t
xy
oi

Been
aes
Peay
eS
pate

RSG
i
eee
oh
5:

 

paitese e
ai
ce
st tesest ages
: ae
o

_

5 esinhebeatasea 2
saat x
SHS ‘ a 3 ar at

a

af
3

i>
a

eee
egies
See

+
Seid

 
33
Dey

_ |

 

 

Cornell Mniversity Library

BOUGHT WITH THE INCOME
FROM THE

SAGE ENDOWMENT FUND

THE GIFT OF
Henry W. Sane

1891

Avauaa 5/7/92

 

 

L l

 
6 GORCTLL

 

All books are saber to recall after two weeks.
Olin/Kroch Library

DATE DUE

GAYLORD PRINTED IN U.S.A

 

 

 

i ao i ihaaralty Library
RD 33.D!

of the vascular s'

‘Wit il

 

                            

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

olin
AGE |

PEGE

Dirt e

aia

THE

SOCIETY

SYDENHAM

INSTITUTED

CCXULIIL

MEDC

ots

 

LONDON

MDCCCLIV.
aie ne
Pee Thee
yor Re
ON

LESIONS OF THE VASCULAR SYSTEM,
DISEASES OF THE RECTUM,

AND OTHER

SURGICAL COMPLAINTS,

BEING SELECTIONS FROM THE

COLLECTED EDITION OF THE CLINICAL LECTURES

OF

BARON DUPUYTREN

SURGEON-IN-CHIEF TO THE HOTEL-DIEU AT PARIS.

TNANSLATED AND EDITED BY

F. LE GROS CLARK

SURGEON TO, AND LECTURER GN SURGICAL ANATOMY AT,
ST. THOMAS'S HOSPITAL.

LONDON :

PRINTED FOR THE SYDENHAM SOCIETY.

MDCCCLIV.
A. 49% 02-

PRINTEL BY 0. E. ADLARI,
BARTHOLOMEW CLOSE.

aN
PREFACE.

SuHortiy after the appearance of the former Volume of
the ‘Legons Orales’ of Professor Dupuytren, which I had
the honour of editing for the Sydenham Society, the Council
proposed to me to continue the Translation ; and a Report
was accordingly submitted to them, embodying a classified
arrangement of the contents of the remaining Volumes.
A considerable time, however, elapsed before the decision
of the Council was definitively communicated to me; and the
restricted leisure now at my command has further delayed
the appearance of the present Volume, and somewhat cur-
tailed it of its proposed dimensions. Indeed, I may add
that I have exercised the discretionary power entrusted to
me, in omitting certain articles and substituting others, be-
lieving that I should, thereby, render my contribution more
generally acceptable to the Members of the Society.

As on the former occasion, I have deviated so far from the
original text as the abridgment of details and an uniform
style required.

The practical utility and tested applicability of the

doctrines taught by an acute observer of such rare experience
a
vi PREFACE,

as M. Dupuytren, impart a peculiar value to his writings:
the reader’ must not be surprised, therefore, if he occasionally
discover, in perusing this Volume, that the opinions and
practice advocated by more recent Authors have been antici-

pated by the great French Professor.
F. 1. GC.

Sprinc GARDENS;
London, 1854,
TABLE OF CONTENTS,

PART I.

ON LESIONS OF THE VASCULAR SYSTEM.

SECTION TI.

PAGE -

 

Of Aneurism complicating Tractures and Fire-arm Wounds, and their Treat-
ment . ‘ ¥ ‘ y i ‘ 1
SECTION II.
On Symptomatic Gangrene, consequent on Arteritis  . 3 ounkag!. BG
SECTION III.
On Ligature of the principal Arterial Trunks . Z : : - 28
SECTION TV.
On False Aneurism of the Brachial Artery, and Varicose Aneurism.. » 78
SECTION V.
On Varices of the Lower Extremities, and Varicocele; their Causes and
Treatment é < : ‘ , 3 . 95
SECTION VI.
On Wounds of the Heart, their Causes, Symptoms, and Treatment « 105
PART II.
ON DISEASES OF THE RECTUM.
SECTION I.
On the Excision of Hemorrhoids 3 ‘ : : . 119
. SECTION II.
On Prolapse of the Rectum ° - 3 : . 139
SECTION III.
On Fissure of the Anus : F 148
SECTION IV.
155

On Stricture of the Rectum
vill CONTENTS.

PART ITI.

MISCELLANEOUS.

SECTION I.

On Congenital Hare-lip, with Remarks on the proper period of operating ;
and on Accidental Hare-lip ‘ ‘ ‘ A -

SECTION ITI.
On Ranula, and its Treatment -
SECTION III.

On the Introduction of Foreign Bodies into the Air-tubes and the Csophagus,
and the Treatment of these Accidents

SECTION IY.

On the Treatment of Goitre by the Seton : :
SECTION V.

On permanent Contraction of the Fingers, and its Causes

8

SECTION VI.

On the Growth of the Toe-nail into the Flesh
SECTION VII.

On Traumatic Emphysema.—Emphysema arising from Fracture of the Ribs,
and from Laceration of the Lungs and the Pleura

SECTION VIII.
On Nervous Delirium . . oS
SECTION 1X.
On Abscess of the Right Iliac Fossa =
SECTION X.
On Central Laceration of the Perineeum during Parturition, and the Birth of
the Child by the Rent .

SECTION XI.
On Vital and Mechanical Dilatation of the Urethra

SECTION XII.

On Hydrocele, and its principal varieties

SECTION XIII.

On a particular sort of Fibro-cellular Encysted Tumour, known by the name of
Nervous Ganglions or Tubercles : 5 “!

INDEX

PAGE

192

215

220

241

280

294

324

336

361
371
“

PART TL.

LESIONS OF THE VASCULAR SYSTEM:

SECTION I.
-
OF ANEURISM COMPLICATING FRACTURES, AND FIRE-
ARM WOUNDS, AND THEIR TREATMENT.

Tue affection of which I am about to treat in the present
chapter is one of not infrequent occurrence, and consists
in the accompaniment of a fracture or fire-arm wound by
laceration of a principal artery and extravasation of blood,
possessing the characters of an aneurismal tumour. This
serious complication not only compromises the existence of
the limb, but threatens the life of the patient ; and, according
to the practice hitherto adopted, offers but one of two alterna-
tives,—the sacrifice of the injured member by amputation,
with all its attendant risks,—or the death of the sufferer.
These disastrous results, it has appeared to me, ought not
necessarily to be consequent on the complication in question ;
and I now propose to point out how they may be avoided, by
a plan of treatment at once more gentle and more sure.

There is a system of vessels which spring from the heart
and terminate in various parts of the system. Their texture
is fibrous, thick, and elastic, and their function is to distribute

1 This memoir was read. before the Royal Apeney of Sciences, in 1825; it is
published entire in the ‘ Lecons Orales.’

Sy 1
2 ANEURISM COMPLICATING FRACTURES,

a fluid, suited, by the process of respiration, to stimulate and
nourish the structures it supplies: I speak of the arteries
and the arterial blood. As long as a healthy equilibrium is
maintained between the circulating force and the powers of
resistance in the vascular system, the impulse of the heart
suffices to propel the blood with momentum enough to dilate
and call into play the elastic property of the arteries; but it
is incapable of rupturing these vessels, and thereby of pro-
ducing a fatal effusion of blood. Disturbance of the equili-
brium alluded to is the rife cause of a multitude of disorders
in the animal economy, which, sooner or later, prove fatal ;
more speedily, no doubt, where the heart is- the seat of the
diseased action, but scarcely less surely where the arteries are
affected.

Thus, when an artery has lost its tone from some cause or
other, and yields at any given part of its course to the impulse
of the heart, which propels the blood with undue force, a
sangifineous tumour is speedily formed; and this augments
with varying rapidity ; and, when it bursts, almost inevitably
entails a fatal hemorrhage. Again, if an artery is wounded,
and the blood poured out around the seat of injury, the
tumour which ensues is as likely to prove mortal as in the
former case.

The causes of these diseases are numerous and varying. It
is unnecessary to enumerate all of these, as it is my especial
object to confine myself at present to two which have been
almost overlooked by writers, viz., fractures and wounds from
fire-arms.

It is easy to conceive how the fragments of a broken bone,
or a cannon-ball or other similar projectile, may give rise to
the formation of an aneurism, by slowly altering or at once
destroying the walls of an artery; and, in reflecting on the
frequency of these accidents, it would seem to be a natural
inference that this form of aneurism would be by no means
rare. Yet there is scarcely a single instance on record;
proving that either these cases are really rare, or that the
attention of observers has not been directed to them. The
only example, indeed, which I have been able to find in
ancient or modern literature on the subject, is the following
one by J. L. Petit.
AND FIRE-ARM WOUNDS. 3

Case I.—Fracture of the Leg. Division of the artery by a
fragment of the tibia—* In a fracture of the leg, without any
external wound, I saw the artery which passes between the two
bones (doubtless the anterior tibial) laid open by the sharp
edge of the broken tibia. Ecchymosis spread itself over the
whole leg and foot; the part became cold and discoloured,
and appeared gangrenous. I laid open the leg by an incision of
about six inches in length, extending above and below the frac-
ture, and discovering the open vessel, arrested the hemorrhage
without displacing the bones; the case was then treated as
an ordinary compound fracture. In order to command the
bleedings effectually, it is essential to bring into view the
bleeding vessel, that immediate compression, the ligature, or
styptics, may be successfully employed. These are the three
resources at our command, by which to suppress hemorrhage.’”

Though writers on the subject, since the time of Petit,
have not failed to enumerate aneurism as amongst the casual-
ties which may result from fracture, not one of them has
cited a fresh example of this serious complication. Even in
M. Boyer’s work on surgery, the only instance mentioned is
one with which I furnished him some fifteen years since.

I anticipated, at the least, being able to meet with some
such cases in works on gun-shot wounds; but here, like-
wise, both in ancient and modern literature, I have been
equally disappointed.

Yet, for all this deficiency, the cases are far from rare, I
have witnessed as many as seven since 1806; and I have no
doubt, now attention has been awakened to the subject, that
many more cases will be observed and recorded. It may be
that practioners have overlooked this serious complication of
fractures and gun-shot wounds, because they regarded it as be-
yond the ordinary resources of art to cure. Be that as it may,
the universal recommendation is to amputate in such cases.
Such is the practice I have witnessed in several instances,

_which were treated by a very able and experienced surgeon.
The following are examples in point.

.

1 Traité des Maladies des Os; Paris, 1736, tome ii, p. 46. It is not stated
whether the tumour in question pulsated, or what means were resorted to for arresting
the bleeding in this case. The application of a ligature on the femoral artery would
have been a more appropriate course here.

*
4 ANEURISM COMPLICATING FRACTU RES,

Case Il.—Fracture of the Leg, followed by extravasation
of arterial blood. Amputation.—Jacques Picard, aged 61, of
sanguineous temperament, was admitted into the Hétel-Dieu
for an accident which occurred thus, Whilst driving a coach,
he was thrown beneath the wheels, one of which passed over
both of his legs near the ankles. The left leg was found to
have suffered a simple fracture; but the swelling was already
too great to put the limb in splints, therefore an evaporating
lotion was applied.

The swelling was greater on the following day; and the
right leg was also swollen and discoloured near to the ankle.
Emollient applications were now substituted, and continued
for twelve days. Suppuration then took place over the right
foot and lower part of the leg, and the matter was evacuated.

After the lapse of a few more days, the swelling of the left
leg the while increasing, fluctuation became manifest here
also; the left limb was going on favorably. At the close of
the third week, the surgeon-in-chief was tempted to make
an incision into the fluctuating tumour of the right or frac-
tured leg; but instead of an abundance of pus, only a very
small quantity escaped, together with abundance of clots,
followed very speedily by the discharge of florid, arterial
blood. The femoral artery was compressed at the groin,
by which the hemorrhage was arrested; and amputation was
immediately decided upon. This was forthwith performed
above the knee, the swelling having already included that
joint. The patient made a slow recovery, the bone pro-
truding and requiring resection, some time after the primary
amputation.

On examination of the limb, large quantities of clotted
blood were found distributed amongst the muscles on the
back of the leg, and the arteries were found to be ossified
throughout; but, though the limb was successfully injected,
the exact source whence the extravasated blood was derived
could not be discovered. In the following case this was more
evident. ~

Casr III.—Fracture of the leg, accompanied by extravasa-
tion of blood. Amputation,—Claude-Gérard Calaz, aged 55,
of small stature and feeble power, having the legs: bowed
AND FIRE-ARM WOUNDS. 5

forwards, was thrown from a ladder, and broke his left leg,
in 1806. When brought to the hospital, it was evident that
the left tibia was fractured very obliquely below its upper
third, the upper fragment threatening to penetrate the skin.
The limb was placed in a favorable condition and position,
and for the first week all went on satisfactorily and as usual,
with the exception of a considerable tendency to riding of the
fractured extremities of the tibia, attributable, apparently, to
the curvature of the bones. But towards the end of a fortnight,
the patient began to complain of pains in the calf of the leg,
which he ascribed to the tightness of the bandages, and expe-
rienced relief when they were slackened. After the lapse of a
few days, however, the same suffering returned ; but, when the
limb was examined towards the close of the month, there was
no appearance to account for this continued pain. It went
on increasing, nevertheless; and in the course of a few days
afterwards, swelling, accompanied by tension and a blueish ap-
pearance, was evident about the middle of theleg. On further
examination, a sort of tremulous movement, increasing and
diminishing alternately, became perceptible, such as might have
been taken for the pulsation at the ends of the fingers ; this was
observed on the front as well as the back part of the leg. This
swelling, moreover, was observed to diminish a little in volume,
and to lose its regular pulsating character, when the popliteal
artery was compressed; but all the signs above enumerated
were restored when the compression was removed from the
artery,—circumstances which left little doubt as to the true
nature of the tumour. On prosecuting the examination, the
popliteal artery was found to be sound; the inference, there-
fore, was, that the aneurism was associated with one of the
arteries of the leg. It was evident that death must ensue
unless some decided step were taken to save the patient; and
the alternative of amputating or placing a ligature on the
femoral artery held out but little hope, in consequence of his
bad constitution and enfeebled state.

The fracture, however, appeared to be almost entirely con-
solidated, and so the apparatus was removed; but in less than
four hours the rapid extension of the swelling determined the
question in favour of immediate amputation, preparatory to
which an incision into the leg cleared up any remaining donbt
6 ANEURISM COMPLICATING FRACTURES,

on the subject, by giving exit, first to some dark, infiltrated.
blood; and subsequently to a bright arterial stream. The
operation was performed through the thigh, and by a circular
flap. The patient went on favorably for a time, till he was
attacked by pneumonia, under which he sank and died.

Examination of the amputated limb.—A careful dissection
was made, and the aneurismal sac exposed; the soleus muscle
formed its superficial boundary, and laterally it was limited by
the deep layer of muscles of the leg. It projected anteriorly
through the lacerated interosseous ligament, opposite the seat
of fracture, so as to press forwards the anterior muscles of the
leg. It was filled with solid clots. The source whence the
extravasation proceeded was found to be an irregular, lacerated
opening in the perineal artery, caused by the sharp fragments
of the broken fibula having penetrated it. This vessel was
pervious as far as the seat of injury; but entirely obliterated
below it. The tibia was firmly united; and a longitudinal
fracture was observed extending upwards from the point where
it had been broken across.

Casz IV.—-Fracture of. the leg, with wound of the anterior
tibial artery ; terminating fatally—Antoine Dagomet, aged 30,
a cooper, was admitted into the Hétel-Dieu in 1809. He had
fallen down some stairs and fractured his left leg. The
tibia was broken about its middle, and not much displaced ;
the fibula had given way near the ankle, and its upper frag-
ment projected through the skin. The leg was already, on
his admission, very much swollen.

The fracture was reduced, much blood escaping by the
wound: a suitable apparatus was applied, the wound being left
free, to allow the extravasated blood to escape. The next day
the apparatus was saturated, and yet the limb was more
swollen and tense than on the previous evening. He was bled
from the arm.

Each day a large quantity of clots came away ; suppu-
ration set in, and in the course of a fortnight was abundant
and of a bad character. An abscess formed on the inner side
of the leg, which was opened, and pus with decomposed blood
evacuated. The accompanying constitutional disturbance was
considerable, and the patient’s powers daily diminished.
AND FIRE-ARM WOUNDS. 7

Days and weeks passed by, until between two and three
months had elapsed, the patient continuing to lose blood: the
limb was then examined, and the fracture found to be united,
some loose fragments of bone having separated. His general
health was also improving, when suddenly a profuse hemorrhage
occurred, accompanied by excessive distension of the leg. The
surgeon-in-chief had only just time to compress the femoral
artery, and to make an incision along the leg, to try if the
introduction of lint would arrest the bleeding. It, however,
returned on the following day ; amputation was performed, and
the man died seventeen days afterwards.

An examination of the limb showed the anterior tibial
artery opened in five or six places. Both fractures were
united.

I have here narrated three cases of aneurism or extravasa-
tion of arterial blood, consequent on fracture, and in which it
was thought there was no alternative but amputation of the
limb. Nevertheless, this mutilating operation was successful
in one only of the three cases. It would, therefore, seem
that, apart from the maiming nature of the remedy here
adopted, the danger of the operation itself is another and
grave reason for avoiding it if possible; for, even in favorable
cases, scarcely less than a fourth part of all amputations of the
limbs terminate fatally.

We should never lose sight of the importance of preserving
whilst we are curing,—a principle which is well illustrated in
the history of the treatment of aneurisms. These cases were
formerly allowed to run their course and terminate by fatal
hemorrhage; or amputation was practised, whereby the patient
was not only subjected to a distressing mutilation, but was
exposed to all the additional risks attaching to the operation
itself.

The discovery of the circulation by Harvey, and the employ-
ment of the ligature to arrest hemorrhage by Ambroise Paré,
afforded the necessary information, and its application in the
cure of aneurisms; and this speedily led to the substitution of
the ligature for amputation in the treatment of this disease.
It seems, therefore, strange, that the peculiar form of aneurism
of which I am now treating, should be regarded as curable
only by amputation. As a reference to facts alone can prove
8 ANEURISM COMPLICATING FRACTURES,

the validity of this conclusion, I proceed to narrate some cases
in point.

Cast V.—Fracture of the leg, accompanied by wound of one
of the arteries—Marthe Marie Barbe, a female, aged 62, of
spare habit, but enjoying pretty good health, slipped and fell
whilst running in the street, in January 1809. She felt pain,
and was conscious of a snap at the lower part of her leg at the
time of the accident. On the following day she was brought to
the Hétel-Dieu, and I at once detected that both bones of the
leg were broken at the junction of the middle and inferior
thirds. The fracture was oblique, and accompanied by dis-
placement of the fragments forwards and backwards: there
was likewise great swelling and tension of the surrounding
soft parts. On attempting the reduction, I felt at the back
part of the leg, in the calf, diffused but strong pulsation, dis-
tinct to the eye as well as to the touch, and synchronous with
the heart’s action: this was controlled when pressure was made
on the femoral artery, but returned as soon as it was removed.
There could, therefore, exist no doubt as to the real and
serious nature of the case, which was evidently one presenting
the complication of an artery wounded by the fractured ex-
tremity of one of the bones, either at the time of the accident,
or subsequently in moving the patient; and I inferred from
the position of the extravasation, that the posterior tibial was
the vessel lacerated ; and that the lower fragment of the tibia,
which projected backwards, had produced the mischief. As
the circumstances of the case did not call for immediate inter-
ference, and its nature was such as to demand reflection, I
determined to defer taking any step until the evening.

What was I todo? The age of the patient was against
her: but was she to be abandoned to her fate, without an
attempt to save her?

Should I adopt the practice of J. L. Petit, and cut down
upon the wounded artery and tie its bleeding extremities?
The difficulties of such a search at the bottom of a deep
incision through the muscles, and in the midst of soft parts
confounded together by a mass of extravasated blood, restrained
me from acting on this suggestion. Supposing even that I
succeeded in securing the bleeding vessel,, the. operation itself
AND FIRE-ARM WOUNDS. 9

would expose the patient to all the perils attending the exposure
of a large cavity filled with blood, in direct communication
with the fractured extremities of the bones; to say nothing of
the consequent difficulties and hazard associated with the
dressing of such a wound.

One other alternative presented itself, viz.: that of amputa-
tion through the thigh. This certainly had the merit of
being a simple and expeditious mode of extrication from the
difficulty. But, apart from the distressing mutilation which
such a proceeding would entail on the patient, even if she
recovered, I could not but be mindful of the fatal result
which had attended a similar step in several cases analogous to
the present.

The preferable course seemed to be the application of a
ligature on the main artery of the limb at a distance from the
seat of mischief. This would arrest further bleeding from the
lacerated artery, and allow time for it to close. It would
further supersede the necessity for laying open the large sac
containing the extravasated blood in the neighbourhood of the
fracture, and exposing it to the risk of inflammation and
dangerous suppuration. This, then, seemed to me to be a
reasonable step; but I had neither precedent nor experience
to guide me with regard to its safety. I feared that the
obstruction to the circulation might induce gangrene; or, on
the other hand, that the too speedy restoration of the blood to
its natural course through collateral channels might render
the attempt useless: or, again, that the irritation set up by
the fragments of the broken bones and the presence of the
effused blood, might be succeeded by inflammation and suppu-
ration. I resolved, however, to make the attempt of tying the
femoral artery in the middle of the thigh; and this operation
was accordingly performed with unusual facility. A triple
ligature was carried round the vessel, and tightened, with the
effect of immediately arresting all further pulsation in the
tumour.

I was gratified to find that neither the temperature nor
sensibility of the limb were in the least interfered with. On
the fifth day, the anastomotic branches around the knee could
be both seen and felt. On the sixth day, the tumour was
reduced one third in bulk, and continued to diminish pro-
10 ANEURISM COMPLICATING FRACTURES,

gressively, until it ultimately quite disappeared. The ligature
on the artery came away on the fifteenth day, and the wound
made for its application was healed in six weeks.

Some spots which made their appearance on the leg led me
to fear at one time that gangrene was impending; but this
proved to be a false alarm. A slough, produced by the pres-
sure, separated from the heel, and the wound which it left
healed kindly.

In the meanwhile, the union of the fracture proceeded but
slowly. Whether this tardiness was owing to the obliquity of
the fracture and the quantity of blood poured out around it,
or whether it was due to the restriction of the circulation
consequent on the operation, I do not pretend to decide.
But, be that as it may, the formation of the callus was
scarcely commenced at the end of the first month; and it
was not perfectly consolidated before the expiration of four
months. The woman perfectly recovered the use of her limb ;
and I have had the opportunity of seeing her from time to time
for fifteen years afterwards in the enjoyment of perfect health.

In 1815, M. Delpech, of Montpellier, met with a case similar
to, and even more complicated than, the preceding, which he
treated in the same way, and with corresponding success. The
following is an abstract of the case.

Cass VI.—*“ Fracture of the leg, accompanied by laceration
of one of the arteries..Jacques Boudet, a postilion, st. 30,
of strong constitution, was run over, whilst in a state of
drunkenness, by a laden cart, and his left leg crushed by the
wheel, which passed over it. He was conveyed to the Hospital
of St. Eloi (Montpellier); and, on examination, the injury
proved to be a comminuted fracture of both bones of the
leg, near the centre; there was, likewise, discoloration and
excessive distension of the skin. The tumefaction of the
limb was accompanied by distinct pulsation all round, but
especially towards the calf; this was synchronous with the
heart’s action, and controllable by pressure on the femoral
artery.

