tion, i. 381; Hennen, Pitcairn, Gunning,
and Guthrie  on  immediate amputation,]
 i. 381; Guthrie's reasons for an early per-
 formance ofthe operation,  i. 382; symp-|
 toms which may require the performance
 of amputation at a time more or less pos-
 terior to the  date of the injury, i. 383;
poisoned wounds, i. 383; definition, i.
384;  dissection-wounds, i. 384; symp-
toms and treatment, i. 384 ; cause of  the
symptoms after injuries in dissection, i.l
 384;  South objects  to the application of]
caustic  in dissection-wounds,  i.  385;
J.  Shaw on  dissection-wounds and their
treatment,  i. 385;  Basedow considers
dissection-wounds agree with malignant
pustule, i. 385; South and Lawrence on
the absorption of poisonous matter in dis- j
section-wounds,  i. 385; details  of Dr.
 Pen's  case, i. 386; South on the  mosti
dangerous punctures,  those received in!
cases  of simple or puerperal peritonitis, i.
386;  South on the consequences of dis-
section-wounds, i. 386; stings of bees,
wasps, &c, i. 387; Dr. Gibson and Law-
rence  on the fatal effects of the stings of
bees and  wasps,  i. 387; Dr. Moseiey's
case of  scorpion-sting, i.  387;  Allan,
 Curling, Kirby,and Spence on theeffects
ofthe scorpion-sting, i. 387; bites of  the1
gnat, mosquito, harvest bug, bete-rouge,
and American tick, i. 388 ;- Dr.. Moseley
on the chigoe, i. 388;  symptoms follow-
ing the bite of a viper, i. 389; local and
 general treatment, i. 389 ;  Pennock and ,
 Rodrigues on the  effects  of cupping-
 glasses in viper-bites, i. 389;  Fontana on{
 the effects of viper-bites, i. 389; Vincent's I
 case,  i. 389; South  on viper-bites, and
 their  treatment*, i.  389*; ©r. Mead  on.
 viper's fat a local remedy in viper's bite,
 i. 390; Celsus, Astley Cooper, and Home
 on the application of a ligature above the
 bite, i. 390; suction of venomous bites,
 i. 390;  Celsus' observation on the inno-
 cuous qualities of the poison of serpents
 when introduced into the  mouth, con-
 firmed by Russel,  i. 390;  Dr.  Mead's
 case of the bite of a rattlesnake, i. 390;
 Sir David Barry on  the application  of
 the cupping-glass  over  snake-bites,  i.
 391; Dr. Mead's  experiments on viper-
 poison,  i.  391 ;  snake-bites and their
 treatment, i.  391;  Dr. Barton  on the
 symptoms produced by the bite of the
 rattlesnake, i.  392;  Professor Owen's
 case of viper's bite, i. 392; Home's case
 of  bite of the rattlesnake, i. 392; Dr.
 Russell on the symptoms produced by
 the bite  of a cobra de capello, i. 394;
 Russell's  eases  of  fatal  snake-bite,  i.
 395 ; Barton  on the treatment of  rattle-
 snake-bites, i  395; Russell on the treat-
 ment of snake-bites injlndia with theTan-
jore pill, i. 395; Ireland  on  the  use  of
 arsenic in the bites  of the great lance-
 headed viper of Martinique, i. 396 ; Rus-
 sell on the physical qualities of snake-poi-
 son, i. 396; Barton on the employment of
 the ligature in snake-bites, i. 396; bite  of
 a rabid  beast, 396;  bite of beasts much
 excited, or when disturbed during copula-
 tion, may produce canine madness, i. 397;
cause of dog-madness, i. 397; spontaneous
 development of hydrophobia in man,i.397;
 signs of incipient madness in the dog, i.
 397; Hertwig on canine madness, i. 397;
 progress of the disease, i.  398; signs  of
 dumb-madness in the dog, i. 398; Youatt
 on rabies in the dog, i, 398; Youatt on
 the peculiar bark of the mad-dog, i. 399;
 Youatt on the saliva of the mad-dog, i.