On the following day, the swelling was still further increased,

‘ [The abstract in the original is taken from the ‘ Chirurgie Clinique, of M.
Delpech. It is still further curtailed in the translation.—T. ]
AND FIRE-ARM WOUNDS. 11

and spots of ecchymosis had made their appearance at various
parts, even to above the knee. Acting on the precedent
afforded by the successful case already related, the femoral
artery was tied towards the upper part of the thigh. The
ligature was cut close to the knot, and the edges of the wound
approximated throughout. The patient complained first of
numbness in the limb, and subsequently of a feeling of cold,
but the temperature of the foot was natural.

Through the day, the patient was thirsty, with a full, hard,
and quick pulse ; complained of acute pain in the heel. Bled
to 12 ounces. Had a restless night.

On the following day he was better, and the swelling of the
leg had somewhat diminished. The colour of the skin was
also improved, and no pulsation could be detected in the
swelling. The limb retained its normal temperature, and
there was less numbness. On the fourth day, a few vesica-
tions appeared, but the cutis beneath was sound.

On the tenth day, the wound in the thigh was almost
entirely healed. On the twenty-fifth day, it opened again,
to allow the exit of the ligature; the union of the fractured
bones was going on satisfactorily. At the end of three months
the patient walked about without crutches; and, though there
was some little difference in the volume of the two limhs, there
was not the least deformity.”

The conclusion to be drawn from these two cases seems
obvious,—viz., that such an injury as was inflicted in each
is curable by ligature of the main artery higher up; and that
even when the laceration of the artery is accompanied by an
aneurismal swelling.

In both of the above instances the skin was uninjured. It
may, therefore, still be a question whether the same practice
would be applicable where the fracture is compound. Judging
from the ordinary consequences of such fractures, unaccom-
panied by arterial lesion, I cannot but infer that the issue
would be as satisfactory.

It now remains for me to point out, that fire-arm wounds,
complicated with aneurism, do not call for amputation, any
more than fractures accompanied by similar vascular lesion ;
and that, in like manner, they may be cured by the applica-
tion of a ligature on the main artery of the limb. This I
12 ANEURISM COMPLICATING FRACTURES,

shall prove, as in the former instance, by the narration of
cases.

Case VII.—Gun-shot wound, accompanied by division of one
of the arteries of the ley-—M. De Gombaut, aide-de-camp to a
distinguished lieutenant-general, received a pistol-ball through
the upper part of his right leg, in February 1818. It passed
from before, backwards and inwards, traversing the interosseous
space, and slightly injuring the tibia and fibula in its
passage.

Severe hemorrhage immediately ensued, blood pouring forth
abundantly from both apertures which the ball had made.
This was temporarily arrested by compresses, and the patient
was removed home.

The leg swelled and became, first, acutely painful, and after-
wards alarmingly benumbed ; nevertheless, the limb retained
its vitality. There was no external hemorrhage until the
thirteenth day; but in the interval blood was extravasated,
so as to form an aneurismal swelling which increased day by
day, and evinced its true character by the pulsations in it
which were synchronous with those of the heart.

The tourniquet of Petit arrested the pulsation in the tumour
each time that it was applied over the femoral artery, or when
it was tightened. But after a time, as is generally the case,
the column of blood worked a passage for itself under the
compress, either by raising it or separating the soft parts; and
at length hemorrhage took place on the thirteenth day from
the receipt of the wound. This was renewed at intervals, and
greatly reduced the patient.

It was at this time that I was called in to see the patient.
The foot and leg were tumid, purple, cold, and numbed. At
the upper part of the leg was a tense tumour, which expanded
and contracted with each beat of the heart. Over this swelling
were the two openings, one in front, the other behind, made
by the ball at its entrance and exit. These apertures had
been for the last few hours closed by plugs of coagulated
blood, which each pulsation threatened to dislodge. The
tourniquet, which was still applied, served only to moderate
the force of the current of blood. It was evident from the
history, as well as all the past and present symptoms of the
AND FIRE-ARM WOUNDS. 13

case, that the ball had cut through one or more of the large
arterial trunks in the leg.

What was to be done? To do nothing would be equivalent
to abandoning the patient to speedy and certain death from
hemorrhage. The employment of pressure had failed; should
an attempt be made to tie the bleeding vessels at the seat
of injury? This seemed impracticable, inasmuch as it was
impossible to decide what vessel required a ligature, whether
to cut down through the front or back of the limb, or whether
the bleeding might not proceed from more than one trunk.
Moreover, these operations on the arteries of the leg are not
easy under favorable circumstances; and in the present
instance, where the surrounding parts were so broken up
and disorganized, such a proceeding may be fairly deemed
impracticable. Amputation seemed to be the most prompt
and certain remedy. But this operation is, in itself, by no
means devoid of danger; indeed, if I can depend on statistics
in my possession, at least one fourth part of the individuals
subjected to this mutilation perish, even among the young
and vigorous, such as war selects for its victims on the field
of battle. I rejected this alternative; and fortified by my
previous success, and for the reasons detailed in case V, I
decided on giving the preference to tying the femoral artery.
Moreover, I had the satisfaction of feeling that, in case I was
disappointed in the anticipated effect of a ligature on the main
trunk of the limb, I could still proceed to the completion of
the amputation, of which the step I was about to undertake
might then be regarded as the first stage.

The artery was accordingly tied in the middle of the thigh
with a single ligature; an assistant, meanwhile, commanding
the vessels at the groin. Before tightening the ligature, I
ascertained that pressure on the exposed artery entirely arrested
the pulsation in the tumour. The wound being simply dressed,
the limb was semiflexed and laid on its outer side, resting on
a pillow; the aneurismal swelling was enveloped in compresses
dipped in strong lead wash, and the rest of the leg and foot
was surrounded by warm clothing.

The operation was simple and soon completed. It is but a
trifling merit to acquit one’s self well in this the mechanical part
of our profession; but the most consummate art is insufficient
14 ANEURISM COMPLICATING FRACTURES,

to ensure success and guard against accidental circumstances
which may arise in the after-treatment. Gangrene may
ensue from the circulation failing to be re-established; or
the collateral circulation might too speedily carry the blood
onwards, and so lead to further hemorrhage; or, at a later
period, inflammation, suppuration, decomposition of the extra-
vasated blood might induce a fatal termination.

I cannot say that I much dreaded a deficiency of circulation
in the limb, as the patient was young and vigorous. As to the
risk of hemorrhage, arising from too speedy restoration of the
circulation, I trusted that the inflammation which necessarily
followed the division of the lacerated vessels, and the presence
of the extravasated blood, would operate as a safeguard against
its return. Any accidental consequences resulting from inflam-
mation, suppuration, &c., must of course be met and treated
according to circumstances; and if amputation were, after all,
required, this last resource was still in our power.

Our fears proved groundless, and our hopes were realized ;
for the natural functions of the limb, dependent on a sufficient
supply of blood, were not for a moment interrupted. There
was but a moderate amount of inflammation; the extravasated
blood was removed by a gentle suppurative action, or escaped
by the wounds, and that which was infiltrated was gradually
absorbed. -The general treatment was limited to the employ-
men of antispasmodic medicines to quiet the nervous system
in the first instance, and a cautious diet ; appropriate dressings
were employed according to the varying condition of the limb.

The ligature separated from the artery on the twentieth day.
The condition of the leg improved. The suppurative process
brought away, in the course of time, some fragments of bone,
and pieces of dress, which escaped by the back wound. At the
end of six weeks the wounds were closed ; and in three months
from the receipt of the injury M. de Gombaut walked as well
as before he was wounded.

It seems to me to be a just inference that the successful
termination of this case is attributable to the step which was
taken in cutting off the course of the blood through the divided
vessel, and thus allowing time for the healing of the lacerated
openings in it, before the re-establishment of the circulation by
collateral branches. And, if we may judge by analogy, the
AND FIRE-ARM WOUNDS. 15

obliteration of a vessel wounded by a gun-shot ought to take
place more speedily than when the wound is inflicted in any
other way.

I may venture to conclude this paper by remarking that the
two forms of complicated injury which I have illustrated in
the preceding pages, viz. arterial lesion accompanying frac-
ture or fire-arm wound, have hitherto been considered remedi-
able only by amputation. Jt occurred to me that this mutila-
tion might be obviated by placing a ligature on the principal
artery of the limb, at a distance from the seat of injury. Suc-
cess has attended the experiment in the hands of others as well
as myself; and I trust that, as the operation becomes more
known and appreciated, more limbs will be saved by this course
of proceeding.
SECTION II.

ON SYMPTOMATIC GANGRENE CONSEQUENT ON
ARTERITIS.

The varieties of gangrene, to which the epithets “ sponta-
neous, senile, dry,” &c., have been severally assigned, have
hitherto been studied almost exclusively with reference to their
external characters. Moreover, practitioners have kept in view
the necessity of arresting the gangrene by topical applications,
and procuring the separation of the affected parts, without di-
recting their attention to other and more general measures.
Struck with the obscurity which involved this disease, I endea-
voured to throw some light upon it by the aid of pathological
anatomy, and was soon convinced that although the cause had
been overlooked, it nevertheless existed, and was often to be
discovered in inflammation if the principal arteries of the parts
affected, which presented a reddened appearance, with the blood
coagulated in them and blocking their canals so as completely
to arrest the flow of blood through them. The coagulation may
arise in different ways; either by the contact of the blood with
the inflamed membrane, or by mixing with coagulable lymph,
or by ulceration of the artery. Examination after death has
proved the existence of all these conditions. When amputa-
tion has been performed for an affection of this nature, the
vessels are so filled with fibrinous clots, or a mixture of fibrin
and pus, as to prevent the blood from escaping, and to super-
sede the application of ligatures.

The etiology of symptomatic gangrene has been misunder-
stood until recently. Old age and feebleriess were regarded as
the chief cause of the disease; but this explanation cannot be
admitted, as it has been known to attack the young and middle-
aged also, Ossification of the arteries, again, has been regarded
as a potential cause of this condition; but investigation proves
that this change of structure is often nothing more than simple
coincidence and that in some instances it is even the consequence
SYMPTOMATIC GANGRENE. 17

of arteritis. Indeed, ossification alone of an artery is insuffi-
cient to retard, in any very appreciable degree, the course of
the blood through it. How often are limbs dissected in which
all the arteries are ossified, and yet there had been no senile
gangrene: and it must have occurred to every surgeon, when
amputating or operating for aneurism on an old patient, to find
one or more arteries in a limb entirely ossified, and yet the
circulation has been as free as if no such lesion existed. Ossi-
fication alone is an insufficient explanation ; it is the oblitera-
tion of the arterial trunks, and the arrest of the flow of blood
through them which is the true cause of this malady ; and this
leads me to the consideration of the question, how this ob-
literation is brought about.

In investigating the cases of individuals who are subjects of
symptomatic gangrene, it will be almost always found that they
have been addicted to spirit-drinking or gross feeding, or that
they have been affected with some chronic disease of the heart,
of the aortic valves, and of the great vessels—all of which are
causes that operate most frequently in provoking irritation and
inflammation of the arterial system. In most cases the gan-
grene is preceded by pains, sometimes of a very acute charac-
ter, by fever, and other symptoms which announce the presence
of inflammation ; and pathological anatomy, as I have already
observed, always demonstrates, in such a case, the existence of
inflammation in the arterial coats. Such morbid actions may,
doubtless, occur in arteries already diseased, indurated, or ossi-
fied, as we observe frequently in old people; but they are also
met with in young subjects, in whom no trace of such morbid
changes exists. In a word, this inflammatory action may co-
exist with the calcareous deposit seen in the vessels of the old,
or it may occur quite independently of such condition; and
ossification of an artery may itself result as the consequence of
a former attack of arteritis.

Lastly, direct experiment on living animals proves, that in-
flammation of an artery which is excited by irritation, and which
is followed by coagulation of the blood and the exudation of
plastic lymph which glues it to the arterial walls, produces
similar effects, determining artificially the same form of sympto-
matic gangrene as may, under other circumstances, occur spon-
taneously. M. Cruveilhier has indeed established the fact that

2
18 SYMPTOMATIC GANGRENE

the injection of irritating substances into the arteries of an
animal occasions inflammation of the internal coat of these
vessels, and consequent mortification of the parts to which they
are distributed.

Casz I.—Gangrene of the left leg ; hypertrophy of the heart,
with ossification of the arteries, &c.—Catherine Dupuix, aged
71, a servant, was admitted into the Hétel-Dieu, in March, 1824.
She ceased to menstruate at forty, and continued in excellent
health until seven or eight years since, when she began to suffer
from cold hands and legs, livid spots occasionally appearing on
the palmar surface of the fingers; but these disappeared after
some leeches were applied.

Between two and three months since, a black spot appeared,
without apparent cause, on the third toe of the left foot,
accompanied by pain which deprived the patient of sleep; and
in the course of two months the entire anterior half of the
foot became the seat of dry gangrene. On both the upper
and lower surfaces of the foot there was a violet-coloured circle
of inflammation, to which the patient referred her suffering :
the pulse intermitted irregularly. The patient was blooded
with marked relief: the foot was poulticed. At the expiration
of a week Dupuix complained only of the sensation of, cold.
Two days subsequently she was again bled, with the same
beneficial result of subduing the inflammation on the back of
the foot ; and the redness almost entirely disappeared from that
part. At the early part of the following month, however
(about a fortnight after her admission), the patient became
delirious ; the disease again began to spread, and she gradually
sank, and expired on May 5th.

Autopsy.—tThe toes of the mortified foot were denuded, dry,
black, and considerably diminished in volume: the tendons
and a part of the ligaments were destroyed, and the bones
themselves had become diminished in size. The third meta-
tarsal bone was partly carious. The arteries of this part of
the limb presented traces of common osseous degeneration, in
an early stage: here and there clots were noticed which
plugged the vessel. The veins, as far as the middle of the
thigh, and especially the deep ones, were filled with dark clots.
At some spots these clots had the yellowish appearance of
CONSEQUENT ON ARTERITIS. 19

fibrin. On cutting transversely through the left ventricle of
the heart, its opposed sides were found to be in contact, so as
to obliterate the cavity; and the aortic opening was narrowed,
but presented no ossific deposit. At some points of the aorta,
the first traces of atheromatous degeneration were observable ;
at others there were bony patches of limited extent: there
was one of larger size immediately above its bifurcation. The
right carotid, femoral and brachial arteries presented, here
and there, flaky deposits of bone; in the affected limb these
were more numerous; indeed, both tibial arteries were almost
entirely converted into bone.

This case exemplifies the correctness of the principles I have
laid down, viz., that in symptomatic gangrene there is very
often disease of the heart and great vessels; and it proves,
moreover, that the abstraction of blood has a marked influence
on the progress of the disease, which was thus twice suspended,
and its fatal issue for a time averted. It can scarcely be
doubted that the purple patches on the hands were associated
with the constitutional affection; they disappeared after
leeching. Symptomatic gangrene may show itself in less
common situations, as exemplified in the following case.

Cast II.—Gangrene of the scrotum and nates: death and
autopsy.—Louis Poinier, aged 60, was admitted into the Hétel-
Dieu, April 3d, 1824. From the little information which could
be obtained respecting him, it appeared that he had been
ailing for some days, and had suffered from purging and
vomiting. On examination, the scrotum and nates presented
great tumefaction, and the skin of this region was dark and
exhibited patches of commencing gangrene; his pulse was
feeble, the surface bathed in a clammy perspiration, and the
patient was delirious. He did not long survive his admission:

Autopsy.—There was thickening of the arachnoid, and the
pia mater was infiltrated with albuminous fluid. There was
pus in the areolar tissue of the scrotum, but no trace of urine.
The right cavities of the heart were hypertrophied and dilated ;
and the aorta presented several incrustations at different parts.
In the iliac vessels. there were several clots. The vasa deferentia
were a little thickened, but not otherwise altered in texture
and appearance, as high up as the internal ring, At this
20 SYMPTOMATIC GANGRENE

point, however, they almost suddenly assumed .an osseous
character, which they retained until they gained the side of
the prostate, and then resumed their natural texture. The
deposit of bone appeared to be in the fibro-cellular tissue ;
and the vessels had acquired a thickness of two lines at
least.

Ossification of the vasa deferentia is a circumstance of rare
occurrence: the foregoing is the only example I have ever
witnessed of it. In the following case another part was the
seat of the gangrene,

Case III.—Symptomatice gangrene attacking the nose and
Jingers: death and autopsy.Auguste Gumery, aged 69, was
admitted into the Hétel-Dieu, March 21st, 1825. When I
saw him he could not give any account of himself. His nose
was of a deep violet hue, and so was the skin of the cheeks;
and the little finger of the right hand was similarly affected.
In these parts heat and sensibility were extinct. There was
extreme general prostration, and the patient sank rapidly.

Autopsy.—In addition to the parts above mentioned, the
fore-arm and nates presented patches of slough. The heart
was large’: its right side filled with clots, and its left ventricle
manifestly thickened. The mitral valve and tendinous chords
were ossified, as were likewise, in fact, the coronary arteries.
The aorta possessed numerous bony patches in its tharacic
division ; the brachio-cephalic, right subclavian and common
carotid arteries participated in the same condition; many
points had a red tinge. The unusual seat of the gangrene
constitutes the peculiarity in the above case: the following
presents other points of interest.

Case IV.—Arteritis ; coagulation of blood ; gangrene and
death.—Rigolet, aged 40, was admitted into the Hotel-Dieu,
with commencing gangrene of the right leg, July 15, 1882.
She was a woman of spare but active frame, who had always
enjoyed good health. She said she had recently suffered from
cholera; but on being questioned, the only symptom was
violent cramp in the right leg. A dull pain was felt in the
iliac fossa of the same side, and extended, first along the inner
part of the thigh, and then along its posterior aspect to the
CONSEQUENT ON ARTERITIS. 21

calf of the leg, thus gaining the sole of the foot and toes.
The next symptoms in these parts were a stinging sensation
and lancinating pains, succeeded by a burning feeling. After
this, and about ten days before her admission into the hospital,
the foot became cold, and purple spots made their appearance ;
the pain also became so severe as to prevent her sleeping.
When I first saw this patient, the right leg, as high as the
knee, was swollen to double its natural size. The skin was
tense and shining, and of a purple hue, which increased in
intensity towards the toes; and the discoloration was so dis-
posed as to impart a mottled appearance to the surface of the
limb. There were some points of vesication, and the loss of
sensibility was proportioned to that of temperature; but, for
obvious reasons, the movements of the leg were not yet
materially interfered with. The circulation still continued
unobstructed through the upper third-of the leg. The pulsa-
sion of the femoral artery of the affected limb could scarcely
be detected, so indistinct and feeble was it ; the vessel appeared
as if converted, throughout its entire course, into a hard and
almost incompressible cord. I believed this to be a case of
arteritis; and accordingly ordered that the patient should be
bled, and the limb enveloped in a poultice.

The bleeding quieted the pain, and the patient slept. It
was repeated on the following day. On the succeeding day
its effect was more remarkable, the pain had almost entirely
ceased ; the swelling was diminished; the heat and sensibility
were restored at many points; but the vesications on the foot
burst, and left exposed the gangrenous skin. The patient was
bled a third time on the 22d. A few days afterwards, a line
of demarcation seemed to be forming about four fingers’
breadth below the knee: the patient could no longer move
her foot, but complained (probably feeling as those who have
suffered amputation) that she occasionally felt severe pain in
it. This apparent arrest of the disease proved deceptive.
Mortification again extended upwards, ultimately involving the
whole thigh, and the patient expired, thirty-five days after
her admission into the hospital.

Autopsy.—The body was much emaciated. The gangrenous
limb was still much swollen, and the true skin dark, hard, and
dry. Three large eschars presented themselves on the right
22 SYMPTOMATIC GANGRENE

side and back of the pelvis, extending from the iliac crest
across towards the left side. In the middle of the thigh the
femoral artery was contracted, but in other respects had a
normal appearance: it was filled with a filiform, reddish clot,
which seemed as if it had been formed after death. Near the
crural arch the artery resumed its natural calibre, but was
hard, incompressible, and occupied by a clot, which was red on
the surface, and slightly adherent to the lining membrane of
the vessel; in its centre it was grey, and seemed to be formed
of discoloured and broken-up fibres. This condition existed
as high as the common iliac trunk, and even extended a little
into the left iliac, but without obliterating it. The right
internal iliac vessel was also obstructed by the presence of a
similar clot. The fermoral vein of the same side was occupied
by a reddish clot. The vessels on the left side, the aorta, and
the heart were nearly empty. Between the gangrenous and
sound parts the capillaries were highly injected. The skin of
the leg was dark and hard, like parchment; the subcutaneous
cellular tissue was of a greyish-yellow colour; the muscles and
nerves were bright red; the vessels near the ham were filled
with clot similar to that in the thigh, but lower down they
contained a reddish serum. ‘The deep areolar tissue was in-
filtrated with this serum, and at some parts sloughy ; the bones
were pale. The viscera were healthy, with the exception of
an increased redness of the small intestine.

In this form of gangrene, resulting from arrest of the sup-
ply of blood, the dead parts shrivel and dry, from the absence
of the nutritive fluid on which their vitality depends. It is,
therefore, easy to understand why the odour given out in these
cases is quite different from that dependent on acute inflam-
mation of the affected structures,

The indications of symptomatic gangrene are very remark-
able. In fact, from the first, it is entirely a local disease,
and very puzzling to those unacquainted with its true patho-
logy.

All the important organs perform their functions healthily ;
and it is only as the disease advances, and doubtless, in a
measure, as absorption takes place, that the constitution seri-
ously sympathises, and death ensues.

Gangrene is ushered in by a feeling of discomfort and
CONSEQUENT ON ARTERITIS. 23

numbness, attended by a sensation of coldness and pallor of
the part, which are very remarkable. It is not, as one might
suppose, a corpse-like coldness, such as would result from the
affected part being reduced to the temperature of the surround-
ing air; but the loss of heat exceeds this, and the ther-
mometer marks a lower degree of temperature than that which
is imparted even by flowing water. Many experiments have
satisfied me of the fact, that the temperature of a part on the
eve of mortifying, is below that of the dead body or the sur-
rounding atmosphere. With the loss of heat there is also
loss of sensibility ; but pain, and that of the most acute and
agonizing character, accompanied by distressing itching, often
attends this complaint. These phenomena are speedily suc-
ceeded by slight swelling, a mottled and violet hue of the
parts ; sometimes these latter sigus are absent. Often vesi-
cation occurs; and beneath the raised cuticle an eschar is
seen; at other times, there are no vesications, but in their
place dark spots appear, which become eschars; sensibility is
lost, and the affected parts die and become dry.

But the most interesting symptoms to watch are those
which take place in the artery. The pulse is imperceptible to
the finger, or even entirely ceases. In the course of the.
artery is felt a hard, round cord; and an accurate estimate
may be made of the extent and progress of the disease by the
limit of pulsation, and natural feel of the artery. This cir-
cumstance was noticed in the case above related: two days
before the patient’s death, I predicted that the interval iliac
artery would be found plugged as high as the aorta. But it
is right to bear in mind that the hard round cord which is
felt, in these cases, in the course of the femoral artery, may
be the obstructed vein. The sloughs on the pelvis, in this
case, further presented this peculiarity, that they were limited
to one side; a fact, which the obliteration of the correspond-
ing arteries accounted for.

Case V.—Symptomatic gangrene, followed by phlegmon and
death.—Brochard, aged 63, in good health, experienced pains,
two years back, in his legs. The right hand, and especially
the little finger became, ultimately, the seat of his suffering.
This finger became insensible, and vesications, filled with fetid
24 SYMPTOMATIC GANGRENE

serosity, made their appearance. He suffered so much that,
in a fit of rage, he amputated the ungual phalanx of the
offending member. ‘The disease, however, was far from being
arrested by this mutilation, and the patient was admitted into
the Hétel-Dieu, in September, 1828. He was labouring
under great constitutional disturbance, as evinced by a quick,
sharp pulse, and a coated tongue, black at its base. The
whole of the limb below the elbow was swollen, and the
seat of acute pain. The brachial artery could be traced in one
part of its course, where several points of ossific deposit were
discovered. Gangrene did not extend, but he became de-
lirious, and died about a fortnight after his admission.

On examination of the body, the inflamed parts were found
bathed in pus; the muscles were separated from each other ;
and the last three fingers were in a state of gangrene. The
axillary and brachial arteries, and those of the fore-arm were
inflamed at many points, and presented numerous ossific
patches. The veins were healthy. The aortic opening in the
heart was contracted, and there were numerous thick osseous
deposits scattered over this great trunk, as well as in the
arteries of the lower extremity. There was an hydatid cyst in
the liver.

Women are less subject to gangrene than men. It
was formerly taught that this disease was more common
in winter than in summer, on account of analogy to that
form of the affection which results from frost-bite. But both
the theory and consequences are equally false: it is in sum-
mer that symptomatic gangrene is most frequently met with;
and it is this circumstance which first led me to conclude,
& priori, that some other cause was to be sought for than
simple obstruction of the. circulation.

The treatment has varied according to the supposed origin
of the disease. Pott, who made some valuable observations
on senile gangrene, first employed bark and opium. But,
finding the former of these drugs mischievous, he limited him-
self to the use of the latter, and with considerable success.
Yet, even in the hands of this able surgeon, many fatal cases
occurred, and a more available method of treatment was there-
fore still a desideratum. I have, myself, given every form of
stimulant, but anly with the effect of feeding the disease;
CONSEQUENT ON ARTERITIS. 25

when it had its origin in arteritis or ossification ; and my views
on this subject did not begin to take a right direction until
the following case occurred in my practice.

Casz VI.—Symptomatic gangrene. Usual treatment with-
out effect. Bloodletting, and recovery.—A woman, aged sixty
and odd years, came to the Hétel-Dieu, to be treated for
senile gangrene, affecting the toes of the left foot. She had
suffered excruciating pain for some months prior to the appear-
ance of the gangrene, and had been prevented from sleeping.
The toes themselves presented the usual appearance of dry
gangreue, and the neighbouring parts of the foot were swollen
and livid, and the odour emitted was very offensive. For
many months I had recourse to the usual forms of treatment,
including bark and opium, administered internally and applied
locally ; but still the disease extended, involving soft and hard
parts alike in its destruction. A careful examination proved
the non-existence of any important organic lesion. Vexed and
disappointed, I determined on trying a different plan of treat-
ment, and in this I was guided by the pulse, which was full
and hard, and the florid face. I bled her: the pain was
mitigated; sleep returned ; and the progress of the gangrene
was suspended ; in short, the patient had not felt so well since
the commencement of her attack. At the expiration of a
fortnight, the symptoms returned, and she was bled again,
with similar benefit as on the former occasion. This treatment
was adopted at each recurrence of the symptoms: the morti-
fied parts separated, and the stump healed. Ultimately the
patient left the hospital quite well.

Since the occurrence of the above case, many patients af-
fected with senile gangrene have been treated by bloodletting,
and always with similar success. But, is this treatment appli-
cable to all forms of this disease? I think that it may be
advantageously adopted, whenever the disease is accompanied
with acute pain and much swelling, the pulse is hard and full,
and the face flushed.

The foregoing case was published in 1824, by Mr. Marjolin,
in the first edition of the ‘ Dictionnaire de Médecine.’

In all the cases of symptomatic gangrene which have come
under my care, I have employed repeated bleeding, and have
26 SYMPTOMATIC GANGRENE

thus succeeded in curing, or at least relieving, two thirds or
three fourths of the patients. The following recent case will
serve further to exemplify the advantage of this plan of
treatment.

Case VII.— Senile gangrene, cured by bloodletting. —
Pierre-Esprit M—, aged 71, a labourer, was admitted in the
Hétel-Dieu, early in March, 1833. Some days since he ex-
perienced an icy-cold sensation in the left great toe, which
was speedily followed by an increasingly acute pain, the part
itself becoming swollen, and assuming a livid hue. After the
lapse of some days, a vesicle, enclosing a dark brown fluid, appeared
on the inner side of the great toe towards its centre; and from
this point a slough extended gradually, until the entire toe, as
far back as the metatarso-phalangeal articulation, was involved
in it. This slough was hard and dry; and the patient’s suffer-
ing was such as to deprive him of both sleep and appetite.
There was constitutional disturbance, but no disease of the
heart or great vessels; the crural artery, however, on the
affected side, was hard, resisting, and evidently ossified. The
patient asserted that he had always enjoyed perfectly good
health; that he had not been the subject of any accident to
the toe, and could not account in any way for the complaint
he was labouring under.

Being persuaded that this was a case of senile gangrene
consequent on arteritis, followed by plugging and obliteration
of the principal arterial trunks in the lower extremity, I did.
not hesitate to bleed the patient largely from the arm, and
ordered the application of a poultice to the diseased part. The
relief was marked and immediate: the patient slept soundly,
his spirits rose, and his appetite returned. There was no re-
lapse after this amendment: the gangrene was arrested ; a line
of demarcation was formed ; and after the slough was thrown
off, the part cicatrized, so that the patient was able to leave
the hospital well at the end of April.

Opium is a valuable remedy; and, when combined with
antiphlogistic measures employed according to the condition
and_ power of the patient, I am acquainted with no better
mode of arresting the progress of symptomatic gangrene at any
period of its course. The surgeon will, of course, avail himself
CONSEQUENT ON ARTERITIS. 27

of other suitable means, both local and general, by which to
second the influence of these important and primary agents,
opium and bloodletting. -
A very interesting question here presents itself: if the
gangrene continue to extend, is it not sound practice to am-
putate all the affected or menaced parts, in order to preserve
the rest? This operation has been performed by a well-in-
formed surgeon frequently, and with success, during extension
of the gangrene; why not follow his example? This is the
answer to the question. Where the gangrene is consequent
on some cause acting from without, both cause and effect may
at once be removed; but in cases like the above, where gan-
grene is but a symptom, it is clear that amputation can have
no direct influence in arresting the disease. In short, it may
be laid down as a rule, that amputation ought to be deferred
until the line of demarcation is defined, and the exciting cause
of the disease has been subdued. ‘There are, however, ex-
ceptions to this rule, as proved by a case under my care, in
which gangrene attacked both feet, and destroyed the patient.
This man had had his left great toe amputated two years be-
fore, for a similar,affection, and had recovered. When his
body was examined, very many of the arteries were found ossi-
fied, even including the cardiac branches. The principal
arteries of the lower extremity were obliterated ; and the vena
cava itself presented some patches of ossification.
SECTION III.
ON LIGATURE OF THE PRINCIPAL ARTERIAL TRUNKS.

Ligature of the principal arterial trunks is one of the most
brilliant triumphs of modern surgery. Not long since, the un-
fortunate subjects of aneurism in these arteries were doomed
to almost certain death ; for, spontaneous cure, or that by com-
pression, are of rare occurrence. It is true that occasional in-
stances have been met with, in which aneurisms have been cut
short by inflammation, abscess, gangrene of the sac, or even by
compression of the artery by the sac; yet these cases were but
ill noted, and were consequently lost to science.

One of the main difficulties which for a long time impeded
the advance of this branch of surgery, was the incorrect views
which prevailed regarding the re-establishment of the circula-
tion ; an impression existing that the collateral branches were
insufficient for this purpose. These misgivings were in part
dissipated when Anel made known his method of treatment,
and the mechanism of anastomosis was better studied. Then
success was seen to attend the employment of the ligature on
the brachial and femorai arteries, for aneurism at the bend of
the elbow and in the ham. Still, for some years, no attempt
was made to tie the iliac or subclavian trunks—the risk was
thought too great. But, after a time, these vessels also were
tied between the seat of disease and the heart. This method
of operating was inapplicable to cases where the aneurismal dila-
tation is situated at the origin of the carotid or subclavian
trunks, or in the common iliac or brachio-cephalic arteries. I
propose, therefore, to arrange the observations I have to make
in the present chapter, under two heads: the first comprising
those cases in which a ligature may be applied upon an artery
between the heart and seat of disease; the second, those cases
in which it is necessary to apply the ligature between the anen-
rism and the capillaries. In order to render the subject more
LIGATURE OF THE ARTERIAL TRUNKS. 29

complete, I will also say a few words on Valsalva’s method, and
on compression,

Of the different forms of treatment proposed for the cure of
aneurism, that of Valsalva, which consists in local and general
depletion, has obtained a high repute. It was formerly more
resorted to than at present, and I have remaked that it dimi-
nishes the resistance of the walls of the aneurism more than it
enfeebles the heart’s action; and I have further noticed that
when the surgeon, tired of employing this mode of treatment
ineffectually, begins to supply the patient with nourishment,
with a view of operating, the tumour, surrounded by parts
which have lost their elasticity, increases rapidly under the
influence of the vis a tergo, threatening a fatal issue if situated
in the subclavian or iliac regions. Pounded ice, iced water, or
snow, may, under certain circumstances, be successfully applied
to aneurismal tumours; but I cannot say the same of astrin-
gents and actual cautery, which are now generally abandoned.

Althongh Valsalva’s method is far from possessing the re-
commendations ascribed to it. by its inventor and his partisans,
there are circumstances in which it has been of real benefit, as
exemplified in the following instance.

Casz I1.—Aneurisin of the axillary artery, cured by Valsalva’s
method.—Nicholas Robert, aged 61, a tiler, of sanguine tempe-
rament, was admitted into the Hétel-Dieu in 1806, with a large
tumour occupying the right axillary and subclavian regions.
The corresponding limb was cedematous, and the pulse was
scarcely perceptible. The first symptom which attracted his
attention was a dull pain, accompanied with slight numbness,
which subsided under the use of lotions. But two months be-
fore his admission, these symptoms reappeared, and the patient
soon discovered a tumour, which, as it enlarged, aggravated the
cedema and numbness of the arm. When admitted, the swel-
ling presented an ovoid form, extending from above the level
of the clavicle, to a point in the axilla below the nipple. The
skin which covered the tumour was painful, shining and hard,
and conveyed to the finger the sensation of deep fluctuation ;
at first, and on a superficial examination, but very slight pulsa-
tion was perceptible, but on a closer examination, it became
more distinct, especially at the commencement of the axillary
30 LIGATURE OF THE

artery, just as it escapes from under the clavicle. Fearful of
operating under these circumstances, M. Pelletan had recourse
to Valsalva’s method. The patient was bled and put on a low
diet ; vinegar compresses were applied to the tumour.

On the following day the swelling was softer, and the skin
less tender. He was again bled, and on the succeeding day
there was a sensible diminution in the bulk of the tumour,
which could now be felt to consist of two lobes. This treat-
ment was persisted in, and on the twelfth day, the turhour was
diminished in size one third, and the pulsations had become
very obscure. He had become, however, extremely feeble from
want of nourishment ; he had no sleep, and the general consti-
tutional disturbance was alarming, yet the appetite did not
fail. A more liberal diet soon restored him, and the case con-
tinued to proceed favorably.

Within a month of the patient’s admission the parietes of
the sac were more firm, and fluctuation was still apparent. A
bag of ice was applied to the swelling, and renewed twice a day.
This was continued for three weeks, and then the place of the ice
was supplied by salt and water. Within two months from his
entrance into the hospital this patient was dismissed in a very
satisfactory condition. The tumour was considerably diminished
in size, especially at its upper part, so that the pectoral muscles
could be readily distinguished ; but in the axilla it was still as
large as two fists. As the absorption of the fluid part of the
blood proceeded, there seemed but little reason to doubt that a
fibrinous clot alone would be left for the absorbents ultimately
to remove. I inferred that the artery was obliterated above
the axilla, and that the blood found its way into the limb by
the collateral circulation alone.

Ten months after his dismissal, Robert came to the Hétel-
Dieu, and I had the opportunity of carefully examining him.
A very small and hard tumour was all that was then perceptible
in the axilla, and this appeared rather as if attached to the
neighbouring part of the chest than to the artery. The pul-
sations of this vessel were feeble above the clavicle, but more
distinct below it. The brachial and radial arteries pulsated
but feebly. When the axillary artery was compressed behind
the clavicle, all pulsation ceased in the limb, which was well
nourished and strong. There was a considerable depression in
PRINCIPAL ARTERIAL TRUNKS. 31

the breast itself near to the tumour. The patient had begun
his work immediatetly after leaving the hospital, and had con-
tinued it without intermission or inconvenience since.

Latterly, recourse has frequently been had to compression in
cases of aneurism, the compress being applied on the artery
above the tumour. Of the various instruments used for this
purpose, my compressor is that which is most commonly and
successfully employed. It is made of different sizes, so as to
be adapted to the arm or thigh, and suitable for children or
adults. Isolated and free around the limb, it touches it only
at two opposite points; and thus is well calculated to fulfil
the desideratum of interrupting or arresting the flow of blood
through the main trunk, whilst the collateral circulation
is unimpeded. Though this instrument thus satisfactorily
fulfils its purpose, some patients are unable to bear it; and,
indeed, in the majority of cases, recourse must be had to the
ligature, which, after all, is the most efficient method of treat-
ing aneurism hitherto proposed.

Cass II.—Aneurism of the popliteal artery, cured in three
weeks by compression. —In September, 1818, André Ivanowitz,
a Pole, aged about 30, of sanguineous temperament and vigo-
rous constitution, was sent to me to be treated for popliteal
aneurism. He gave the following history of himself. He was
serving in the army in 1815, and deserted when his regiment
was about to pass under the Russian rule; he swam across the
Loire, and proceeded towards Paris. He had scarcely begun his
journey when he experienced a feeling of lassitude, and after-
wards of heaviness and numbness throughout the back of the
right leg, including the ham. This was followed by sharp pain,
and he was obliged-to complete his journey more leisurely than
he had commenced it. Bathing and rest mitigated these symp-
toms, and in a fortnight he had quite lost them. Hight or ten
months afterwards, during which time he was actively occupied,
he fell down stairs, in such a way that his leg was forcibly bent
on his thigh, and had the whole weight of his body thrown
upon it. He experienced at the time a tearing sensation and
pain in the ham, and was quite unable to support himself on
this leg. He dated the origin of his disease from this injury ;
but he was probably mistaken, as the foundation of it was most
32 LIGATURE OF THE

likely laid at the period of such great exertion immediately after
he quitted his regiment. Indeed, this seems to be the natural
explanation of the suffering he endured during his journey ; and
the fact that the diseased artery was only progressively dilating
accounts for the patient being able, without inconvenience, to
follow a laborious occupation. I therefore infer that some part
of the coats of the diseased artery gave way when the accident
occurred; for it is at least improbable that a healthy artery
would yield under compression, though laceration may result
from extension. However this may be, in the course of eight
or ten days afterwards he perceived a tumour as large as an
egg inthe ham. He did not feel any pulsation; but it will
be seen, in the course of the case, that this sign might have
‘been present without being noticed. The pain, however, ceased,
and a constant sense of numbness and lassitude about the back
of the leg alone remained. He continued his occupation, but
was forced from time to time to keep entirely at rest, in conse-
quence of the weakness of the limb, and the occurrence of acute
pain when he worked hard. As the swelling increased, the
symptoms became more and more aggravated in proportion, and
at length he was wholly incapacitated from using his limb.
Two years had now elapsed since his fall, and he consulted a
medical man, who mistook the nature of the disease, and di-
rected that a liniment should be rubbedin. Shortly afterwards,
its true nature was detected, and the patient was sent to me.

When I first saw him, the tumour had acquired the size of
a turkey’s egg, not only protruding backwards, but also thrust-
ing to either side the boundaries of the ham; the pulsations
in it were distinct, and synchronous with the pulse; but these
had been overlooked by the patient, till his attention was
directed to them. The knee-joint was immovable, partly
owing to the presence of the tumour, partly to the oedematous
condition of the limb; the numbness was constant, and he
suffered pain whenever he attempted to walk. The urgency
of the case induced me to recommend an immediate operation ;
but the patient, without refusing to submit, begged me first
of all to try some gentler method of treatment.

I had succeeded, a short time before, in curing, in a few
days, a similar case of extensive aneurism by compression of
the femoral artery; but I was disposed to regard this result
PRINCIPAL ARTERIAL TRUNKS. 33

as one of those lucky chances, which occur occasionally in the
course of a long practice, and which cannot be referred to as a
precedent. Indeed, before this, only two well-authenticated
cases of cure of aneurism by compression had been recorded ;
and in both instances the patients had been compelled to wear
the apparatus that had been used for a very long time. This
consideration had deterred me from resorting to this mode of
treatment in other cases; but the present occasion afforded
me another opportunity of demonstrating, as the result proved,
that the duration of the treatment was due to the imperfection
of the instruments, rather than to the principle which they
were designed to carry into effect. I accordingly applied to the
middle of the femoral artery the compressor I usually employ
to arrest the flow of blood in amputation. The principle upon
which this instrument acts is similar to that of the ordinary
tourniquet, but modified so that, whilst it perfectly commands
the femoral artery, it makes pressure upon only two points,
which are exactly opposite to each other; and when once
applied, its hold is so firm that no jar can loosen it, nor do even
walking or other movements disturb its accurate adaptation to
the limb. The patient was instructed to relax the compression
whenever it produced severe pain, either in the limb or at
the seat of its application. The tumour itself was covered with
pounded ice.

He attended strictly to the directions given to him; when-
ever he felt much pain, a few turns of the screw relieved him ;
and after a few seconds he again tightened it as before. The
first effect of the compression was greatly to increase the
numbness; but about the fifth or sixth day this symptom
disappeared altogether, and almost suddenly. The patient had
also by this time partly regained the power of moving the leg
on the thigh; and the tumour, as well as the oedema of the
limb, had diminished; moreover, when the compression was
removed, the pulsation was found to be weaker. The amelio-
ration of all the symptoms continued, and the patient was
enabled, as he got more accustomed to the pressure, to wear
the instrument more continuously, removing it only at longer
intervals; he himself remarked that, at each removal, the
pulsation in the swelling sensibly diminished. On the twen-
tieth day the limb had resumed its natural size, shape, and.

8
34 LIGATURE OF THE

sensibility ; and he was able to move it freely; he then took
off the instrument himself and returned to his work. When
I saw him a few days subsequently all pulsation had ceased ;
and after the lapse of a month the only trace left of the
tumour was a hard immovable mass, as large, at most, as a
pigeon’s egg; and he was able to use the limb as if nothing
had ever been the matter with it.

To what is the cure in these two cases due? Was it
accomplished by obliteration of the femoral trunk, as a conse-
quence of adhesive inflammation produced by compression ?
Certainly not; for in both instances the pulsation of the artery
could be traced to the opening in the adductor magnus. It
can only be referred to coayulation of the blood in the aneu-
rismal sac, induced by rest and the absence of impulse from
behind ; the application of ice to the swelling would, of course,
assist in procuring this result.

The proceeding now generally adopted is that of Anel or
Hunter. When an artery is thus tied, it is essential that it
should be exposed at such a distance from the sac, as to insure
its being perfectly healthy, and in a position where it is most
easily accessible, and most readily admits of the successive
steps of the operation being performed. Another point of no
less importance is to preserve about the seat of operation a
sufficient number of collateral branches to maintain the circu-
lation below the seat of ligature; further, the artery should be
tied not too near the large collateral branches, especially the
upper ones; for their proximity is one of the most rife
causes of secondary hemorrhage. The external incision should
be free; and the division of the fascize should be more extended
than that of the skin.

The diagnosis of aneurism is easy when the disease is recent;
but it becomes very embarrassing when it is of long standing,
large, and irregular. If an artery is in any way covered bya
cyst, a cold abscess, or by deep glandular enlargement, or a
collection of blood or of gelatiniform matter, it is necessary to
be especially careful, as there are no regions where large arteries
exist, in which, under these circumstances, aneurisms have not
been mistaken for abscess. Lastly, the aneurismal sac may
give way to a small extent, and the blood become extravasated
little by little, until a tumour is formed in the cellular tissue
PRINCIPAL ARTERIAL TRUNKS. 35

at a distance, presenting neither pulsation, nor any other of
the physical signs which distinguish ordinary aneurism. I
have witnessed one very singular case of this kind, in which
the blood escaped from an opening in the aorta, and burrowed
along the areolar tissue of the neck, forming several tumours,
the opening of which was followed by trifling hemorrhage,
but so incessantly renewed, that the patient ultimately sank
under it.

Cast III.—Aneurism of the subclavian artery, mistaken for
an abscess.—Marie Charlotte: Margue, aged 69, came from the
country into the Hétel-Dieu, in April, 1810, suffering from two
gangrenous sloughs in the inside of the elbow; and these were
accompanied ‘by cedema and loss of power of the limb. A
fortnight after admission, the patient was going on well, when
she complained of a little swelling, about the size of an almond,
in the axilla of the affected side. The dresser took this for a
swollen gland; and though he could not detect the pulse at
the wrist, he attributed this to the cedema, or to ossification or
contraction of the artery. Six days later, as she suffered more,
I examined her myself. On feeling the tumour, fluctuation
was distinct, but no pulsation could be detected. I believed
it to be an abscess; and I founded this opinion on the history
of the case; the existence of ulcers at the elbow, the marked
decrease of suppuration, the rapid development of the tumour,
and finally the complete absence of pulsation. (To have re-
moved all doubt, the artery should have been compressed above
the tumour.)

The opening of the supposed abscess was deferred until the
following day, when the patient was further questioned respect-
ing the history of her complaint, &c. and her answers appearing
satisfactory, I'took a long, narrow and sharp-pointed bistoury,
and passed it slowly and cautiously into the most prominent
part of the tumour, where fluctuation was most apparent. On
withdrawing the instrument, it was followed by a jet of arterial
blood. I at once closed the opening with my finger, and felt
the pulse of the diseased limb. The artery seemed full but
without pulsation. I was, for a moment, disposed to ascribe
this jet of blood to the section of a superficial branch greatly
enlarged by inflammation. The removal ‘of my finger from
36 LIGATURE OF THE

the orifice, however, speedily satisfied me that I had indeed
opened an aneurism; and now, for the first time, I detected a
slight quivering sensation in the tumour, like that of a body
in vibration.

Margue was again questioned; and from her answers, which
were now true, we learned that four months previously she had
had a fall by which her shoulder was injured, Neither frac-
ture nor dislocation could be detected by a surgeon to whom
she applied; but being dissatisfied, she consulted a bone-setter,
who said her shoulder was out, and used immoderate violence
in pretending to set it to rights. The condition of the arm
for which she was admitted was the consequence of this
violence; but she dated the origin of the axillary swelling to
a fall on the elbow which she had some days subsequent to
her admission into the hospital. The wound was closed with
plaister, compress, and bandage.

_ But some more decisive measures were called for in order
that the patient’s life might be saved, and I proposed tying
the sub-clavian artery where it passes between the scaleni
wouscles, To assure myself and others of the feasibility of
this operation, I performed it on the dead subject repeatedly
and without difficulty. Some such decisive step was now
rendered essential; for the tumour, which pulsated, pressed
upwards the clavicle, and an indistinct whirring sound, such
as attends the passage of blood from an artery into an aneu-
rismal sac, was audible. The division of the swelling into two
parts was now also ascertained, the smaller of which pulsated,
and extended below and along the clavicle; the larger fluc-
tuated. There seemed to be no reasonable objection to the
operation ; for, though the clavicle was raised by the tumour,
this disadvantage to the operator was amply compensated for
by the guidance which the pulsating artery afforded. Gan.
grene of the limb from privation of blood was another result
suggested ; but, how many considerations founded on theory
disappear at the bed-side of the sick! Moreover, English
surgeons had succeeded in tying the external iliaqartery, which
is to be regarded as the more serious operation of the two;
and the scapular branches of the subclavian trunk subserve the
same purpose in the collateral circulation, as the obturator
and ischiatic branches of the internal iliac in the lower. Finally,
PRINCIPAL ARTERIAL TRUNKS. 37

certain death awaited the patient if left to herself. These
considerations induced me to propose the operation, but un-
fortunately M. Pelletan, whose position made his verdict deci-
sive, did not take the same view of the case, and preferred the
adoption of milder measures; and thus French surgeons were
robbed of the honour of being the first to perform this beautiful
operation.