 400; Youatt on the condition of the lum-
 bar portion of the spinal cord in rabies,
and dumb-madness in the dog, i. 400;
 Youatt  on a  peculiar paralysis of the
muscles of the tongue and jaws occasion-
ally  occurring in  mad  dogs, i.  400;
 Youatt  on the insensibility to pain  in
 mad- dogs, i. 400; Youatt on the diagnosis
 between pain in the ear in canker and  in
 hydrophobia in the dog, i. 401; Youatt
 on the  period of incubation  of rabies  in
 the dog, i. 401;  Hertwig's  experiments
 show that the saliva is the vehicle ofthe
 mad poison, i. 401; Trolliet considers the
 mucus from the  inflamed  mucous mem-
 brane of the  bronchi  the vehicle  of the
 poison,  i. 401; Hertwig's  experiments
 also show the  contagion  to be  in the
 blood of the mad beast, i. 401;  Youatt 
ANALYTICAL INDEX.
941
  excision, i. 411; South on excision of the
  scar,  i.  412; internal  prophylactics of
  hydrophobia, i.  412; plan of treatment
  recommended by Wendl, i. 412; Brera
  and  von Schallein's treatment,  i. 412;
  Marochetti on the presence of pustules
  under the tongue after the bite of a  mad
  animal, i. 413; Marochetti's plan  oftreat-
  ment, i. 413;  Watson's objections to Ma-
  rochetti's views, i. 414;  general treat-
  ment, i. 414.
Wright, Dr.  on  ligature of the  external
  iliac, ii. 538;  case in which he performed
  the operation of lithectasy, iii. 376.
Wright on  amputation  just  above  the
  ankle,  iii. 674.
Wrist, fracture  ofthe bones of, i. 615; dis-
  location of, ii. 232; exarticulation of the
  hand at, iii. 721; excision of, iii. 734.
Wry neck,  ii. 421.
Wutzer on the use of the suture in vesico-
  vaginal fistula, ii.  192; puncture of the
  bladder above the pubes after this opera-
  tion, ii. 194;  after-treatment, ii.  195; on
  congenital  dislocation  of the knee, ii.
  248;  modification  of Gerdy's operation
  for the radical cure of rupture, ii. 284.
  excision, i. 411; South on excision of the
  scar,  i.  412; internal  prophylactics of
  hydrophobia, i.  412; plan of treatment
  recommended by Wendl, i. 412; Brera
  and  von Schallein's treatment,  i. 412;
  Marochetti on the presence of pustules
  under the tongue after the bite of a  mad
  animal, i. 413; Marochetti's plan  oftreat-
  ment, i. 413;  Watson's objections to Ma-
  rochetti's views, i. 414;  general treat-
  ment, i. 414.
Wright, Dr.  on  ligature of the  external
  iliac, ii. 538;  case in which he performed
  the operation of lithectasy, iii. 376.
Wright on  amputation  just  above  the
  ankle,  iii. 674.
Wrist, fracture  ofthe bones of, i. 615; dis-
  location of, ii. 232; exarticulation of the
  hand at, iii. 721; excision of, iii. 734.
Wry neck,  ii. 421.
Wutzer on the use of the suture in vesico-
  vaginal fistula, ii.  192; puncture of the
  bladder above the pubes after this opera-
  tion, ii. 194;  after-treatment, ii.  195; on
  congenital  dislocation  of the knee, ii.
  248;  modification  of Gerdy's operation
  for the radical cure of rupture, ii. 284.

Youatt on rabies in the dog, i.  398; on the
  peculiar bark of the mad dog, i.  399 ; on
  the saliva of the mad dog, i. 400 ; on the
  condition of  the lumbar portion of  the
  spinal cord in rabies and dumb madness
  in the dog, i. 400; on a peculiar paralysis
  of the muscles  of the tongue and jaws
  occasionally  occurring in mad  dogs, i.
  400; on the insensibility to pain, i. 400;
  on the diagnosis between pain in the ear
  in canker and in hydrophobia in dogs, i.
  401 ; on the period of incubation of rabies
  in the dog, i. 401; on the appearances on
  dissection, i. 401;  caution against suffer-
  ing dogs to lick  the face or hands, or any
  other part  of the  body, i. 403; on the
  peculiar delirium in hydrophobia, i. 407;
  on the tenacity  of  the  human saliva in
  hydrophobia, i.  407;  objections to the
  excision of the bitten parts, i. 410.