The treatment by Valsalva’s method was adopted, and the
patient was at once bled. This prostrated her very much;
and on the fourth day a slough separated, followed by hemor-
rhage. This was shortly succeeded by further loss of blood,
from which the patient did not rally; and she expired on the
morning of the 20th of May.

Before examining the body, the external charac‘ers of the
tumour were the subject of observation. It was very large,
and pressed forwards the great pectoral, and backwards the
latissimus dorsi, muscles. The superjacent integument was of
a dark livid hue, and exhaled a distinctly gangrenous odour.
There were two openings in the skin, one of which was the seat
of puncture, and the other the spot from which slough had
separated ; and from both a bloody fluid oozed. The integu-
ments being carefully raised, the two pectoral muscles were
detached from their origin and turned back. Some further
dissection displayed the tumour in its full extent. It was
equal, at least, in size to an infant’s head. Above the tumour
the artery retained its ordinary calibre for about two inches in
extent, so that it might have been tied at this point, if a
ligature can be placed upon this vessel below the clavicle.
This bone was very much pushed upwards; the vein was but
little disturbed, being situated external and anterior to the
artery; and the relation of the latter vessel to the brachial
plexus of nerves was unchanged,

At the border of the tumour there was a considerable dila-
tation of the arterial parietes, which was separated from the
main swelling by a deep depression, in which were lodged the
median nerve and axillary vein; the latter of these was in a
disorganized state. A probe introduced into an opening made
in the dilated portion of the artery, readily found its way into
the cavity of the tumour ; and, in like manner, when introduced
into a healthy part of the artery, it passed into both the
88 LIGATURE OF THE

aneurismal dilatation and the interior of the tumour. On
laying these open, the larger one was found to be bounded by
the cellular tissue, and containing clots of blood; it was this
which had been mistaken for an abscess. The interior of this
tumour communicated with the true aneurism by an orifice at
the back and outer part of the latter; the laceration having
probably been the consequence of the violent blow on the
elbow sustained by the patient. The neighbouring muscles
were shrunk. Below the tumour the artery was much di-
minished in calibre; and immediately beneath the sac the
obliteration was complete; a fact which accounts for the absence
of the pulse on the affected side.

In reviewing the chief points of this case, we caunot but
conclude that the aneurism was occasioned by the severe
pulling to which the arm had been subjected by the bone-
setter; an analogous case is reported by M. Flaubert, in the
‘ Répertoire d’Anatomie,’ as having occurred at the Hétel-Dieu
of Rouen. The error in diognosis is deserving of notice, as
proving the existence of difficulties, especially in cases of
tumours, in that branch of the healing art which is regarded
as most sure and free from such mistakes. The employment
of a grooved needle is advisable wherever a doubt exists as to
the nature of a tumour. The present case was clearly one of
true aneurism, complicated with false or secondary aneurism
by the rupture of the sac. The distension of the integuments,
and the compression and cold employed to restrain the hemor-
rhage, sufficed to account for the gangrene which ensued.

I was convinced by the foregoing case, that ligature of the
subclavian would have been the proper treatment, and deter-
mined to perform this operation in any similar instance which
might present itself. Many years, however, elapsed before the
opportunity was afforded me, during which I tied successfully
the common carotid and external iliac trunks. At length, in
1819, a man came to the Hétel-Dieu, with axillary aneurism,
the details of whose case I now proceed to narrate.

Case 1V.—Ligature of the subclavian artery for Salse
axillary aneurism.—-C. le Chevalier, aged 37, by trade a joiner,
but for many years a soldier, was admitted into the Hétel-
Dieu, in February, 1819, with false aneurism of the left axillary
PRINCIPAL ARTERIAL TRUNKS: 39

artery. Having been taken prisoner in Spain, in 1811, he
tried to make his escape, but was pursued by a horseman in
charge of the prisoners, and struck down by a blow with a
sword on the back part of the left shoulder. He fainted from
loss of blood; and the wound was then dressed. In three
weeks the small wound was healed, without any further
bleeding.

Two months afterwards the patient felt a small pulsating
tumour, about the size of a nut, in the axilla. This continued
to increase in size during the two years that he was kept a
close prisoner, until it attained the size of a hen’s egg, and
the pulsation became more forcible. The fatigue attending a
long march further aggravated the symptoms; and the large
size of the tumour, together with the suffering it entailed, and
his incapacity for work, at last induced him to come to the
Hotel-Dieu.

On admission, the cicatrix of his wound was apparent, being
situated in the depression which separates the teres major from
the teres minor, and subscapularis. The tumour occupied the
axilla, and was as large as the head of a child a year old;
rounded but uneven, especially at its lower part, and covered
with distended veins; it was hard and resisting to the touch,
and pulsated strongly. It raised the arm from the side, and
distended the great pectoral muscle, pushing upwards the whole
shoulder, and deepening the depression behind and above thé
clavicle. The arm was attenuated; the fingers were numbed ;
and the movements of the limb were limited ; the brachial artery
and its branches did not pulsate, but the heat and sensibility
of the surface generally were unchanged, The subclavian
artery pulsated strongly; and when compressed by carrying
the finger down deeply behind the clavicle, the tumour also
ceased to pulsate.

Under these circumstances something decided was required,
and the question was what should be done. My objection to
Valsalva’s treatment was, that I had frequently observed this
debilitating practice had the effect of weakening the action of
the heart less than that of the aneurismal swelling, and thus
tend to a fatally rapid enlargement of the latter. Compression
beyond the tumour was obnoxious to the objection, that, by
retaining the blood in the sac, and thus concentrating the
40 LIGATURE OF THE

force of the circulation upon its parietes, it would tend to
produce rupture of the aneurism ; pressure, again, made upon
the sac itself, would probably produce immediate gangrene.
Lastly, compression above the sac would scarcely be regarded
as available. in a case like the present.

The only alternative, therefore, was to tie the artery; and
then came the further question, whether the ligature should
be applied below the tumour. The result of such an attempt
on the femoral had proved its disadvantages. Brasdor had
proposed this plan to the old school of surgery ; and Deschamps
had practised it in a case of extensive aneurism in the upper
part of the thigh. A ligature was passed, with great difficulty,
below the sac, but its increase was so rapid, that on the
fourth day rupture appeared imminent; and a new operation
was then decided on; two ligatures were placed on the artery
above the aneurism, and one below it; but the loss of blood
during the operation was so considerable that the patient died
eight hours afterwards.

Should the sac be opened, and a ligature be placed on the
artery above and below it? In the first place death from
hemorrhage would be a probable consequence of such a pro-
ceeding ; or if the patient survived the operation, the exposure
of the interior of so large an aneurism must be followed by
inflammation and suppuration, which would speedily prove fatal,
by involving the neighbouring parts.

I therefore determined on adopting the alternative of plac-
ing a ligature around the artery above the tumour. Still,
another question remained to be solved : which part of the sub-
clavian trunk (for the axillary was out of the question) should
I select for this operation? The subclavian artery may be
divided into three distinct parts on the left side; the first
comprising that division between its orifice and the scaleni
muscles; the second, whilst it is between the scaleni; and the
third extends from these muscles to the front of the first rib.
This third division is sufficiently superficial in thin people with
low shoulders; but where the shoulders are high and the neck
is short, and especially when a tumour exists (as in this case)
to displace the clavicle upwards, the artery is deeply buried
behind this bone. Further, in this position, the nerves are so
closely associated with the artery, that it is difficult to separate
PRINCIPAL ARTERIAL TRUNKS. 4)

them from it. This latter objection does not apply to the
second division of the artery, which here lies isolated between
the scaleni, and separated also from its accompanying vein.
The depth at which the vessel lies, in the first part of its
course, together with its proximity to the pleura and lungs,
render the operation of placing a ligature around it here both
difficult and dangerous,

For the above reasons, the middle division of the course of
the subclavian artery was selected for operation; and asa preli-
minary caution the patient was bled. He was placed on a couch,
in the recumbent position, and I commenced by making an inci-
sion, extending somewhat obliquely from above downwards and
outwards, at the lower part of the left side of the neck and about
an inch above the clavicle. After a little dissection the outer
border of the scalenus was sought for, and when found it was
completely divided near to its insertion with a button-pointed
bistoury. The artery could then be felt distinctly pulsating at
the bottom of the wound: A curved director was carried round
the vessel, and a probe, armed with a silk ligature, was passed
along the groove and brought out on the other side. Having
ascertained by repeated trials that the artery alone was included
I tightened the ligature, and all pulsation in the tumour imme-
diately ceased. Scarcely any blood was lost during the opera-
tion ; three small arteries had been tied at its earliest stage.
The wound was lightly dressed; and the arm, supported by a
pillow, was surrounded with bags of hot sand.

- During the day the patient complained of slight pain in the
throat, and was therefore bled; the tumour continued without
pulsation. He passed a quiet night; and on the following day
the arm retained its warmth, muscular power, and sensibility :
there were slight darting pains in the tumour. On the sixth
day the wound was suppurating healthily, and the tumour had
diminished in size. The bowels not having been moved, a pur-
gative was administered, which had the desired effect. On the
eleventh day the ligature came away, without the least loss of
blood. Seventeenth day; the wound closing, and purulent
discharge diminished ; tumour reduced by one third, and pulse-
less. Thirtieth day; wound almost healed; patient began to
use his arm; sac still contracting in size, but soft and fluc-
tuating, as if it threatened suppuration. Goulard lotion or-
42 LIGATURE OF THE

dered. From this date the patient continued to improve steadily;
the tumour became firm, and diminished to one fifth of its
former bulk at the end of eleven weeks. The warmth, sensi-
bility, and muscular power of the limb remained unimpaired.
The circulation was characterized by a peculiarity common to
all limbs in which the principal artery has been tied, viz., that
the arteries are entirely without pulsation; to the touch they
appear full, but the blood, in passing through the collateral cir-
culation, ceases to be influenced by the heart’s action, and the
vessels are therefore pulseless.

In the course of a few months after quitting the hospital,
Chevalier resumed his former occupation, and continued free
from any complaint for three years. At the end of this time,
he was attacked with inflammation in the axilla, after excessive
exertion, and was again admitted into the Hétel-Dieu. There
was a swelling as big as a fist in his arm-pit, and the skin over
it was thin and red, appearing at one point as if about to
burst. There was no pulsation in this tumour; and as the
patient had suffered from rigor and was constitutionally ill,
there was little doubt that matter had formed. The patient
objected to an opening being made, and therefore the pus was
allowed to discharge itself spontaneously, which it did in the
course of a fortnight, in great abundance. The character of
the secretion, mixed with broken-down clots, indicated the
source of the suppuration; but not a single drop of arterial
blood escaped. The aperture was enlarged, and the patient
made a good recovery, leaving the hospital in about a couple of
months afterwards quite well.

There are many points of interest and deserving of attention
in this case, both in reference to the disease itself, and the ope-
ration adopted for its relief.

In a recent case of axillary aneurism near to the brachial,
the artery may be tied between the tumour and the clavicle.
But in more advanced cases, where the tumour has attained a
large size, and occupies the axillary close to its origin, it is re-
quisite to tie the subclavian. M. Pelletan attempted to place
a ligature on the axillary artery immediately beneath the cla-
vicle, for a large aneurism filling the arm-pit, yet leaving a
considerable interval between the tumour and the clavicle; but
the operation was abandoned after several ineffectual attempts
PRINCIPAL ARTERIAL TRUNKS. 43

to carry the ligature round the artery, which were frustrated
by its extreme depth. The patient died of inflammation of the
chest, at the end of three weeks.! Even in attempting to tie
the subclavian artery, the operator may be foiled by the enor-
mous development of the tumour, and the displacement of the
clavicle: this happened to Sir A. Cooper,”

The peculiarity of the operation in the foregoing case, is the
position selected for the application of the ligature and the di-
vision of the anterior scalenus for the purpose of exposing the
artery. By this proceeding, which is both simple and sure, the
artery is most readily found, and all risk of injuring or tying
either vein or nerves is obviated.*

Compression or lesion of nerves seems to be the most com-
mon cause of gangrene after operations for aneurism, Cases
have been recorded by Dr. Orpen and by Van Swieten, where,
after spontaneous cure of aneurism, the limb has continued
useless, apparently from long sustained pressure on the nerves.

We learn also from the above case, that the collateral circu-
lation is equal to the task thrown upon it, whether near to or
distant from the trunk. Many cases are recorded, which illus-
trate the correctness of this remark. Lastly, we are taught
what course nature takes to rid herself of an useless mass of
blood still retained within the original aneurismal sac. Inflam-
mation is established, and suppuration ensues; and thus, by a
spontaneous opening of the sac, without risk of hemorrhage,
the offending matter is cast off and the cure is completed.

Casz V.—False consecutive aneurism of the right axillary
artery, treated by ligature of the subclavian, Jacques Marie
Clologe, aged 38, a custom-house officer, was admitted into the
Hétel-Dieu, in March, 1819, with aneurism of the right axillary
artery. Six years previously he had been the subject of a se-
vere attack of syphilis, followed by gonorrhcea on two occasions.
He suffered, in consequence, from disease of the nasal bones,
deafness, pains in the bones, &c, He was cured of these affec-

1 Pelletan; ‘ Clinique Chirurgicale,’ tom. ii, p. 40.

2 ¢London Medical Review,’ t. ii, p. 300.

3 This appears to be the commentary of the French editor, who takes no notice
of the serious risk to the phrenic nerve in this operation. The suceeding remarks

also seem to come from the same pen.—T.
44, LIGATURE OF THE

tions, and his general health had been for some time very good,
when he was wounded at the siege of Strasbourg. The injury
was inflicted by a Cossack’s lance, which penetrated the interval
between the great pectoral and deltoid muscles on the right
side of his chest, and about three inches below his clavicle.
This occurred in 1815.

He lost a large quantity of blood and fainted, when the he-
morrhage ceased spontaneously. In a fortnight, the small
wound had healed and the arm in part recovered its mobility ;
but after the lapse of a month, a pulsating tumour, about the
size of a pigeon’s egg, made its appearance in the axilla, unat-
tended, however, with any discoloration of skin. The hand and
arm swelled, but the patient continued to work; the tumour
increased in size, the pulsations becoming more forcible, and
the pain suffered more severe. For six months he was kept in
bed, and had the whole limb, as high as the tumour, firmly
bandaged. This treatment was attended by some reduction in
the general swelling of the arm and the size of the tumour, as
well as diminution in the force of its pulsation. The patient
was then set at liberty, and for nearly two years was entirely
free from any inconvenience, except that he could not use the
affected arm. The hand was wasted, and the fingers were much
flexed. He came to Paris three months before his admission ;
and a week prior to the date of his applying at the hospital,
without any assignable cause, the tumour suddenly increased
during the night, and its subsequent extension was attended
with excruciating pain.

When admitted, the cicatrix of the original wound was still
apparent. In the axilla, and extending as high as the clavicle,
there was a large, colourless swelling, the skin covering which
was very thin, and traversed at parts by distended veins, The
strong pulsation in this tumour—synchronous with that of the
heart—the tension and thinning of the skin, and the acute suf-
fering of the patient combined to suggest the impression that
it would speedily burst. As a consequence of the disease, or
perhaps of the treatment which had been adopted, the hand
was wasted, and the fingers were much bent ; the corresponding
clavicle was forced upwards, and the subclavian artery sunk into
a deep hollow ; and the arm, which was raised from the side by
the tumour, was powerless. The pulse at the wrist was but just
PRINCIPAL ARTERIAL TRUNKS. 45

perceptible. The patient suffered acutely and without inter-
mission; he perspired profusely and got no sleep. He was
bled, and an evaporating lotion was applied to the swelling.

During the night all the symptoms became aggravated, and
he was again bled, with some relief. On the following morn-
ing he was much prostrated; and as there could be no doubt
about the nature of the disease or the proper treatment to be
adopted, the operation of tying the subclavian artery, as in the
previous case, was proposed, and gladly acceded to by the pa-
tient. It should be remarked that the subclavian artery could
be felt pulsating, by carrying the finger down to it above and
behind the clavicle; and that pressure in this position arrested
the pulsation in the tumour.

Standing on the left of the patient, I made an oblique in-
cision from the border of the sterno-mastoid downwards and
outwards towards the clavicle, dividing the skin, subcutaneous
cellular tissue, and several small arteries which required liga-
tures, A paroxysm of pain interrupted the operation, which
was resumed after the lapse of a quarter of an hour. A
grooved curved probe was passed, with some difficulty, beneath
the artery; but on attempting to introduce a stylet, armed
with a ligature, I was foiled, as it would not follow the curve
of the probe. At this stage of the operation, in endeavouring
to disengage the artery from its connections to the plexus of
nerves and the surrounding areolar tissue, a sudden jet of
scarlet blood arrested the attention, this was stopped by press-
‘ing with the finger at the bottom of the wound, and the bleed-
ing did not recur when the pressure was removed. It -was
evident, however, that either some artery had furnished this
blood, or that the sac had been opened.

One extremity of a grooved probe was then perforated, and
this occupied a quarter of an hour; after which, this instru-
ment was passed around the artery, and threaded with a
needle armed with a ligature. After removing the probe the
ligature was tied, the effect, of pressure upon the artery having
been tested previously by raising the probe, and found to be
satisfactory. The agony occasioned by tightening the ligature
induced an apprehension that some nervous trunk had been
included, a second knot was therefore tied without further in-
creasing the pressure, for I knew that it was not essential that
46 LIGATURE OF THE

the ligature should be tight to produce inflammation and ob-
literation of an artery, and that temporary ligatures had
answered the same purpose. Pulsation ceased, but there was
still an almost imperceptible vibration or tremor in the swell-
ing. A reserve ligature was left at the lower part of the
wound ; and after the application of a simple dressing, the
patient was carried to bed.

During the day he suffered a good deal in the back of the
neck, but the pain had entirely left the tumour; and pul-
sation was no longer perceptible, either in the swelling or in
the radial artery at the wrist. The limb was surrounded with
heated sand-bags, and retained its natural temperature, as well
as its sensibility and muscular power. There had been no
loss of blood since the operation; and the patient had per-
spired profusely. In the evening the limb was slightly be-
numbed, and a tremor or vibration could be felt on placing the
hand on the tumour.

After a quiet night, the patient continued comfortable. The
tremor in the swelling was more distinct, but he was free from
pain ; and this favorable condition was uninterrupted for the
first twenty-four hours. I may here remark, that the opera-
tion was protracted by unforeseen delays; and that much
difficulty would have been obviated by division of the anterior
scalenus muscle. Moreover, the large size of the tumour,
by raising the shoulder, threw the artery into a deep depres-
sion behind the clavicle.

On the second day, there was a return of pain, and want of
sleep ; the vibration in the tumour was still more apparent.
On the third day, this increased to distinct though slight
pulsation. Ice was applied, but removed on the pain becoming
aggravated; and afterwards the tumour seemed to become
larger and more painful. A restless night succeeded; and on
the fourth day the tumour had still further extended itself,
and pulsation in it became more distinct. The skin had
assumed a purple hue, and dark-coloured vesications had ap-
peared here and there.

I was perplexed to acconnt for this return of pulsation ;
for, though I was prevented from drawing the ligature as
tightly as I should otherwise have done, by the conviction on
my mind that a nerve was included, it was, nevertheless, tight
PRINCIPAL ARTERIAL TRUNKS. 47

enough to arrest the flow of blood on the first’ day. The
pain still increasing, some blood was taken from the arm.
In the night hemorrhage from the wound took place, which
was stopped by the introduction of a finger into the wound ; a
compress was afterwards applied.

On the fifth day, the patient presented a pale and ema-
ciated appearance: his suffering was great, and the tumour
continued to pulsate. He lost more blood in the course of the
day, but the hemorrhage was arrested by tightening the band-
age which confined the compress. It again recurred, however,
on the sixth day, when an attempt was made to render the
temporary ligature available; but this was rendered abortive
by the extreme pain it occasioned. Further bleeding took
place in the night. On the seventh day, the little finger be-
came gangrenous. Ice was continued-.to the tumour, but
without controlling the pulsation in it. During the succeed-
ing night, the patient became suddenly insensible and con-
vulsed ; respiration was short and frequent, and the pulse rapid
and irregular, This state continued through the eighth day ;
stimulants produced only a temporary revival, and he ulti-
mately died comatose in the afternoon.

Autopsy.—tThe great and small pectoral muscles and the
deltoid were raised, distended, and wasted. Some rather soft
clots of dark blood had penetrated to the front of the tumour,
pressing before them the great pectoral and deltoid muscles,
which at this spot were converted into a blackish mass; and
the superjacent skin, which was traversed by dilated purple
veins, gave out a gangrenous odour. ‘The thin layers which
surrounded the tumour on its sides and back, broke under
pressure rather than were crushed. The centre of the tumour
was occupied by dark, semifluid blood, and this extended in a
thin layer external to the clots first mentioned ; as much as
two pounds was removed in all. At the bottom of the cavity,
a small aperture, four lines long and one wide, was perceived,
and this communicated with the artery. The lining mem-
brane of the vessel seemed to extend for about an inch and a
half from the circumference of this opening, right and left ;
and was supported by a thick, red tissue, containing osseous
concretions, similar to those so often met with between the
inner and middle coats of an artery. There was no line of
48 LIGATURE OF THE

demarcation indicating the exact point of origin of these
tissues, which surrounded a cavity capable of containing a
hen’s egg. Another larger cavity surrounded this, having for
its parietes all the muscles mentioned above, and extending
from ‘the clavicle to the middle third of the upper-arm. The
interior of this larger cavity was irregular, and its sides black ;
and there was a direct communication between the two by a
ragged opening, the larger cavity having also been rent on the
inner side of the artery, and thus permitted the escape of blood,
which had diffused itself amidst the nerves of the brachial
plexus.

Below this point, that is behind the tendon of the great
pectoral muscle, a rounded, uneven tumour was seen to spring
abruptly from the dilated artery. This was developed on all
sides, but especially outwards, and to the extent of two inches
along the vessel, so that its point of origin from the artery
could not be seen until it was raised and drawn on one side.
The exterior of this tumour was formed of elastic white tissue,
similar to the outer coat of arteries: internal to this was a
reddish tissue containing osseous concretions; and the lining
membrane was that of the artery itself. The parietes of this
sac became thinner, as they receded from the artery; and at
the distance of a few lines were immersed in the black blood
which has been mentioned as filling the great cavity.

The internal mammary artery, and some of those supplying
the neck, seemed abnormally dilated at their origin. The
posterior scalenus muscle was slightly involved in the wound.
The inferior of the three brachial nervous cords was included
in the ligatures; whilst the artery itself was perforated with-
out being completely enclosed in the nooses. Pus and dark
blood filled the wound.

The posterior part of the left hemisphere of the cerebrum
presented a greenish hue beneath its membranes; more deeply
the substance of the brain was soft, grey, and disorganized ;
and some greenish fluid escaped from the part. The structure
of the brain generally was somewhat firmer, and permeated by
injected vessels, The disorganization extended about two lines
in depth, and communicated with the ventricle of the same
side, although the arachnoid lining of this cavity was very
little altered in character. The pia mater was a litte injected.
PRINCIPAL ARTERIAL TRUNKS. 49

Air was extravasated beneath both membranes. The other
organs were healthy.

This case is valuable in illustrating the course, the symp-
toms, and the progress of aneurismal tumours. It also exhibits
the importance of not trusting too entirely to the best laid
plans for performing an operation, as new features so com-
monly present themselves in particular instances, taxing the
ingenuity and resources of the operator, and demonstrating
the absurdity of attempting to reduce surgery to the condition
of a strictly mathematical science. The casualties attending
such operations are also exemplified; and the post-mortem
appearances furnish an interesting commentary on the forma-
tion and development of aneurismal tumours. I would throw
out as a suggestion that, possibly, the accident of wounding
the artery and tying the nerve might have been obviated by
dividing the anterior scalenus muscle.

The case which I shall relate next is one of ligature of the
common carotid artery, for a disease consisting in dilatation of
the arteries, and the original development of an accidental
tissue, similar to that of the corpora cavernosa penis (aneurism
by anastomosis). The gravity of diseases affecting the carotid
artery and its branches, had often made it a subject of regret
that the same treatment could not be adopted in reference to
them as to the arteries of the extremities.

Yet many considerations seemed to encourage the expecta-
tion that such operations would not be unattended by success ;
for, frequently the carotids had been tied, singly or at the
same time, in the lower animals, without danger; but, with
perhaps too scrupulous a rejection of the dogma—that what
applies to animals generally may be equally applied to man—
surgeons left these experiments in the hands of physiologists,
and thus threw away the opportunity of generalizing on a
subject which afforded such natural and reasonable grounds
for a practical deduction. Nor were the numerous decided
examples of spontaneous obliteration of the carotid trunk
regarded as a sufficient justification of the operation; for,
though such instances were unaccompanied by any functional
disorder of the brain, it was well known that a process of
gradual diversion of the circulation is much less hazardous to
the parts supplied than its sudden arrest.

4
50 LIGATURE OF THE

Other motives likewise influenced surgeons in shrinking
from this operation. The impracticability of compressing the
carotid in case of accident ; the number and importance of the
nerves, veins, and other parts around the vessels, and the
difficulty of excluding all from the ligature; and finally, the
risk attending a sudden interruption of the supply of blood to
the brain, the importance of which could not but be regarded
as of a far graver character than where a limb was the seat of
operation.

Further observation and experience demonstrated the fallacy
and groundlessness of many of these objections; as, for instance,
the difficulty of disentangling the artery from the adjacent
tissues, or the lack of blood, from the interrupted circulation,
to the brain. Surgeons also learned that, however essential
it is to be able to command the supplying artery, in the
operation of laying open the aneurismal sac, it is needless in
Anel’s operation of tying the artery between the heart and
sac.

Still, in spite of these ascertained facts, patients were allowed
to suffer and die, until Sir Astley Cooper’s first case paved the
way to a bolder and better practice. It is true he was unsuc-
cessful the first time; but the failure was due to circumstances
which were unconnected with the operation. His second
attempt succeeded, as the operation has in almost every in-
stance since.

The following case is interesting, both as an illustration of
the safety of the operation, and of a singular disease.

Cast VI.—-Ligature of the carotid artery in a case of aneu-
ri3mal dilatation of the arteries of the ear, temple, and occiput,
§c.—E. Dumand was admitted into the Hétel-Dieu, in April,
1818. He was 20 years of age, of feeble constitution, tall,
spare, and of bilious temperament ; he followed the trade of a
wheelwright. He had had from birth two little spots, com-
monly called wine-marks, on the outside of the concha of the
right ear ; but there was no deformity beyond a little thicken-
ing at the stained spots. The only inconvenience he experienced

' [Regarding the influence exercised on the brain by the sudden interruption of
the current of blood through one of its supplying trunks, the reader would do well
to consult more recent authorities.—T.]
PRINCIPAL ARTERIAL TRUNKS, 51

was an itching sensation, which led the child to scratch the
part ; whenever, in so doing, he injured the skin, scarlet blood
flowed from the wound.

At twelve years of age the ear began to enlarge, and changed
its colour to a dark violet. In the course of three years more
he was conscious of slight movement in the part, and the ear and
spots had increased to twice their original size. Eight months
after he first experienced pulsation in the part, hemorrhage
was occasioned by an attempt to snatch his hat from his head,
and was difficult to suppress. The patient was thereby reduced,
but the symptoms were for a brief season ameliorated. They
soon, however, assumed their former activity, and the youth
was induced to abstain from any physical excitement, in conse-
quence of noticing that the volume and pulsation of the ear
were thereby augmented. Temporary benefit was derived
from pressure on the affected part; but after the lapse of some
months a second hemorrhage took place spontaneously, and
stopped of itself. A third and fourth bleeding drove him to
seek medical aid; and styptics and pressure were vainly tried
in the hope of arresting the progress of the disease.

He then went to the Hétel-Dieu at Sens, where, after an
attempt to compress the supplying arteries, which could not be
borne, these, viz.—the temporal, auricular, and occipital, were,
at intervals, successively tied. But the relief was only partial
and temporary, and the bleeding recurred. Lastly an attempt
was made to tie the external carotid; but, in my opinion, it
was only the dilated temporal branch that was taken up. Be
that as it may, the result was not more encouraging than in
the previous operations. The patient returned home ; and the
disease still increasing, he determined to come to Paris.

The diseased ear was twice as long as the other, and as thick
as a finger; the helix and antehelix were obliterated. The
whole ear was of a dark violet-red colour, soft and compressi-
ble; pulsation was distinct to the eye as well as the hand, the
ear being raised, at each beat of the heart, from the side of the
head. Nearly the whole of the hairy scalp covering the
temple and occiput was of a bluish colour, and presented an
uneven surface. Pressure on the common carotid arrested all
pulsation in the tumid part, which became at the same time
pale and shrunk. On removal of the pressure, the diseased
52 LIGATURE OF THE

tissue again became distended and red, and pulsated with even
increased violence for a time. The part appeared to the
patient to be hotter than natural; and the force with which
the blood was injected into it was -productive of even a
painful: sensation. His health, as well as his sight and
hearing, was unimpaired.

‘Two distinct elements evidently co-existed in the formation
of this diseased‘-mass. One was developed in the form of
broad, sinuous, irregular and knotty conduits which crept over
the temple and ear, to which they imparted a wrinkled appear.
ance. These.conduits were full and compressible, and divided
and subdivided, until they decreased from the size of the little
finger to that of a crow-quill; and thus could be traced into
the substance of the skin. The arrangement of these conduits
and their synchronous pulsation with that of the heart, left
no doubt as to their arterial origin. The other element was
analogous in its structure to the normal erectile tissue, met
with in the corpora cavernosa penis and other parts of animals ;}
and this filled the interstices of the network formed by the
dilated arteries, and imparted the violet hue, the increased
temperature, and other peculiarities noticed in the diseased
mass. The hemorrhage was due to lesion of this element;
and this accounted for the blood flowing instead of being emitted
in jets.

The history and circumstances attending the case, proved
to my satisfaction that nothing short of tying the common
carotid would hold out any prospect of a cure; and I accor-
dingly performed the operation on April 8th, in the following
way. The patient being placed in a recumbent posture, an
incision three inches in length was carried along the inner
border of the sterno-mastoid muscle ; and on this muscle being
drawn outwards and the larynx a the artery was readily
exposed. A grooved director was first passed beneath it; and
along this an appropriate needle, armed with a single ligature
consisting of four threads waxed together, was introduced.
After the experiment of drawing up the ligature so as to prove
its power in arresting the supply of blood to the diseased part,
and which was satisfactory, it was tied, without any other
unpleasant symptom than a pain felt at the instant in one of

' [An account of these normal tissues has been omitted.—T.]
PRINCIPAL ARTERIAL TRUNKS. 53

the right bicuspid teeth. Though materially diminished in
size, the ear did not shrink so much as was anticipated ; this
was attributed to the retention of the blood in the erectile
tissue ; but the pulsation had entirely ceased.

The patient was wearied by having been subjected to ex-
amination and questions during the day; and to this I in great
measure attribute a violent headache from which he suffered
in the evening; he also had some numbness in the arm of the
opposite side, and vomited his broth. He was bled, and had
a mustard bath for his feet.

On the following day the headache had abated, but he
again vomited ; the mustard bath was repeated, and nothing
but slops ordered. On the third day, these symptoms had
nearly ceased: there was no pulsation in the tumour, nor in
the arteries leading to it; the ear itself was diminished in
size, but continued red and hot. On the tenth day, the size
of the ear was reduced one third. On the twelfth, the ligature
came away; an abrasion on the surface of the swelling, which
bled before the operation, was suppurating kindly.

This favorable condition continued up to the eighteenth
day, the erectile tissue continuing still to decrease in volume.
Then, for the first time, a slight dilatation and contraction in
this part was perceptible, although there was no pulsation in
the supplying arteries. Careful compression was made on the
ear. On the thirtieth day, these movements were visible. At
the end of six weeks the patient had some constitutional dis-
turbance, which, however, speedily subsided. The wound of
the operation had then quite healed. At this period, and
subsequently, various forms of compression were attempted,
but ineffectually. Even a dense covering of plaster of Paris,
applied when the ear was emptied of its blood, failed; for the
expansive power of the tissue burst open the mould and broke
it into fragments. The only remedy, extirpation of the diseased
part, was forbidden in this instance by its extent. In fact, all
had been done that could be done, ‘in curing the aneurismal
dilatation of the arteries; the remaining disease is of far less
importance, and must be left to take its course, until the
general powers of the system begin to fail, when this diseased
tissue likewise may be expected to lose its active properties
and to degenerate.
54 LIGATURE OF THE

Case VII.—-Aneurism of the internal carotid, treated by
ligature of the common carotid artery. Death——E. Gogue,
aged 76, a widow, was admitted into the Hétel-Dieu, in July,
1818. She was thin and feeble, and had been subject from
childhood to palpitations and fainting fits, which recurred
every four or five months. Eight years previously she first
perceived a small lump behind the angle of the jaw on the
left side; for a long time this did not sensibly increase, but
during the last three months, it had grown so rapidly that she
was induced to apply for surgical advice.

At the time of her admission, the tumour had attained the
size of a young child’s fist, and extended from the os hyoides
upwards to the lobe of the ear, and from the angle of the jaw
backwards to the posterior border of the sterno-mastoid muscle ;
it projected about an inch from the surface, and also backwards
into the pharynx. Its outline was regular and oval, and its
consistence soft and elastic. It pulsated and expanded with
each beat of the heart; but this pulsation ceased when the
common carotid was compressed, and then the swelling
diminished a little in volume. She swallowed and opened
her mouth with difficulty; and the left half of the tongue
seemed to be partially paralysed. Her rest was disturbed,
but her health was otherwise good; there seemed to be no
disease of the heart.

The inference drawn from these signs was, that some branch
of the carotid was the seat of aneurismal disease ; and the age
of the patient rendered it probable that the whole arterial
system had undergone some morbid change. I should remark
that the patient complained of most acute suffering when the
carotid was compressed above the clavicle.

There were many circumstances which seemed to forbid an
operation in this case; but the certain, and probably early,
fatal issue of the disease, determined me to give the patient
such chance as surgical interference offered.

The patient was placed in the recumbent posture, with the
shoulders supported. An incision, about two inches in length,
was made along the anterior edge of the sterno-mastoid muscle,
down nearly to the clavicle. The intervening tissues being
divided, the artery was exposed below the omo-hyoid, and a
PRINCIPAL ARTERIAL TRUNKS. 55

single ligature was readily carried around it. Pulsation in the
tumour immediately ceased.

No untoward symptom occurred during the day. In the
evening the patient complained of great pain in the throat, for
which she was bled and leeched, with relief. But two days
later the wound assumed a grey colour; and subsequently con-
stitutional disturbance ensued, and was succeeded by prostration,
cough, and dyspnoea. She expired on the ninth day from the
operation.

Autopsy.—The brain, which was carefully examined through-
out, presented no trace of disease, either as regards consistence,
the presence of pus, apoplectic effusion, or other evidence of
inflammation, with the single exception of the lateral ventricles
containing four ounces of bloody serum. The membranes of
the cord were also healthy. The mucous surface of the whole
intestinal canal, from the cardiac orifice of the stomach down-
ward, was of an uniformly dirty grey colour, but otherwise
unchanged. There was no recent morbid change in the
lungs; but the left ventricle of the heart was considerably
hypertrophied, and the orifice of the aorta‘was narrowed. The
whole arterial system was more or less diseased, presenting the
osteo-calcareous form of degeneration in various degrees; at
some parts in smaller patches, and at the earliest period of
degeneration ; in others, the entire calibre of the artery was
more or less encircled by cartilaginous or osseous rings ; this
was particularly remarkable about that part of the aortic arch
which gives origin to the left subclavian artery. ;

On examining the carotid artery at the seat of ligature, it
was found to be surrounded by a large abscess, the contents of
which had only partially emptied itself by the external wound,
the pus having also burrowed into the chest as low down as
the posterior mediastinum. The oval aneurismal sac was
developed from the outer side of the internal carotid, and
appeared to have diminished in size since the operation.
Above and externally, it was covered by the thinned sterno-
mastoid muscle, beneath which, and farther forward, was the
eighth pair of nerves and the internal jugular vein, the latter
still pervious, though contracted. In front, the sac was covered
by some branches of the cervical plexus and the platysma, and
higher up, by the digastric and stylo-hyoid muscles. Internal
56 LIGATURE OF THE

to it was the external carotid and its branches, the ninth nerve,
and the pharynx.

When the parts were removed, it was palpable that the
tumour resulted from a rupture of the external wall of the
internal carotid artery. The orifice in the vessel was two
lines wide, and the edges of the opening could be traced for
a short distance into the sac; the internal wall of the artery
was quite sound. The interior of the sac presented
several osseous incrustations, which no doubt originally formed
a part of the wall of the artery. The sac, which was soft,
contained some dark but recent coagula, and a small quantity
of liquid blood. Where the ligature was applied on the com-
mon trunk, it had entirely given way at one point; but at
other parts the continuity of the vessel was maintained by the
integrity of the outer coat, the middle and inner coats having
retracted to the extent of a line above the point where they
were cut through. A small clot had formed below the ligature,
and its upper extremity was covered by a pink layer of albu-
minous matter, the product of inflammation, which was in
contact with the outer coat of the artery.

In both the inferior mesenteric and right common iliac
arteries, there were small aneurismal dilatations, arising from
the same cause,—viz., degeneration of the elastic coat of the
vessels. The veins, as far as they were examined, appeared to
be healthy.

This case illustrates, in an interesting manner, the origin of
that form of aneurism which may be denominated “ senile.”
The column of blood, acting on the deteriorated tissue of the
middle coat, distends the outer coat, and this in turn gives
way. The effects of the ligature corresponded with what
experiment had shown before; and the presence of the clot
proved the reparative effort of nature. If the operation had
succeeded, the patient’s life would have been prolonged; and
this is a justification of its performance.

The following abstract of a case in which the carotid was
tied, illustrates the occurrence of hemiphlegia after that
operation.

A youth, aged 18, was admitted into one of the Paris hospitals,
in 1834, with a pulsating tumour on the left temple, above the
zygomatic arch. It had existed about fifteen months ; pressure
PRINCIPAL ARTERIAL TRUNKS. 57

on the carotid arrested its beating. Opinions were divided as
to the exact nature of this swelling, some thinking it aneuris-
mal, others regarding it as an erectile tumour. The surgeon
under whose care the case came adopted the former opinion,
and determined to tie the carotid. Both common and external
carotids were accordingly secured ; and after this double opera-
tion the pulsation ceased. For six days all went on favorably,
but on the seventh, after the separation of the ligature, bleeding
came on; and this recurred seven different times. The patient’s
strength gradually gave way, and he expired a fortnight after
the operation; hemiplegia of the right side having supervened
a day or two before death. On examination of the body, the

disease proved to be an encephaloid tumour, and no aneurism ;
‘the brain presented no morbid change to account for the
hemiplegia.

The causes of death after ligature of the carotid are various.
In a case related to me of a Russian soldier on whom this
operation was performed for wound of the external carotid, the
patient died after an attack of fever and delirium. In another
case, on which I operated myself for hemorrhage coming on
after a wound of the external carotid, the patient died exhausted
in less than a week.

In speaking of aneurism of the lower extremity, I may
remark that, with the exception of the external iliac, cases
requiring operation here are much more frequent than in the
upper extremity.

In comparing the case already described, in which I tied
the subclavian, with the next to be narrated of the external
iliac, many points of remarkable contrast present themselves
in the details of each, although they both terminated favor-
ably. But it is impossible to calculate on the course and issue
of such cases with certainty ; there are so many points associated
with the condition and constitution of the patient, the history
of the disease, &c., which frustrate the attempt to reduce the
prognosis to a mathematical certainty. The result of the two
cases alluded to would induce a conclusion that ligature of the
external iliac is fraught with much more risk and difficulty
than that of the subclavian; whereas, it is found to be gene-
rally the less difficult of the two, and not attended with more
danger.
58 LIGATURE OF THE

Different modes of operating, in placing a ligature on the
external iliac artery, have been proposed. The first consists
in dividing the abdominal parietes perpendicularly, in a line
extending from the outer border of the rectus muscle to the
point at which the artery passes beneath the crural arch. In
the second method, that of Abernethy, the incision is made
in the course of the artery, and straight; whereas, in Sir
A. Cooper’s operation, a semicircular incision is made, com-
mencing near the anterior superior spine of the ilium, and
terminating a little above the abdominal ring. This last
mode of proceeding is to be preferred, not only on account
of the facilities it offers for the performance of the operation,
but also because the peritoneum is thereby more secure from
the risk of injury. Care, however, should be taken not to extend
the incision too far inwards, so as to approach the ring, as the
epigastric artery would be thereby endangered. It is easier
to tie the external iliac in females than males, as the artery is
less deep. An accumulation of fat naturally enhances the
difficulties of the operation.

Casz VII.—Ligature of the external iliac artery.—F. Berger,
aged 45, formerly a soldier, but latterly a stone-cutter, of good
constitution but irritable temperament, was in the act of lifting
a plank, the corner of which rested on his groin, when he
experienced a sharp pain there; but its transient nature did
not interrupt his occupation. Two months afterwards, he
perceived a lump, as big as a nut, in the groin, about two
inches below Poupart’s ligament; but he took no heed of it.
A twelvemonth afterwards, on making an effort, the tumour
suddenly attained the size of a hen’s egg. Lastly, three weeks
before his admission into the hospital, he fell on the edge of a
large copper pan, his whole weight being received on this
unfortunate tumour, which increased so much that he was
sent to the Hatel-Dieu.

On his admittance (August, 1816), the tumour in the groin
was of the size and shape of a large pear, with its base above,
and extending a little above the crural arch. It alternately
expanded and contracted at each pulsation of the heart; and
these movements ceased on arresting the course of the blood
through the artery to the tumour. When the sac was par-
PRINCIPAL ARTERIAL TRUNKS. 59

tially emptied, its parietes were felt to be hard and irregular.
It was determined first to try pressure and the application of
ice before having recourse to the ligature.

In the first instrument which was constructed with this
view, the fulcrum or point of counter-pressure was the sacrum,
and the vessel was compressed against the pubes with the aid
of a pad acted on byascrew. Ice was applied over the tumour
in a bladder. LExcruciating pain was, however, occasioned,
and the patient could not bear the interruption of the circula-
tion for more than twenty minutes at a time. Subsequently,
a better contrivance was adopted, by which the movements of
the body did not influence the pressure. This was more on
the principle of a truss, and was very efficient, insomuch that
the tumour very sensibly diminished whilst it was employed.
But the patient, after a few days, became irritable under the
pain, and refused to submit any longer to this treatment,
urgently begging for the operation. Accordingly, after suita-
ble preparation, his wish was complied with.

The patient was placed recumbent; and 1 commenced the
operation by carrying an incision from a point an inch below
and before the spine of the ilium, to the outer border of the
crural ring. The skin and muscles being successively divided,
the areolar tissue around the vessels was exposed; this proved
to be remarkably dense, and contained a considerable number
of lymphatic ganglia, so that there was some little difficulty
in passing this ligature beneath the artery. This was ulti-
mately effected about an inch above the tumour; and another
reserve ligature was introduced about half an inch higher up.
When the knot was tightened all pulsation in the sac ceased.
During the progress of the operation, the patient made an
effort by which the edges of the wound were almost approxi-
mated, and the bulging of the intestines endangered the peri-
toneum. The interposed hand of an assistant obviated these
ditticulties.

Judging by the similar operations on the subclavian artery,
I anticipated a favorable progress and speedy cure, but was
disappointed in both expectations. I will refer to the various
drawbacks which occurred, as illustrating the importance of
judicious after-treatment as well as skilful manipulation.

The patient bore the operation without a murmur, but
60 LIGATURE OF THE

afterwards felt sick and faint. He was well supported in bed,
with his thighs bent on his pelvis, and the affected limb enve-
oped in bags of ashes and hot cloths. There was neither
numbness nor loss of muscular power in the extremity through
the day, and the temperature continued unabated ; indeed, to
himself the limb on the affected side seenied hotter than the
other, though this was not really the case. He complained
of pain in the epigastric region, and had continual eructations
of gas. In the middle of the day there was considerable
excitement of the circulation; and he passed a sleepless night.
He had nothing but slops.

On the second day the local symptoms were unchanged,
except that the limb appeared to have acquired an unnatural
temperature; it was, therefore, more lightly covered. The
stomach continued distended with flatus. The face was shrunk,
and the lips and tongue were covered with a dry and dark
coating. An injection of tamarinds in water produced a slight
feculent evacuation, with much gas, and relieved him. But
subsequently the pain, distension, and febrile excitement in-
creasing, he was bled; and afterwards slept. In the evening
he wandered a little; and the excitement of the circulation
returning, he was again bled, and injections were repeated.

On the third day there was general improvement; but the
bowels did not act, notwithstanding the use of castor-oil in-
jections.

On the fourth day there was still further improvement, and
it was followed by a night of sleep.

On the fifth day the wound was dressed. Suppuration
profuse. A small dark spot was perceptible at the outer angle
of the wound, probably occasioned by pressure. The tumour
was reduced to one third of its former size; and there was no
pulsation either in it or the arteries below. He was allowed
at this time broth and lemonade. The pain in the epigastrium
had subsided, but the eructations continued; and his tongue
was red and dry, and his pulse frequent. He was also troubled
with a slight cough. During the day he became slightly
delirious ; this ceased after a copious dark motion, which -was
brought away by injection.

On the sixth day the pulse was quick, and the tongue dry
and brown. There was perceptible, for the first time, a slight
PRINCIPAL ARTERIAL TRUNKS. 61

tremor in the tumour. A little beer was allowed him. He
passed a better night.

On the seventh day there was further improvement; and
several copious, liquid motions were passed. He had some
appetite. The wound was suppurating healthily, The tumour
pulsated perceptibly both to the touch and eye, on the eighth
day; and this increased on the ninth day, attended by pulsa-
tion in the abdomen, associated apparently with the trunk of
the artery above the ligature; but the tumour had further
diminished in size.

During the four succeeding days nothing particularly worthy
of notice occurred, except that the patient had troublesome
hiccup. His diet was improved.

On the fourteenth day the pulsation above the tumour
ceased ; and that in the sac itself was irregular and intermit-
tent ;—a peculiarity confined to this spot, as it was not per-
ceived in any artery at other parts of the body.

On the sixteenth day, both the ligatures came away spon-
taneously. The reserve ligature formed a small loop, the borders
of which were cemented with dried pus; that which was tied
tightly presented but a small ring, but containing no trace of
the divided artery.’

The improvement, both local and general, continued up to the
evening of the twenty-third day, when, after much restlessness
and the appearance of some streaks of blood in the pus, hemor-
rhage occurred, but soon ceased; so that when the dressings
were removed, its source could not be detected.

On the following day, the twenty-fourth, there was a second
and more profuse bleeding, accompanied by sharp pain in the
wound; the blood did not come in jets, but was unquestionably
arterial. Pressure made an inch above the wound produced
no effect; but when applied below the wound, the bleeding
stopped. A compress was accordingly fixed in this position.
The patient’s face, however, betrayed the effects of the loss of
blood, and eructation had again commenced.