Young, Dr., on the genus carcinoma, iii.
  455.
on the appearances on  dissection in the
doof, i.  401 ;  Yrouatt's  caution  against
suffering dogs to lick the face, or hands,
or any other part of the body,  i. 403;
Lawrence's details  of  the  Hon.  Mrs.
Duff's case,  i. 403; Lawrence on the
communication of hydrophobia from  one
human being to another, or from man to
beasts, i. 403;'Magendie and Breschet's
experiment, i. 403 ; period of incubation
of hydrophobia in man, i. 403;  Galen,
Mead, and Hale Thomson  on the  pro-
tracted period  of incubation of hydro-
phobia, i. 404; Dr. Bardsley's case of the
disease twelve years after the bite had
been inflicted, i. 404;  his opinion that the
disease was not hydrophobia, i. 404; sup-
ports his view by the  opinions of Darwin,
Haygarth, and R. Pearson, i. 404; Elliot-
son on the period of incubation, i. 404 ;
Dick on the nature of the disease in  hy-
drophobia, i. 405; symptoms of incipient
hydrophobia, i. 405;  Urban's  opinion
that there is a  circlet of small vesicles
around the wound or scar, i. 405;  general
symptoms, i. 406; Elliotson on the symp-
toms of, i. 406 ; Elliotson on the  diagno-
sis between true and  spurious hydropho-
bia, and inflammation of the pharynx, i.
406; disposition of hydrophobic patients
to bite doubted by South, i. 406; Powell
and Magendie's cases, i. 407; Cline, jun.
on the dispositionof hydrophobic animals
to use their weapons of offence, i. 407;
Elliotson on a general morbid irritability
in hydrophobia, i. 407;  Youatt on the
peculiar delirium in, i. 407; Bardsley
and Babington's cases, illustrative of this
delirium, i. 407; Lawrence on the pecu-
liar delirium  of  hydrophobia, i.  407;
Youatt on the tenacity of the  human
saliva in, i. 407; Elliotson on the dura-
tion of the disease, i. 407; Mead on the
increase of muscular strength in hydro-
phobia, i. 408; Elliotson on abortive hy-
drophobia,  i. 408; Dr.  Bardsley on the
stages of hydrophobia, i. 408 ;  Marcet,
Babington, and Callisen on the premoni-
tory pains of, i. 408; post-mortem appear-
ances, i. 409; Locher on vesicles of the
spleen in hydrophobia in dogs, i.  409; the
post-mortem  appearances in  Elliotson's
case,  i. 409;  proximate cause,  i. 409;
Harder on the action  of  the poison on
the system, i. 409; Langenbeck on hydro-
phobia as caused by a qualitative altera-
tion of  the Wood by the poison, i. 410;
prognosis,  i.  410; treatment of the bite,
i.  410; Youatt*s objections, to excision of
the bitten  parts, i. 410;  South  on ex-
cision, i. 411;  Cline's directions for the
Young  on compression  in scirrhus,  iii.
  511.
Zang on laying open a cold abscess  lon-
  gitudinally, i. 105; on the more general
  application of the trephine, i.  454; on
  suture of urethral fistula, ii.  178 ; on the
  treatment of recto-urethral and recto-vesi-
  cal fistulae, ii. 185; on  ligature of the
  common carotid, ii. 509 ; mode of ampu- 
942
ANALYTICAL  INDEX.
  tating the thigh with the flap from the
  inner side, iii. 660.
Zeiss on the introduction of'charpie under
  the edge of the nail, and on the use  of
  foot-baths in treating ingrowing of the
  nail, i. 223 ; on the operation for removing
  the diseased nail, i. 223; case of ligature
  of the carotid, ii. 508.
Zeller's operation for united fingers and
  toes, iii. 17.
Zembsch's opinion on the lymph-swelling,
  i. 61.
Zimmermann on the elimination  of the
  molecular fibrin, i. 43.
Zink on the situation and direction of sco-
  liosis, ii. 433.
Zittmann's decoction in the treatment  of
  syphilis, ii. 100 ; formula for it, ii. 100;
  mode of employing it, ii. 100.
THE END. 
 
 
i MAY 20  1960