1 I never used the reserve ligature after this occasion. Experiments have satis-
fied me, that there is greater risk of inducing hemorrhage than of preventing it by
their use; and that they cannot arrest bleeding, as the inflamed portion of the
artery on which such ligature would act, would readily yield under the pressure and
give way.
62 LIGATURE OF THE

It was perplexing to comprehend whence this bleeding arose.
When the artery was tied, it was distinctly seen, and the
pulsation in the sac ceased for six days. But subsequently,
when pressure was made on the artery above the seat of liga-
ture, it did not control the circulation through the sac. Its
supply must, consequently, have been obtained from a more
distant source. Compression of the abdominal aorta, indeed,
stopped the pulsation ; I therefore concluded that the collateral
circulation was established through the medium of the com-
munication between the internal iliac and internal mammary
arteries. Still the question arose, as to how the blood found
its way into the sac itself, as the femoral artery did not pulsate
below it. This, I conjectured, must be through the anasto-
mosing branches of the epigastric with the internal mammary ;
and, in tracing the course of the former vessel, this was proved
by the distinct and well-defined pulsation which could be felt,
through the abdominal parietes. Thus, so far from there being
any cause for apprehension that the collateral circulation
would be deficient, its freedom was the source of all the
existing inconvenience and risk, which bid fair to render the
operation abortive.

What, under these circumstances, was to be done? I
could not tell how far the profunda artery might aid in
supplying the sac; and, moreover, it seemed reasonable to
believe that the blood entered it at its lower extremity. The
alternative of searching for and tying the supplying vessels,
or that of laying open the sac itself, was not to be entertained,
on account of the difficulty and risk attending such modes of
proceeding; I therefore determined to employ pressure, and
this was applied below the wound, for it was useless higher up.
During the day, hemorrhage occurred two or three times ; and
at last was arrested by pledgets of charpie being passed down
to the bottom of the wound and firmly fixed there. The thigh
was plexed on the pelvis, and lemonade with wine was allowed
him in addition to his broth.

On the twenty-fifth day, the dressings were moistened with
fresh blood, and were removed. The limb retained its tem-
perature and natural functions. Fresh discharge of pus soon
took place from the wound, and he improved. But, on the
thirtieth day, restlessness induced another bleeding. Again
PRINCIPAL ARTERIAL TRUNKS. 63

fresh pledgets were applied; and an improved diet was allowed.
From this time there was no further hemorrhage; and a few
days afterwards the compress and pledgets were removed. It
was then ascertained that the sac was emptied of its contents,
and that all pulsation had ceased. Indeed I had little doubt
then that the sac had burst, and that the clots which had been
removed from the wound had~been discharged from it. Still
there was much constitutional disturbance, which lasted some
days, when a fluctuating swelling appeared below the sac.
This was opened, and a quantity of fetid and thin pus escaped.
Shreds of tissue were subsequently discharged, and the opening
was extended to facilitate their exit.

The patient subsequently suffered from nervous pains and
other depressing symptoms; and it was not till he got change
of air and of scene that he rallied. At the end of two
months he was convalescent. Eleven years afterwards he
was seen quite well, and following his laborious occupation
as a mason.

Case VIII.—Aneurism of the external iliac artery. Death.
—The following case illustrates the importance of exercising
discretion in the performance of serious operations, that dis-
credit may not be unjustly attached to the science of surgery,
which is due only to the operator. A man, 45 years of age,
tall and of feeble constitution, and occupied as a nightman,
was admitted into the Hétel-Dieu, in October, 1828. Three
weeks previously he had felt, without any apparent cause, a
violent pain reaching from the groin to the lower part of the
thigh, which was soon followed by a sensation of numbness
and cold. Exertion distressed him, and he was soon laid up.
He had long been subject to a cough, and had suffered from
the venereal disease, from cedema, and ulcers of the legs.

On examination, a rounded tumour, of the size of an egg,
was perceived in the left iliac fossa, pulsating with the heart,
and yielding to the ear a whizzing sound; the pulse was
irregular, but the heart’s impulse moderate; though the
abnormal sound caused by the passage of the blood through
the arteries seemed to indicate a diseased condition of these
vessels.

Now the external iliac artery had been tied in several in-
64, LIGATURE OF THE

stances, but always for ancurism, situated in the groin, or at-
most, only partly above Poupart’s ligament. But, in this case
the sac occupied the position at which the ligature was applied
in the instances referred to; and, moreover, the precise limit
of the tumour was not defined. The whole space traversed by
the external iliac artery does not exceed, at most, four inches ;
and in this course it gives off but two branches, the epigastric
and circumflexa ilii, and these very close to the crural arch.
Assuming that the aneurism sprung above the origin of these
branches, there was but a small space left for operation be-
tween it and the bifurcation of the common iliac; and it is to
be borne in mind, in contemplating an operation of this sort,
that the proximity of a large trunk interferes with the forma-
tion of a clot in the interior of the vessel, which is so essential
to the process of obliteration.

Aneurisms in this part of the external iliac are rare.
Béchard mentions having met with two such instances, after
death, which had not been suspected during life; and in which
nothing short of a ligature on the common iliac trunk would
have afforded a chance of success.

But, supposing there had been, in this case, room to tie
the external iliac, how was I to proceed, Sue, formerly Li-
brarian to the Faculty, was the first to point out the practi-
cability of this operation. Mare Séverin records a case of
spontaneous cure, following gangrene, which involved the
entire sac; and Gualtari cites a similar one. Massinini
having opened an aneurism of this kind, emptied the sac,
plugged it with charpie, and then applying firm pressure, had
the good fortune to cure his patient. In 1796, Abernethy
first tied this artery, but unsuccessfully: he also lost his
second case; but his third succeeded. Since then the opera-
tion has been often repeated, and the proportion of successful
cases has been about two thirds of the whole number.

Had I operated in this case, 1 had determined on making
my incision farther outwards than midway between the spine
of the ilium and pubes, and for two reasons. The epigastric
artery is thus avoided, and the peritoneum is more easily
raised from the iliac fossa. But I did not operate, because it
was impossible for me to determine the limits of the tumour,
which might have extended upwards, for aught I knew, so as
PRINCIPAL ARTERIAL TRUNKS. 65

to involve even the common iliac; and, moreover, the separa-
tion of the peritoneum, supposing it to adhere to the sac, as it
probably did, would be no easy task. Lastly, the general
health of the patient, together with the physical signs of
diseased heart and arteries, altogether forbade the operation.

The issue proved the propriety of adopting this decision ;
for the constitutional disturbance increased during the follow-
ing month, after his admission, and he sank rapidly.

Autopsy—There was hypertrophy with dilatation of the
left ventricle: the mouth of the aorta was dilated, and the
interior of the vessels presented several rough patches of a
yellow colour. The lungs were shrunk, and exhibited old ad-
hesions. The abdominal aorta was healthy. On the outer
side of the external iliac artery, a little above the origin of the
epigastric, there was a rounded aperture, about three lines in
‘diameter, which communicated with an aneurismal sac, situated
in the iliac fossa. The parietes of this sac were not very dense,
and were cellular. At its upper part there was a gap, permitting
an extension upwards of the cavity, as high as the left kidney;
this appeared to form an appendix to the main sac; and both
were filled with dark, irregular clots, not such as are found,
deposited in a laminated form, in the interior of old aneurisms.
The remaining portion of the external iliac artery was of nor-
mal calibre. The femoral artery was studded with carti-
laginous patches, and the accompanying vein was dilated, and
its coats thickened. The neighbouring lymphatic ganglia were
enlarged, and otherwise diseased. The peritoneum proved to
be adherent to the sac. There was purulent effusion into
and about the knee-joint.

Next to aneurism of the popliteal artery, probably that of
the femoral is more frequent than any other. The following
case will serve as an illustration of the disease and its cure.

Case IX.—Fulse consecutive aneurism of the left femoral
artery. —J. F. Brozard, a servant, 37 years of age, was ad-
mitted in the Hotel-Dieu, in May, 1819. About two months
before, when striding across the trunk of a felled tree, he was
struck on the lower and inner part of the left thigh. The
contusion was apparently slight, and no ecchymosis followed ;
and three weeks elapsed before he perceived a small, pulsating,

5
66 LIGATURE OF THE

*
and painful tumour at the spot. At first, he paid no attention
to it, but continued to exert himself as usual, which increased
the size of the swelling, and the force of its pulsations. He
then came to the hospital.

On examination, a tumour was found at the lower part of
the femoral region, just where the artery is entering the canal
formed by the adductors and vastus internus muscle. Its size
was equal to that of two fists. The superjacent skin was thin
but not discoloured: the tumour pulsated with the heart.
The affected limb was somewhat wasted; and walking gave
him pain; there was some numbness of the toes.

The pulse could be felt in the art@ies below the knee. Pres-
sure on the femoral artery arrested the pulsation in the
tumour.

As I had cured several cases of both femoral and popliteal
aneurism by compression, I determined to try it in this case.
But, although the artery was thus commanded, the pain occa-
sioned by the pad was such that it could not be borne; and,
moreover, the skin became inflamed at this spot. I therefore
determined to tie the artery.

The thigh being abducted, and the leg flexed, I cut down
on the artery at the inner border of the sartorius; and having
exposed it, I passed a grooved director beneath the vessel, and
along it was slipped a stylet armed with a silk ligature.
When I had ascertained that the flow of blood to the tumour
was cut off by pressure on the artery, I tightened the ligature,
and dressed the wound. Cold applications were employed to
the sac ;.and the half-bent limb. was surrounded by hot sand-
bags.

The limb retained its heat and sensibility through the
day ; indeed, the heat was somewhat augmented. In the
evening he was bled; a precautionary measure, had recourse
to in consequence of the patient being frequently subject to
epistaxis. His bowels were sluggish, which is often the case
where a large arterial trunk is tied. A purgative was there-
fore administered. The progress of the patient was uninter-
rupted. The ligature came away on the fifteenth day; on the
thirty-fifth day the wound was quite healed. This patient
left the hospital quite well; the tumour being reduced to one
fifth of its former size, and the artery obliterated to the
PRINCIPAL ARTERIAL TRUNKS. 67

extent of about three. inches above where the ligature was
applied.

The success attending the operation of tying the femoral
artery is probably in great measure due to the facility of ex-
posing and isolating this vessel. In some instances, partial
gangrene, as of the toes, has followed the operation; but
this does not constitute an obstacle to the cure of the
disease,

The frequency of aneurism in the popliteal artery has been
noticed and accounted for by most authors. But there is one
exciting cause which has not been mentioned, I mean the act
of drawing on tight boots. The forced extension of the leg
produces pain in the ham, which does not subside for many
hours.1_ The operation of tying the femoral artery for this
form of aneurism does not differ from that just described ;
but the narrative of a case will make the subject more com-
plete, and afford me the opportunity of noticing the character-
istics of aneurism at this part of the artery.

Cas—E X.—— Aneurism of the popliteal artery, cured by
ligature, —Hi. Coulé, aged 45, employed in the Venereal Hos-
pital, was admitted into the Hétel-Dieu, in June, 1819, with
secondary false aneurism of the left popliteal artery. Four
months previously, he exerted himself violently in lifting a
stone, and a fortnight afterwards perceived a swelling as large
as a nut in the ham: it pulsated, and pain extended from it
even to the toes. At first, he did not heed these symptoms ;
but as the disease increased, he applied to the surgeon of the
hospital to which he was attached. The nature of the malady
‘having been detected, an attempt was made to arrest its pro-
gress by the employment of pressure; and an apparatus was
contrived for the purpose, consisting of two plates connected by
two straps, and in the centre of that which was placed over the —
artery a pad was fixed, which could be tightened or loosened ©
at pleasure by a regulating screw: the plates were sufficiently
broad to obviate, as far as possible, interference with the cir-
culation by undue compression on the sides of the limb. This
apparatus was applied, and gradually tightened, so as to ob-

1 [It does not clearly appear whether this assigned cause of Replisents aneurism is
given on the authority of Dupuytren, or of his Editor. a J
68 LIGATURE OF THE

literate the calibre of the artery, at the same time that general
antiphlogistic measures were employed. But, notwithstand-
ing all the precautions that were taken, the part on which the
pad pressed mortified ; and when the slough was thrown off, a
long time elapsed before the wound was healed. When an
attempt was made to reapply the pressure, the suffering it
occasioned was so severe that it could not be borne. The
tumour, however, had evidently diminished, both in size and
in the force of its pulsations. The patient was then sent to
the Hoétel-Dieu, when the following appearances presented
themselves.

The tumour in the left ham was about the size of a hen’s
egg, pulsating with the heart. The superjacent skin healthy.
The affected leg wasted, feeble, and numbed; the posterior
tibial still pulsated. Pressure on the femoral artery arrested
the pulsation in the sac, as well as diminished its volume; but
the tension and impulse were again restored as soon as the
pressure was removed.

The compression had been tried in the ham before the
patient’s admission, and it was now applied to the middle of
‘the thigh, assisted by pressure at the groin; but it could not
be borne, and, after a week, was desisted from, as the skin be-
came inflamed. The operation of tying the artery was
accordingly determined on, and performed in a way similar to
the last case, and without difficulty,—a single ligature being
employed. The same precautions were taken to preserve the
temperature of the limb, and with success.

On the day succeeding the operation, there was some con-
stitutional excitement, accompanied by palpitation. For this
he was bled, with relief; subsequently a little digitalis was
given, and the palpitation ceased. The ligature separated on
the twenty-fourth day, and the patient quitted the hospital at
the expiration of three months, quite well. The size of the
tumour was diminished by two thirds, and pulseless. The ob-

literation of the artery extended for about four fingers’ breadth
above the seat of ligature,

Case XJ.—True aneurism of the right popliteal artery,
treated by ligature of the femoral artery, and followed by
gangrene.—Car.. . ., aged 85, a clerk at the Barriers, of
PRINCIPAL ARTERIAL TRUNKS. 69

middle size, and not strong, had had his constitution enfeebled
by excessive hardships, labour, and privations. He had taken
mercury for some syphilitic affection, and had also been the
subject of glandular enlargement in the neck. At 32 years of
age he suffered from dyspnoea and palpitation, for which he
was frequently bled. During a long journey, he experienced
pain in the right ham, and on his arrival in France, he per-
ceived strong pulsation in the part, accompanied by shooting
pains down the leg. These symptoms increased in spite of
palliative treatment, and he came to the Hétel-Dieu five
months afterwards, in February, 1829.

The heart’s action was strong and loud, and a bellow’s
sound was distinctly audible along the course of the aorta.
The popliteal tumour was oblong, and of the size of a small
egg; and there was much tenderness in it, which extended
along the course of the external popliteal nerve; the other
ordinary physical signs of aneurism were present, including
cedema of the foot and leg. He was pale, thin, and flabby in
flesh, but otherwise appeared in tolerable health. After a
few days of preparation by bleeding and a purge, the femoral
artery was tied. Some small arterial twigs required ligatures,
the application of which gave him great pain; but not so
when the trunk was tied.

Two hours after the operation, he complained of numbness
of the leg, and of a burning pain which extended from the
outer side of the thigh to the foot; the temperature, however,
was rather below the normal standard. In the evening, he
experienced a sense of pulsation round the patella, but the
tumour had shrunk and was pulseless. The circulation was
excited, and his face flushed. He was bled, and had some
sleep.

On the following day his general condition was’ somewhat
improved, but the burning pain continued, and the temperature
of the limb had rather diminished. He was ordered an ano-
dyne mixture and broth; and precautions were taken to secure
the proper temperature of the leg.

On the third day the pains were less, but the thigh was a
little swollen, and there was general prostration, accompanied
by profuse sweats. He had epistaxis during the day; and was
bled in the evening. During the night he fainted twice,
70 LIGATURE OF THE

On the fourth day the tumour continued pulseless. The
skin of the extremity was, throughout, warm and sensible ; the
wound looking well. An erysipelatous blush had exhibited
itself on the upper and outer part of the thigh. The pulse
continued high, but there was no evidence of congestion in any
organ, the thigh and leg were enveloped in a poultice.

There was some general improvement on the fifth day; but
on the sixth the foot began to lose its temperature and sensibi-
lity, and became cedematous ; at the same time there was a rest-
less expression in the patient’s face. Anodynes and support
were continued.

On the seventh day the signs ushering in gangrene became
more marked. He was restless and feverish, and complained
of burning heat and pricking pain in the limb; the foot was
chilled, and its sole soft, swollen, and infiltrated. Some spots
of ecchymosis were noticed on either side of the tendo Achillis.
Stimulating liniments, warmth and friction were employed.

Until the twelfth day there was very little change beyond
the extension of the sphacelus in the foot and leg, though the
muscles were not yet involved. A large quantity of not un-
healthy pus escaped from the thigh when an incision was made
in its upper and outer part.

On the nineteenth day the ligature came away without he-
morrhage. From this time there was very little change in the
general state of the patient until his death, which occurred from
exhaustion on the twenty-sixth after the operation. The foot
was in a state of dry gangrene, and there was no indication of
a line of demarcation between the living and dead parts.’

Autopsy.—The lungs and brain were healthy. There were
two living tape-worms in the small intestine, each more than
eight feet long; there was no inflammation of the mucous
membrane in their neighbourhood. There was excessive hy-
pertrophy of the left ventricle, but the valves and endocardium
were healthy. The aorta was dilated, and covered with patches
of atheromatous degeneration ; but there was no ossific deposit.
In the femoral artery which had been tied, there was a_ fibri-
nous clot, about three quarters of an inch long, and truncated

' It should be remarked that this patient stated, on his admission, that his

mother has a very strong pulse, and bled profusely when she had a finger
amputated.
PRINCIPAL ARTERIAL TRUNKS. 71

at each extremity, but tapering in both directions towards the
centre where the ligature was applied; the lining membrane
alone of the vessel appeared to be cut through. In the sac, all
the arterial coats seemed to be entire, except at the lower and
outer part, where the lining membrane alone seemed to have
given way. The popliteal vein adhered firmly to the sac, and
was obliterated at this spot. Pus was effused around the
femoral artery and amongst the muscles.

It may be interesting, in connexion with this subject, to
narrate an example of the old practice of cutting into the sac
of an aneurism, and tying both extremities of an artery. The

notes of the following case were taken by myself some years
since.

Case XII.—Popliteal aneurism treated by incision, termi-
nating fatally—P. L. Bordier, aged 48, of middling stature, and
bilious temperament, had always enjoyed good health till two
years back, since which time he had been troubled in passing
his water. Between two and three months ago he had two
accidental falls, but.they were not attended with any apparent
injury to his leg. He, however, discovered, a fortnight
afterwards, a small pulsating tumour in the ham, This in-
creasing, he came to the Hétel-Dieu, in September, 1806. The
tumour had at this time assumed considerable size, and pre-
sented, well-marked, all the usual characteristics of aneurism.
An operation was decided on and agreed to by the patient..

When brought into the theatre, he was placed in the recum-
bent posture, on his belly, and the femoral artery was com-
manded by a large compress, and a bandage over it which
could be tightened by twisting a stick attached to it above. A
longitudinal incision of about four or five inches was carried
along the back of the ham, and the sac exposed; the second
cut laid open the sac which yielded a jet of arterial blood.
When this opening was enlarged, its contents, almost wholly
fluid blood, were cleared out. It would have been easy to have
discovered the extremities of the artery by introducing a probe
into their communication with the sac; but the patient and
surgeon were both badly placed for this purpose ; and, more-
over, the small external incision and opening into the sac fur-
ther perplexed the operator, who sought in vain for the precise
72 LIGATURE OF THE

spot he wanted to find. I relaxed the pressure, and even
pointed out the arterial opening, yet without avail; but the
operator, provided with an immense curved needle, tried by
the guidance of his finger only, to pass a double ligature around
the artery. This attempt failed, as was proved by loosening
the tourniquet, but a second succeeded, the needle this time
being passed an inch higher up. The tightening of the liga-
ture occasioned great pain. The sac was then examined more
leisurely, and found to occupy the whole popliteal space, dis-
tending the muscles on each side. The course of the artery
could be readily traced to its point of laceration. After emerg-
ing from the opening in the adductors, it took an almost trans-
verse direction outwards, and then ran along the outer wall of
the tumour ; at the lower part of this course the laceration was
situated, and the vessel soon afterwards resumed its normal
position. The operator now considered his work done; and it
was with much trouble that I persuaded him to apply another
ligature on the lower extremity of the artery; and this was
accomplished after several attempts, with the needle as before ;
but I could not induce him to place another reserve ligature
on the upper part of the artery. He then plugged the sac
with at least a pound of coarse lint; and feeling secure that
no bleeding could now occur, he satisfied himself with a loose
bandage round the part. This dressing was by far the most
painful part of the proceeding. The patient was carried to
bed, and the limb was only lightly covered.

At first the limb felt cold, but recovered and retained its
temperature afterwards. On the second day there was serious
constitutional disturbance, accompanied by cough and expec-
toration tinged with blood. On the third day he seemed to
rally a little; but on the fourth he was evidently sinking. His
suffering was extreme, and the limb became enormously swollen;
he died in the evening. The dressing in the sac was not
disturbed.

Autopsy.—The affected limb was livid. The internal arti-
cular arteries were large, and one above communicated freely
with that below and with the recurrent tibial branch, by which
means the injection found its way into both the lower part of
the popliteal and the tibial arteries, The outer articular branches
were much smaller, The ligature first applied had been carried
PRINCIPAL ARTERIAL TRUNKS. 78

through the artery. The second ligature included the artery,
and with it the popliteal nerve. It was impossible to determine
the precise spot at which the third ligature had been applied.
The femoral artery was otherwise healthy, but the aorta was
extensively diseased.. The other organs were healthy.’

The case which I shall next cite, illustrates the risk of se-
condary hemorrhage, even at a considerable interval after the
application of a ligature.

Case XIII.—Ligature of the femoral artery. Secondary
hemorrhage, and death.—J. F. Denis, aged 31, was admitted
into the Hétel-Dieu, in March, 1811, with an aneurismal swell-
ing in the left ham. The disease dated back only two days,
and was attributed to a forced extension of the limb in a fall
he had sustained, The operation of tying the femoral artery
was immediately decided on, and performed by M. Pelletan.
For a considerable time the vessel could not be found, and then
only by drawing inwards the sartorius muscle, Extreme pain
was experienced when the ligature was tightened, and this was
ascribed by M. Dupuytren to the saphenus nerve being in-
cluded.

Nothing worthy of note occurred during the first twelve days.
On the thirteenth, the ligature came away. On the following
day there was some trifling bleeding, for which another ligature
was applied an inch higher up. After the lapse of three more
days, there was further hemorrhage, which was stopped by a
compress on the wound. Still the bleeding continued, and the
operator applied another ligature a little below the groin, when
the hemorrhage recurred, it was from the middle of the ori-
ginal wound, and Pelletan, supposing it to come from the pro-
funda artery, plunged an aneurism needle to the bottom of the
wound, a little above the spot whence the blood proceeded, and
was fortunate enough to seize the vessel, as there was no more
bleeding. Two days afterwards, the limb became cedematous,
and the patient sank exhausted.

When examined, after death, the limb was found livid,
swollen and tense ; and gangrenous near the wound and along
the outer part of the thigh. The whole extent of the enor-

' [This case has, like many others, been considerably abridged ; and its -critical
tone qualified rather than exaggerated.—T.]
74 LIGATURE OF THE

mous wound, and the surrounding muscles, were infiltrated
with fetid pus. The two extremities of the artery were four
inches apart; and the upper part appeared to have been
opened at various points in the different operations. The
highest ligature was applied a little below the origin of the
profunda, and included the sartorius muscle and a part of
femoral artery through which it was passed. The aneurism
was not larger than a walnut, and consisted of a dilatation of
the external coat of the artery, containing a fibrinous clot.

The occurrence of hemorrhage in this case, after the lapse
of a fortnight and the separation of the ligatures, and without
the development of anything in the condition of the patient
which could have led to such a result, is remarkable. As
regards the repetition of the operation, it is probable that well
applied compression would have been effectual in stopping the
bleeding ; at any rate, the course pursued illustrates the fact
that it is useless to apply a ligature on an artery which in-
flammation has rendered friable.

It is scarcely necessary now to insist on the advantages of
Hunter’s operation of tying an artery above and at a distance
from the aneurismal sac which it supplies, as compared with
the older method of cutting down on the tumour, and empty-
ing it of its contents, after placing a ligature above and below
it. But it is interesting to remember that even anterior to
this period, Aétius describes a similar operation, with the
superadded step of tying the artery (the brachial) above and
at some distance from the aneurism.”

It remains for me to notice the operation of tying an artery
between the aneurismal sac and the capillaries. This plan was
suggested by Brasdor, but was first put in practice on the
living subject by Deschamps, who tied the femoral artery for
aneurism at the groin. He was, however, obliged afterwards
to open the sac, and tie the artery above it, in consequence of
the rapid extension of the tumour,. and the impending risk of
its bursting. But the operation was badly performed,

' [This seems so incredible, that the original is appended. “La ligature Ja plus
élevée. 1... comprenait le muscle conturier, et une partie du calibre de l’artére
crurale, qu’elle traversait.”—T.]

? [For an account of these operations, the reader may consult the valuable trans-
lation of the works of Paulus Agineta (vol. ii, p. 310), issued by the Society. —T.]
PRINGIPAL ARTERIAL TRUNKS. 75

as some muscular fibres were included in the ligature, and the
profunda was perforated: the patient survived only eight hours.
This was followed by a failure in a case operated on by Sir A.
Cooper, and for a season discredit was thrown on the opera-
tion, until resuscitated at a later period. The chances of suc-
ceeding would appear to depend on the absence of any branch,
of sufficient size to carry on the circulation, being given off
between the seat of ligature and the sac: yet even this does
not appear to be an essential element of success.’ It is evi-
dent that this mode of operating is applicable only to circum-
scribed or spontaneous aneurism, In reckoning up the points
in favour of this method of operating, it will be found that
where no branch existed between the ligature and the sac,
three cases out of five were successful; and that where the
contrary arrangement obtained, the greater number.of aneu-
risms, especially in the iliac region and groin, have not been at
all arrested in their development. In some others, and more
particularly in the lower part of the neck, the disease has not
only been retarded in its progress, but modified altogether for
a period extending from eight months to two years. I will
close these observations with a case which is interesting in its
details, though it unfortunately terminated fatally.

Case XIV.—Ligature of the axillary artery for subclavian
aneurism.—C., Paris, aged 40, a country labourer, of good con-
stitution, felt a pain in his right shoulder, after some violent
exertion ; and on the third day a pulsating tumour of small
size was discovered above the clavicle. This occurred. five
months before his admission into the Hétel-Dieu. When
admitted, the aneurismal tumour occupied the whole subcla-
vicular space and the lower third of the neck, raising the
sterno-mastoid muscle. It pulsated strongly, though evidently
bound down by a resisting membrane. The carotid of the
same side could be traced down, though not to its origin, until
the tumour was pressed downwards and outwards. At the
upper border of the sternum, and in front and to the right of
the trachea, a large arterial trunk was felt, which was probably

1 The reader is referred to an interesting and successful case, narrated, with re-
marks on this mode of operating, by Mr. Wardrop, in the ‘ Medico-Chirurgical
Transactions,’ vol. xiii, p. 217, as well as to his work on the same subject.
76 LIGATURE OF THE.

the brachio-cephalic. The right arm and hand were cedema-
tous and numbed, and the fingers were almost immovably
semiflexed. The patient’s general health was good, and the
heart’s action healthy, though forcible.

At first he was bled, and kept on a low diet, and pounded
ice was applied to the tumour; but still the disease advanced.
It therefore seemed necessary to perform some operation to
afford the patient a chance of recovery ; and, as it could not
be ascertained whether the brachio-cephalic was not implicated,
I determined to tie the vessel on the capillary side of the sac.
An incision was made parallel to the clavicle, and about two
fingers’ breadth below, commencing near its sternal extremity,
and extending three inches outwards. The great pectoral muscle
and upper third of the smaller pectoral were successively divided ;
and when the axillary artery was isolated, a ligature was passed
around it and tightened, without pain.

Immediately after the completion of the operation, the pul-
sation in the tumour was increased in intensity and irregular ;
but these symptoms speedily subsided. Ice was applied to the
tumour, and a sedative administered. Ten hours after the
operation, the pulse being strong, the patient was bled.

On the second day he was restless and weak. Pulsation in
the tumour had not diminished, but the tension was less; the
arm waswarm. On the fourth day there was but little change ;
he slept more, and the pulsations were diminished in force.
He was allowed a little broth.

On the sixth day bleeding came on, and recurred at inter-
vals, He was bled from the arm three times during this day.
Trifling hemorrhage again on the seventh day. The patient
was now much reduced. Acetate of lead had been taken, but
was now omitted. On the eight day he was again bled eam
the arm. The constitutional disturbance and feebleness in-
creased, and he died on the ninth day.

Autopsy.—There was considerable emaciation. The right
arm was livid and cedematous, and the fingers were black.
The back part of the right lung was hepatized, and exhibited
traces of recent inflammation. The heart was large and flabby;
the ventricles being dilated, but soft andthin. The thoracic
aorta was unnaturally large, especially at its origin. Its inte-
rior exhibited both cartilaginous and osseous deposit in patches.
PRINCIPAL ARTERIAL TRUNKS. 77

The brachio-cephalic artery was also dilated, and similarly
changed internally : the right carotid was healthy.

The aneurismal sac, which was formed by the dilated sub-
sclavian artery, extended over the brachial plexus of nerves,
and was covered by the sterno-mastoid, omo-hyiod, and ante-
rior scalenus muscles; the latter muscle effectually obstructing
the development of the sac towards the heart ; and yet the first
rib was almost entirely destroyed by the pressure. The parietes
of the sac were tolerably thick and resistant, except at some
poimts below, where the pleura alone formed the wall. The
cavity of the aneurism contained only a loose clot of recent
blood. The vertebral, internal mammary and thyroid branches
were completely obliterated. The axillary artery was healthy
where the ligature was applied, and contained a small clot
above this point. There was an opening, at the seat of liga-
ture, into the artery ; but this appeared to have been done in
dissection, or by pulling at the ligature,—an experiment which
the pupils had freely indulged in before the post-mortem exa-
mination was commenced.!

1 [It is scarcely necessary to follow the French editor through the remarks which
are appended to this case, nor to criticise treatment, which could scarcely be ex-
pected to conduct to any buta disastrous issue. Indeed, it is implied, if not admitted,
that the operator himself was of opinion, that the repeated abstraction of blood from
the arm hastened the fatal termination. The hemorrhage was supposed to be
caused by ulceration of some undiscovered small branches, and not from the rent
artery.—T.]
SECTION IV.

ON FALSE ANEURISM OF THE BRACHIAL ARTERY,
AND VARICOSE ANEURISM.

THE operation of bloodletting is generally regarded as too
simple to merit special attention; and thence have arisen the
accidents which I have so often witnessed during the last ten
or fifteen years. Multitudes of hospital students neglect this
operation ; and we constantly see instances in which the skin
over a vein is repeatedly punctured before the vessel itself is
opened. To such ignorance or carelessness we may also ascribe
the many cases of phlegmonous inflammation and phlebitis
which occur,—a result which is, no doubt, likewise due to
foul lancets. But, above all, the neglect of which I have been
speaking, tends to the serious consequencé of varicose aneurism,
consequent on puncture of the brachial artery through the vein,
—an injury of which examples are brought under my notice
repeatedly. Very simple precautions suffice to prevent this
mischief ; and the following axioms should be constantly acted
upon: 1, That a vein should never be opened in the arm until
the pulsation of the artery has been felt for; 2. That the vein in
front of the vessel should never be selected, but that others
should be sought, albeit they be difficult to find, and yield blood
more sparingly.

False aneurism, the result of wound, does not always manifest
itself immediately after the injury, but occasionally some little
time elapses before it becomes apparent ; and this difference gives
rise to the distinction into primitive or diffused, and consecutive
or circumscribed aneurism. Some instances are recorded in
which a small clot has for a time plugged a wounded artery
and prevented the escape of blood; but on its expulsion by
some effort, or the force of the circulation, a circumscribed
false aneurism has resulted.

True aneurisms of the brachial artery at the bend of the
elbow are very rare; but this cannot be affirmed of false
aneurisms at this part, for the reasons already assigned.
FALSE ANEURISM OF THE BRACHIAL ARTERY. 79

Galen, Celsus, and Aétius describe them, and notice the
means of cure. It is, indeed, surprising that operations of
this kind should have, been performed without leading to a
knowledge of the laws of the circulation; and it was not
until Hunter’s time that collateral circulation by anastomosing
branches was understood. The facility which is thus afforded
to the re-establishment of the circulation, after a ligature has
been applied upon an arterial trunk above the seat of injury or
disease, is, in some instances, the cause of the operation failing
in accomplishing the proposed objegt: an aneurismal sac will
thus be supplied with blood, or bleeding (in a case of wound)
will come on from the lower extremity of the vessel. In con-
sequence of the freedom of inosculation increasing in propor-
tion to the remoteness of arteries from the heart, we find that
hemorrhage is comparatively rare in the large trunks,—such
as the subclavian and axillary,—but almost certain in their more
distant subdivisions, under the circumstances referred to.

The prominence of the vein (median basilic) which crosses
the brachial artery at the bend of the elbow, is a great tempta-
tion to an inexperienced or careless operator. I do not hesitate,
therefore, to repeat, that a vein should never be opened where
it is crossing an artery; if another suitable vein cannot be
discovered in this situation, then one must be sought on the
forearm or even on the hand.

There are several ways in which the brachial artery may be
wounded by the lancet: thus, the artery may be punctured
through the vein where these vessels are not in actual contact,
and then the blood is extravasated. Or again, the two vessels
may be made to communicate by a wound, and then the vein
itself is dilated by the access of arterial blood into it; this
form has been denominated varicose aneurism by transfusion.
There is an essential difference between this and all the other
consequences of a similar injury.

Varicose aneurism may occur wherever a vein and an artery
are in immediate contact, "but especially at the bend of the
elbow, the groin, the ham, or the inner part of the thigh.
These.tumours have also been observed at the lower part of the
neck, in the axilla, or at the anterior and inner part of the
clavicle. Independently of the anatomical relation first noticed,
a puncture is necessary to the production of the disease. This
80 FALSE ANEURISM OF

kind of aneurism exhibits itself in the form of a small and soft
circumscribed tumour, which disappears under pressure ; it pul-
sates synchronously with the heart, and on applying the ear to
it, a peculiar thrill is audible. Its development is slow, and it
is less serious in its nature than false consecutive ancurisms ;
but it does not disappear spontaneously as they do. The
constant mingling of the two currents of blood in both the
vessels involved in the disease produces a remarkable change
in their structure and characters. The artery, receiving venous
blood, becomes dilated, thimmed and tortuous; losing, in short,
its own peculiar characteristics, and assuming those of a dilated
vein, below the seat of injury. The vein, circulating arterial
blood, changes also, becoming thicker and firmer around the
wound, but especially so above the diseased part.

Theory led to the adoption of Hunter’s method of operating
in these cases, but experience has proved its inefficiency. There
is, indeed, a peculiarity attached to varicose aneurism, which
makes this operation less applicable to them than to other
forms of aneurism. When a ligature has been applied to the
upper end of an artery in a case of common aneurism, it acts
as an obstacle to the retrograde as well as the direct course of
the blood through the sac, which, together with a portion of
the artery beyond it, becomes converted into a cul-de-sac, in
which the blood coagulates. This is not so in varicose aneurism,
where the communication between the vein and artery readily
allows of the circulation being carried on through collateral
channels, which would be otherwise unavailable. One mode
of meeting this difficulty is to tie the vein above and below the
disease; but this course is open to objections, especially the
risk of phlebitis, which is more likely to ensue in a diseased
than in a healthy vein. Moreover, the varicose aneurism may
be complicated with false consecutive aneurism.

Surgery is rich in the variety of operations, but poor in the
facts, which are requisite to establish the preference to be given
to one mode of proceeding over another. The father of medi-
cine has justly observed, that “life is short and art is long;
whilst opportunities are fleeting, experiments perilous, and
judgment difficult.” To this may be added, that a multitude
of facts are either neglected, abridged, or so carelessly collected,
if preserved at all, as to be almost valueless.
THE BRACHIAL ARTERY. 81

I am not aware of any surgical work which contains a com-
plete series of facts on which to found an exact parallel of
the advantages and disadvantages attending various modes of
operating, applicable to the treatment of different forms of
disease. Indeed, but few practitioners are able to give a
faithful and impartial account of what they have done; and
yet such facts are the only suitable foundation on which to
build positive conclusions respecting the relative advantages
of different modes of operating. These general remarks are
specially applicable to the subject of aneurism. I am not
aware, for instance, that any surgeon has proved by cases,
whether it is more desirable, in varicose aneurism, to tie the
artery both above and below the disease, or merely above it.
But experiment has proved the insufficiency of the latter
method; and that the collateral circulation, which is so
essential an element in the cure of ordinary aneurism, is the
cause of the evil being perpetuated in this particular form of
the disease: for, though for a time it may appear cured,
sooner or later it will reappear; and the best method of avert-
ing this result, is to tie the artery both above and below. The
cases published in Sabatier’s ‘ Operative Medicine,’ and by
M. Breschet,’ place this fact beyond doubt.

Case I.—False aneurism of the brachial artery.—J. L.
Potier, aged 22, was admitted into the Hétel-Dieu, in June
1819. A week previously he had been bled in the median-
basilic vein, and the artery was wounded; scarlet blood was
thrown out in jets, and difficult to stop. The nature of the
accident being perceived, compression was tried, and the whole
arm became swollen and painful, and subsequently inflamed ;
the aneurismal tumour increased in size, and in the force and
extent of its pulsations.

At the time of his admission these symptoms continued,
and a good deal of blood was extravasated around the punc-
ture; and a remarkable whizzing sound was occasioned by
the passage of the blood from the artery to the vein. The
limb preserved its natural heat, and the radial artery could be
felt still pulsating.

In discussing the proper course to be pursued in this case,

i a
1 Vol. iii. + Mémoire sur les Anévrismes.

6
82 FALSE ANEURISM OF

the alternative of adopting compression seemed out of the
question, as it had already been tried ineffectually, and more-
over, the inflamed condition of the arm forbade it. And it
appeared to me that there would be great probability of failure, -
if I tied the artery, in its inflamed state, close to the wound :
moreover, the condition of the surrounding textures would
materially increase this risk, and be in itself a dangerous pro-
ceeding. I therefore concluded that the best mode of pro-
ceeding was to tie the artery high up in the arm. This was
accordingly done in the usual way, and without difficulty or
accident of any sort to the accompanying veins and nerves.

On the first day the patient complained of violent palpita-
tion, to which he had been subject. The heat and sensibility
of the limb were natural; the tumour was pulseless, but there
was still some thrill in the vein, though the radial artery
could not be felt beating at the wrist. Twenty leeches were
applied to the arm.

On the third day the local inflammation was subsiding ;
but the pulse could now be distinguished at the wrist, and
already the tumour began to beat again.

On the fourth day all inflammation at the bend of the elbow
had subsided. The thrill was no longer discernible in the
vein, which had no doubt been obliterated by inflammation.

On the eighth day pulsation in the tumour was as strong
as ever; a small clot plugged the wound (made by the lancet)
and prevented hemorrhage.

On the ninth day, when the dressing was removed, this clot
was detached, and a stream of arterial blood followed, which
was, however, arrested by pressure on the collateral arteries.
It was evident now that the lower extremity of the artery
must be tied; and I at once.made an incision over the wound,
emptied the sac of its dark, coagulated blood, and sought for
the lower extremity of the vessel. A double ligature was
then carried beneath the point from whence the jet of blood
was observed to proceed, aud the artery was thus secured both
above and below the wound in it. At this time an assistant
was compressing the axillary artery against the head of the
humerus, and thus stretched this vessel so as to drag upwards
that poimt of the brachial which had been originally tied.
The consequence was that it gave way at the seat of ligature,
THE BRACHIAL ARTERY. 83

and a gush of blood followed, The subclavian was then com-
pressed ; after which, on removing the pressure, there was no
further bleeding. ‘The artery could not be found, nor could
it be made to bleed again, even though wine was administered
to stimulate the circulation.

The patient was carefully watched, but there was no more
hemorrhage. On the 18th day the two fresh ligatures came
away ; and on the thirty-second he quitted the hospital cured.
The radial artery could then be felt at the wrist.

Nine months afterwards this patient was seen, and his limb
continued quite sound. On examining the arm, and tracing
the course of the axillary artery downwards, the brachial
could be felt pulsating to within a short distance of the upper
cicatrix. From this point the pulsations could be traced to-
wards the back part of the inner condyle of the humerus,
where the vessel broke up into numerous branches. This was
evidently the inferior profunda branch, which had taken the
place, and almost acquired the size, of the parent trunk; the
superior profunda could also be felt, but less distinctly on
account of its greater depth. The radial artery could be felt
pulsating, but the ulnar could not be distinguished.

The following case, though in some respects a parallel one,
offers some interesting points of contrast as regards the treat-
ment and its results.

Case II.—Varicose aneurism of the brachial artery.—Louis
F—, aged 22, a merchant, of plethoric habit, came to Paris, in
1814, to consult me. Two years previously he wounded his
arm with a bradawl, which implicated both the brachial artery
and vein. Blood flowing freely, pressure was employed; the
wound healed, and no further apprehension was entertained.
After the lapse of six weeks the patient perceived an extraordi-
nary pulsation, and a peculiar thrill near the cicatrix. The
absence of any other alarming symptoms, and the advice of
his medical attendant to pay no attention to it, but to use his
arm as usual, induced him to take no further step until he
came to Paris.

At this time, a soft tumour of considerable size was percep-
tible beneath the cicatrix ; it pulsated in the centre, and the
thrill by which its throbbing was accompanied extended to
84, FALSE ANEURISM OF

the neighbouring veins; these, and indeed all the veins of the
arm were dilated, especially when the limb was pendent.
When, on the contrary, the arm was raised, the tumour became
softer, and the whizzing sound was unheard when the artery
was compressed above the tumour; nor did it augment when
that vessel was subjected to compression below. ‘The patient
used his arm habitually, and experienced no pain, but only a
constant numbness.

I suggested that the brachial artery should be tied above
the aneurismal sac, and this was acceded to, and accordingly
performed as in the last case. Soon after the operation the
limb became cold and insensible: and, in spite of every effort,
the fingers did not recover their sensibility nor warmth, but
soon became contracted, and were with difficulty straightened.
On the fourth day there was slight hemorrhage, which ceased
on removing the dressings. On the thirteenth day the liga-
ture came away; and shortly afterwards the peculiar sound
alluded to, and the pulsation in the tumour, which had entirely
ceased, again became apparent, and daily increased. Com-
pression was resorted to, but in vain; in fact, it was evident
that the disease had resumed its former condition, now that
the collateral circulation was established. The arm as well as
the fingers became permanently flexed ;—a condition which
could not be attributed to a nerve being injured, as nothing
but the artery was included in the ligature. There was no
doubt about the propriety of tying the artery below the tumour,
but to this step the patient would not submit. He applied
for other advice, and the sequel was that his arm was amputated.

On examining the limb, a varicose aneurism was found to
exist ; there was considerable dilatation of all the veins, and
thickening of their coats; the lower extremity of the artery
was also dilated and tortuous, and its structure so altered as
to resemble a varicose vein rather than an artery.

This case teaches us that a ligature placed upon the artery
is less likely to be attended with success where the existence
of the disease is of long standing, and that the course adopted
is not applicable in this and similar instances. It also
demonstrates the fact that the artery does dilate, and points
to the inference that such dilatation is attributable to the
circulation of venous blood in the artery below the injury.
THE BRACHIAL ARTERY. 85

Varicose aneurisms are not confined to the bend of the
elbow, though it is their most common seat, They may
occur, in fact, at any part where an artery and vein, which are
in close relation to each’ other, are implicated in a common
wound. The following is an example.

Casz III.—Varicose aneurism of the riyht common carotid
artery and external jugular vein, occasioned by a sabre-wound.—
M. D—, aged 43, was wounded in a duel, twenty years ago,
by a thrust from a sabre a little above the right clavicle, near to
its acromial extremity, He immediately lost a considerable
quantity of fluid blood, which flowed in jets. M. D— arrested
the bleeding by securing some folded handkerchiefs on the
wound; and walked a considerable distance to a hospital.
The edges of the wound were brought together, and the patient
was kept in bed and on low diet for five days, when he left the
hospital, the wound being healed. On returning home, he
and his family were surprised to notice violent pulsation,
accompanied by a peculiar noise about an inch above the
cicatrix ; but, as he felt no inconvenience, he paid no further
attention to it, beyond mentioning it to his friends as a matter
of curiosity.

On examining M. D—’s neck, the old scar was seen; and
above it, over a space about two inches square, pulsations,
synchronous with the heart’s action, were perceptible to the
sight and touch, accompanied by a frequent whizzing and
rushing sound. When listened to, it was like a spinning
wheel in motion; the neighbouring skin was natural in appear-
ance, and the veins were but little dilated; the slightest pres-
sure occasioned giddiness and a peculiar kind of confusion,
especially affecting the right side of the head and the right
eye. On increasing or continuing the pressure, the symptoms
became more distressing, and the patient felt as if he should
faint if it were persisted in. The pulsation was arrested only
by pressure an inch and a half above the cicatrix; below, the
same effect was not produced. The force of the pulsation was
uniform, and not influenced even by violent mental emotion.
He has had palpitation of the heart frequently, but lasting
only for a short time. During the night he heard a constant
movement in the right side of the neck, which he compared to
86 FALSE ANEURISM OF

the prolonged action of a spinning-wheel ; and by it. his head
was raised occasionally from the pillow. The patient’s health
was good, and he was able to pursue his daily occupation as a
tinman. ‘

There can be no doubt that M. D— was the subject of a
varicose aneurism; and, judging from the seat of the wound,
that the right external jugular vein communicated with the
common carotid near its origin. This patient was seen and
examined by the Academy in 1824,

In the cases already cited, we have seen that the puncture
of a lancet or any sharp-pointed instrument, in traversing a
vein and artery in juxtaposition, produces a varicose aneu-
rism ; I now wish to direct attention specially to false conse-
cutive aneurism of the brachial artery, occasioned by venesection
badly performed.

Case 1V.—False consecutive aneurism of the brachial artery,
following venesection. —-A healthy man, about 40 years of age,
was bled in the arm by a midwife, about two months before
he came under my observation. The artery was pierced
through the vein, and the scarlet blood was thrown out forci-
bly in jets. Now, this is a characteristic sign of the injury
in question ; viz.—that the blood is ejected to a considerable
distance, not in a continuous stream as from a vein, but in
jets, at any rate just at first. In the case in question, it
would appear that the midwife knew what mischief she had
done, for she applied a compress, and bandaged the arm tightly
over it. The patient experienced numbness and swelling of
the fore-arm and hand, caused probably by the bandage; and
these symptoms were attended by considerable ecchymosis, but
there was no tumour at this time. After three weeks had
elapsed, a circumscribed pulsating swelling made its appear-
ance, which, in four weeks’ time, attained the size of a pigeon’s
egg. J apprehend the history of this case to be, that the
pressure in the first stage closed the wound in the artery,
which was afterwards re-opened by the use of the arm; and
that then the gradual escape of the blood into the cellular
tissue formed the tumour which subsequently became appa-
rent. °

In this and similar instances, dependence must not be placed -
THE BRACHIAL ARTERY. 87

exclusively on the pulsating character of the tumour, as it is
now well known that a swelling over an artery may have the
pulsation of the vessel communicated to it, although the parts
are only contiguous to each other. In cases like the present
it is observed that, after a time, the skin rises to a point and
becomes very thin, threatening to burst and give rise to serious
bleeding, which may be fatal. It is, therefore, essential to take
some decided step; and, as the urgency of the condition and
the risk of gangrene forbid pressure, the ligature is the only
resource. Under such circumstances the question which
naturally presents itself is, whether the artery should be tied
on both sides of the seat of disease, or only above it. The
former proceeding, although apparently the more sure, is
obnoxious to many serious objections. The proceeding would
be accomplished in the following way: after stopping the flow
of blood through the artery, the skin is divided over the tumour,
the sac laid open, and the opening in the vessel searched for.
This, and the application of the ligatures, is by no means an
easy matter, especially on account of the venous bleeding ; but,
supposing it to be effected, it is very probable that phlegmonous
inflammation may follow. A single ligature above the seat of
disease may, on the contrary, be applied without difficulty, and
with much less risk of unpleasant after-consequences. Yet, it
must be admitted that this operation sometimes fails, in conse-
quence of the iuosculating branches carrying on the circulation
collaterally. This is the case in aneurism of the common
carotid artery and its divisions: a ligature placed below the
tumour suspends for a time its pulsation, but this speedily re-
appears ; and the same may occur in aneurism at the bend of
the elbow.

Sometimes, however, the blood flows in such a way as to
give rise to the impression that the artery has been opened
through a vein, whereas, the super-position of the latter on the
former is the cause of the deception. I was called, some years
ago, in great haste by a celebrated physician, who had just
bled a patient ; and seeing the blood issue by jets, concluded
that he had wounded the artery. I immediately detected the
cause of the mistake; but he persisted in his idea that he had
pricked the artery, and would never relinquish the opinion.

The above case puts me in mind of another which came
88 FALSE ANEURISM OF

under my observation in 1816. A young woman, 18 years of
age, was admitted into the Hétel-Dieu, with occasional hemop-
tysis. Several attempts had been made to bleed her in the
basilic and cephalic veins, but the quantity of blood thus
obtained was insufficient. On one occasion, the median-basilic
was selected. The dresser felt the vein rolling beneath his
finger, but could not distinctly see it. By a sudden movement
of the patient, the opening in the vein was made larger and
deeper than was intended; and scarlet blood was thrown out
in jets, producing a scalding sensation on the arm as it flowed.
The bleeding-bandage being removed without controlling the
hemorrhage, another pupil compressed the brachial artery in
the middle of the arm, and the blood ceased to flow. Being
satisfied that the brachial artery was punctured, a light com-
press was applied over the wound, and the current of blood
through the brachial arrested by pressure above; and I was
sent for. In an hour and a half afterwards I saw the patient ;
and on removing both compresses, to the surprise of the pupils,
nothing flowed. The arm was placed on a pillow, the wound
made by the lancet was left exposed, and the patient watched.
There was no further bleeding, and the wound healed in four
days. The patient remained for two months afterwards in the
hospital, without the appearance of any tumour at the bend of
the elbow; and when again seen, nearly twelve months after-
wards, the arm continued in a perfectly healthy and natural
condition.

In this case, was the artery wounded or not? At the time
there seemed to be every indication of this injury; and yet,
non-recurrence of the hemorrhage disposes me to the belief,
that in this, as in the preceding instance, the operator must
have been deceived. At any rate, if such lesion was sustained
by the artery, the wound must have healed spontaneously ; and
the possibility of this result may be fairly questioned.

After this digression I return to the case under considera-
tion. I determined to treat the disease by tying the brachial
artery above the aneurismal sac. The patient being placed in
the recumbent posture, and the arm semi-flexed, an incision,
about three inches long, was made towards its lower part; the
sheath of the artery, being thus exposed, was nipped up with a
pair of forceps, and opened to a small extent with a bistoury ;
THE BRACHIAL ARTERY. 89

the ligature was easily passed beneath the vessel. As soon as
it was ascertained that pressure upon the artery arrested pulsa-
tion, the ligature was tightened,—a precaution particularly
important in this situation, on account of the existence, occa-~
sionally, of a high division of the brachial. The wound was
then simply dressed.

I was under some apprehension as to the result of this case,
for there might be a communication established between the
upper and lower extremity of the artery; and again, the vein
was large and tender; and though there had been no audible
evidence of a communication between the vein and the artery,
there might, nevertheless, be a small opening which had not
been detected. The patient, however, recovered, without the
occurrence of an untoward symptom.

Case V.—Fealse consecutive aneurism of the brachial artery,
following venesection.— A hawker, about 82 years of age, was
bled for severe headache, and the brachial artery was punctured
through the vein. The surgeon detected the nature of the
injury he had inflicted by the colour of the blood and the
mode in which it issued. He allowed it to flow till the patient
fainted, and then applied pressure so as to prevent a recur-
rence of the bleeding, and directed a continuance of the same
treatment, without, however, informing the patient of the nature
of.the accident. The wound healed ; the patient thought there
was no more to fear, and left off the compress: a tumour made
its appearance at the bend of the elbow, and increased in size
day by day.

When this man was admitted into the Haétel-Dieu, in
December, 1828, the tumour had attained the size of a fist,
rounded, even, fluctuating, and pulsating synchronously with
the heart. This pulsation was distinct when the arm was
flexed, but ceased entirely when it was fully extended. When
the artery was compressed above the tumour, no movement in
the latter was perceptible; but when pressure was applied
below, pulsation became stronger and more apparent. From
these signs it was concluded that the opening in the artery
was small; that the aperture in the artery and that communi-
cating with the aneurismal sac were not parallel; that the
latter received blood by only one channel; and that the
90 FALSE ANEURISM OF

greater part of the blood contained in the sac was coagulated.
It was, therefore, argued that compression, accurately applied,
might suffice to effect a cure. This plan was accordingly tried,
and ice was applied at the same time; but as no good result
followed, the patient’s wish to be operated on was acquiesced
in, and the artery-was tied about two inches above the tumour.
Some delay was occasioned by the patient becoming faint just
when the vessel was exposed, and in consequence of the dif-
ficulty that was occasioned in distinguishing the artery from
the nerve. The wound was simply dressed, and the tumour
covered with ice.

In the evening the limb had resumed its normal tempera-
ture, and a quiet night was passed. On the following day the
radial artery could be felt pulsating, but only for a season ; the
ice was coutinued.

On the fifth day, when the wound was dressed, erysipelas of
the part was apparent; and this continued to extend itself
upwards and downwards, but abated after the discontinuance
of the ice and the employment of blisters.

On the eighth day the sac gave way, and blood mixed with
pus was discharged. This continued; and, on the tenth day,
the ligature came away without hemorrhage.

On the fifteenth day, the different openings communicating
with the sac were laid into one, and the sac was emptied of its
contents ; in the course of the day there was some bleeding,
which was arrested by the application of a compress. After
this, suppuration was fairly established, and the patient made
a speedy and safe recovery.

In reviewing the foregoing case, the question naturally
suggests itself, whether an operation was really essential for
the cure of the disease. Might not forced extension, aided by
compression and ice, have sufficed to obliterate the aneurism ?
This position of the arm, if continued, would have been very
painful to bear, and might have produced anchylosis ; and with
respect to compression and ice, these are remedies by no means :
free from danger, if persisted in for a long time, which. would
have been necessary. I adopted the operation which was per-
formed, after ascertaining that the tumour presented none of
the signs characteristic of varicose aneurism. The rapid return
of the circulation led me to fear that the operation had failed
THE BRACHIAL ARTERY. 91

of its object; and to counteract the tendency to the free
admission of blood into the sac, the continuous application
of ice was resorted to.

As regards the re-establishment of the circulation by anas-
tomosing vessels, I may remark that the blood arrives below
the ligature some time before the arterial trunk shows evidence
of it by pulsation, the distension of the vessel and its elasticity
being the first indication of the phenomenon in question. At
a later period a slight tremor is perceived, probably indicative
of the renewed influence of the heart at the part affected.
This sign is regarded as a token of the success of the operation :
yet it may disappear after an interval, varying from a fortnight
to three months after the operation ; and gangrene has then
supervened. But I may observe that I have never seen gan-
grene follow ligature of the brachial artery where the nerve has
remained intact. If it should be found that blood again
enters the sac freely, then the only alternative is to tie both
ends of the artery. In the case first narrated, the ligature
came away on the tenth day; whereas, in another case, which
occurred about this time in my practice, and in which the
femoral artery was tied, the ligature did not separate till the
twenty-fifth day. How is this difference to be accounted for ?
it is probably due to the size of the artery in each instance, to
the degree of pressure exercised by the ligature, and to the
quantity of areolar tissue included in its noose.

Cass VI.—False aneurism of the brachial artery treated
with ligature ond cured—A young man, aged 22, was bled by
a surgeon in the median basilic vein, which the lancet pene-
trated through, and wounded the artery: fluid blood followed
the puncture, and was thrown out to a great distance. The
nature of the accident being perceived, compression was metho-
dically employed at the seat of injury. At first the hemorrhage
was thus commanded ; but, as it afterwards recurred at inter-
vals, the patient came to the Hétel-Dieu, and was admitted in
June, 1829.

Nine days after the accident there was a tumour at the
bend of the elbow, as large as a walnut, soft, fluctuating, and
expanding and contracting alternately, synchronously with the
heart’s action: pulsation was arrested by pressure on the artery
92 FALSE ANEURISM OF

higher up. The wound in the vein had healed, and there was
no evidence of a communication existing between this vessel
and the artery. I determined on tying the brachial artery,
and this operation was performed on the day following.the
patient’s admission, The subcutaneous cellular tissue was
found to be infiltrated with blood, and the fibro-cellular sheath,
enclosing the artery and median nerve, was dense and friable:
a large vein crossing the incision was divided. When the
ligature was passed, I found that the nerve was also included
in it; and this necessitated a further dissection and re-intro-
duction of the needle. When the ligature was tightened, pul-
sation in the tumour, and throughout the limb below it, ceased.
Not a single untoward symptom occurred. The fore-arm
retained its natural temperature and colour. On the third day
pulsation in the radial and ulnar was again felt, but the tumour
remained pulseless. On the tenth day the ligature came
away ; and on the nineteenth the patient was discharged cured.

This case proves that, though the operation of tying the
brachial is apparently so easy, care is required to avoid including
the nerve in the noose of the ligature: and it serves as an
illustration of the axiom, that rapidity in operating is a poor
compensation for the risk which it often entails.

But the successful issue attending the foregoing case is by
no means uniform; and in many instances it is essential to tie
the artery both above and below the seat of disease, to secure
the patient from all risk of secondary hemorrhage. The fol-
lowing case, which occurred under my notice, will serve as an
illustration of the above remark.

Cast VII.—Fealse.aneurism of the brachial artery; ligature
and repeated secondary hemorrhage.—J. Herbert, aged 17, a
saddler, in robust health, was wounded in the middle of the
left arm with an awl, whilst playing with his companions.
Florid blood immediately spirted from the wound with great
force, and was imperfectly stopped at the time. After the lapse
of some hours he was brought to the Hétel-Dieu.

It was immediately determined to tie the brachial artery, as
the nature of the hemorrhage admitted of no doubt that that
vessel was wounded. An incision was accordingly made in
the course of the artery, through the infiltrated cellular tissue,
THE BRACHIAL ARTERY. 93

and the bulging biceps muscle was partially divided, as it im-
peded the operator. Two ligatures were then applied, one
above, and the other below, the supposed seat of injury, a
number of other parts being included in the nooses. The
bleeding was, however, arrested; and a quantity of lint was
stuffed into the wound, and the arm tightly bandaged.

For a week all went on satisfactorily ; and then, for the
first time, the whole dressing was removed, and a small quan-
tity of blood escaped. Im the evening, violent bleeding oc-
curred. Three ligatures were passed ineffectually beneath the
brachial artery, but a fourth arrested the hemorrhage. On
the ninth day, the patient bled again, and the artery was again
tied ; and a repetition of this operation was required twice more
before the fourteenth day.

On the fifteenth day hemorrhage again recurred; and the
patient being by this time much prostrated, amputation was
determined on, and performed very near to the shoulder-joint.

On the following day, there was bleeding again; and then
for the first time the patient was placed under my care. I
exposed the artery, and tied it higher up. On the seventeenth
day the bleeding once more recurred ; and the patient was by
this time in a state of extreme exhaustion and delirious. The
only remaining hope was to apply a ligature on the axillary
artery ; and this was accomplished, after a long and tedious
dissection, by dividing the pectoralis major about two inches
from its insertion, and likewise a part of the lower border of
the pectoralis minor. The blood lost during the operation
was like red, viscid serosity, but of a bright crimson hue. The
patient survived the operation only a quarter of an hour.
The only circumstance worth recording in the examination
of the body is, that the arteries appeared very thin, and capable
of but feeble resistance. This may account for the persist-
ance of the hemorrhage after such repeated application of the
ligature.

Case VIII.—Aneurism of the brachial artery following a
punctured wound.—A wine-merchant, aged 45, was bled for
hemoptysis, and a wound of the artery through the vein was
manifested by the usual consequences. In spite of firm pres-
sure a pulsating tumour formed at the bend of the elbow, and
94 FALSE ANEURISM OF THE BRACHIAL ARTERY.

attained, in the course of a month, an enormous size. I tied
the artery above the sac, and immediately all pulsation ceased
in the latter. In the night following the operation the patient
had an attack of hemoptysis, for which he was bled twice. I
may remark that it is not uncommon to witness symptoms of
plethora, and even hemorrhage, follow the application of a liga-
ture on a large arterial trunk: sometimes they assume the
form of palpitation, giddiness, or epistaxis, hemoptysis, &c. ;
and bleeding is the proper remedy. In this case the radial
artery soon began to pulsate; but the tumour remained pulse-
less, which I attribute to the presence of a clot between the
seat of ligature and the sac. No untoward symptom occurred
subsequently in this case, and the cure was complete in a
month.

I may conclude the present subject by remarking, that the
operation of tying an arterial trunk above the seat of a wound
is almost always successful, when the injury is recent, and the
edges of the wound are fresh, and, therefore, disposed to unite ;
but that there is much less chance of success when the lesion is
of long standing, and the edges of the wound are consequently
indisposed to adhesion. In the former class of cases, a single
ligature applied above the injury is sufficient ; but in the latter,
it is always requisite to tie the artery both above and below the
wound, The only exception to these rules is, when the injury
is inflicted on an artery near to the extremity of a limb, in
which case it is indispensable to employ the double ligature, on
account of the multiplied communications by anastomosing
branches. This important theory will explain facts which have
been hitherto difficult to understand.
SECTION V.

ON VARICES OF THE LOWER EXTREMITIES, AND
VARICOCELE; THEIR CAUSES AND TREATMENT.

A great variety of means has been adopted to effect a radical
cure of varicose veins, but almost all have been in turn aban-
doned. Ligature and compression are the measures most usu-
ally resorted to. Uniform compression is unquestionably one
of the best remedies ; and, if it has not the advantage of accom-
plishing a radical cure, it affords marked relief, and is free from
danger.

It must not, however, be supposed that compression, simple
as it may appear, is to be recommended without certain precau-
tions, especially when the veins are very large, and the disease
is of long standing; for there is a risk, in such case, of expos-
ing the patient to the effects of congestion in the abdominal
viscera. Indeed, I have more than once witnessed giddiness,
oppression, and other symptoms of venous congestion in the
brain, and also in the chest, which have endangered the pa-
tient’s life. To obviate such effects, I have been in the habit
of taking blood from the arm, once or more often, to relieve
the venous system, before enforcing the horizontal posture or
employing compression.

In investigating the causes to which varices have been as-
cribed, one cannot help being struck with the accuracy exhi-
bited by authors in copying one another, from the time of
Hippocrates downwards. MM. Breschet and Briquet have,
indeed, done more for this branch of practical surgery; but I will
now give the results of my own experience on the subject.

There are efficient physical causes for this diseased condition
of the veins affecting the lower extremities. The erect posture
is one; and when we add to this any long continued vibratory
or shaking motion, we have two causes which, united, consti-
tute a serious impediment to the return of blood from the
lower parts of the body. Servants whose business it is to stand
96 VARICES OF THE LOWER EXTREMITIES,

behind carriages are subjected to the combined influence alluded
to, and are frequently the subjects of varicose veins of the legs.
Coachmen, also, are unfavorably circumstanced; for though
they are sitting, still the lower extremities are dependent; and
moreover, the free use they make of their arms operates nega-
tively, in rendering them more obnoxious to the effects of a re-
tarded circulation in the lower limbs.

The greater frequency of varicose veins and of varicocele on
the left side, is probably due to the mechanical interruption to
the flow of blood, caused by-the position of the sigmoid flexure
of the colon when distended.

There are many communications between the trunks and
branches of veins; though these are less numerous than many
have supposed. And these communications constitute obstacles
to the cure of varices by obliteration of the diseased trunk. But
it must be borne in mind that, for the re-establishment of a
collateral circulation under these circumstances, as where the
saphena, for instanct, has been tied at the knee, there must be
an anastomotic branch without a valve communicating with
the principal trunk, or a direct anastomosis between the super-
ficial and deep veins.

I remarked that many remedies have been proposed for the
cure of varicose veins. Ligature of the trunk in which the dilated
branches terminate, with the view of procuring coagulation of
the blood in the latter, and consequent obliteration of their
canals, is far from attaining the desired end; for, experience
proves that such obliteration does not extend beyond the imme-
diate neighbourhood of the ligature. For the cure of the wound
made by the operation, the patient is obliged to keep quiet and
in the horizontal posture; and the benefit derived is to be as-
cribed rather to these circumstances than to the operation itself.
The proof that such is the case is ‘afforded by the fact that, after
the patient has for a time resumed his ordinary avocations, the
varicosity is as apparent as before the operation.

The risk of phlebitis following this treatment should not be
lost sight of. It has frequently proved fatal; and, considering
the uncertainty of the benefit to be derived, one cannot but
feel convinced that the danger is disproportioned to the pro-
blematical advantage.

There is, however, a modification of the operation referred
AND VARICOCELE. 97

to, which is more certain in its result, and it consists in the
application of two ligatures at distant points, so as to produce
coagulation of the blood contained in the intervening diseased
veins. Thus, for instance, for the cure of varices of the leg,
the saphena should be tied below or on a level with the mal-
leolus, and also below or on a level with the condyle, or even
higher if necessary.

Case I.—Varices of the leg, with ulcer. Ligature of the
saphena vein.—A man, 31 years of age, of good constitution,
was admitted into the Hétel-Dieu, in 1829, with varicose veins
of the legs. When seventeen years old, the veins of the lower
extremities assumed a varicose condition, for which cold bath-
ing in running water was ordered, but with no benefit. Six
years previously to his admission, the tension of the veins had
increased to such an extent, that many burst spontaneously,
and he lost much blood. The right internal saphena vein was
that which was principally affected, being largely dilated at the
groin and throughout the leg, and there was a varicose ulcer
on the inner side of the latter. I tied the saphena on a level
with the malleolus and above the knee, and was gratified by a
result which exceeded my expectation; for, not only were the
ulcer and varicosity in the leg cured, but the tumour in the
groin finally disappeared altogether.

When this man was examined five years afterwards, the
veins of the limb which had been the seat of operation were
in anormal condition, but the disease had been transferred to
the opposite extremity, and a similar tumour existed in the
groin, just where the saphena dips in through the fascia lata,
I may here remark on the diversity of tumours at this spot,
and the importance of forming an accurate diagnosis by atten-
tion to the distinguishing characteristics in each case. In the
present instance, the swelling in question had many of the
characters of a crural hernia, occupying a similar position, being
"soft and rounded, and disappearing under pressure. But,
on relaxing the abdominal muscles, and pressing upwards the
viscera, so as to prevent the extrusion of any portion of intes-
tine, the tumour went and returned, under pressure and its
removal, as before.

I tied this vein, as I tied the other, and the following were

7
98 VARICES OF THE LOWER EXTREMITIES,

the steps of the operation. Having drawn the integument to
one side, I made an incision parallel to the vein, and about
four inches above the condyle of the femur. On allowing the
skin to regain its natural position, this incision corresponded
to the vein: a ligature was then applied, and tightened with-
out pain. A similar operation was performed about an inch
above the outer malleolus. The wounds were immediately
closed. Nothing particular occurred in the progress of the
case, and the patient left the hospital quite well.

The rationale of this treatment appears to be this. The
blood contained between the two ligatures coagulates, and the
clots harden so as to give great firmness to the vessels; when
the coagulated fibrin in the veins is absorbed, these vessels
resume a healthy condition. Though this double operation is
decidedly preferable to the other, yet there is risk of phlebitis ;
and on that account I prefer, in such cases, to employ compres-
sion by laced stockings; prescribing, as a preliminary step, the
horizontal posture for some days, and taking away some blood
‘from the arm.

The success attending the preceding case is by no means
uniform, as the following instances attest; and I must can-
didly admit that frequent failures, and the attendant risks, have
induced me to relinquish this plan of treatment.

Caste II.—Varicose veins of the left leg, treated by ligature.
—J. Quesnel, aged 54, a servant, was admitted into the Hétel-
Dieu, in 1823, having been the subject of varicose veins and
ulcer of the left leg for twenty-eight years. He was operated
on in the same way as the patient in the last case, and the
wounds were closed with strips of adhesive plaster. In the
course of the day the patient experienced uneasiness and numb-
ness of the extremity; and on the following day he had head-
ache and a flushed face. He was bled, and on the fourth day
was better. The veins also were diminished in size, and it
appeared as if the blood in them had coagulated. At the end
of a fortnight, both the ligatures had separated, and in a few
days all the wounds were healed. Yet, when this man got up,
it was evident that the operation had been ineffectual in curing
the varices, which were as large as ever; and he was forced to
have recourse to the artificial support of a laced stocking. |

°
AND VARICOCELE. 99

Casu I11.— Varicose ulcer of the“left leg treated by ligature.
—P. Leproux, formerly a sailor, was admitted into the Hétel-
Dieu, in 1823, with varicose ulcers of the left leg, from which
he had suffered for eight years. Above and around the ulcers
the divisions of the saphena vein were largely dilated. In this
instance I thought that a ligature applied on the trunk of the
saphena, in the middle of the thigh, would effect a cure. Ac-
cordingly, after preparing the patient by bleeding and cooling
medicine, I performed this operation. In the course of the
same day he had rigors and severe headache, for which he was
largely bled. On the following day he was better, and at the
end of a week the ulcers were nearly healed, and the vari-
cosity of the veins was diminished. On the twelfth day the
ligature came away, and the wound soon afterwards healed.
But in this patient, likewise, the varices resumed their former
size as soon as he got up and moved about.

Associated with the subject now under consideration is a
common variety, known by the name of Varicocele. This
disease consists in a varicose condition of the veins of the sper-
matic cord; and is met with exclusively, in its commencement,
between the ages of twenty and thirty. The anatomical con-
ditions which favour the production of this complaint are, the
vertical position of the spermatic veins, their length, the ab-
sence of valves in them, the alternations of vacuity and reple-
tion to which they are so frequently subjected, and, above all,
the multitude of veins which, under the title of corpus pampi-
niforme, give origin to the veins of the testicle. Varicocele
most usually occurs on the left side, as Morgagni correctly
pointed out,—a circumstance probably due in part to the fact
that the spermatic vein of this side terminates, at a right angle,
in the corresponding emulgent vein: pressure exercised by
accumulated feces in the left iliac portion of the colon is,
doubtless, also a reason why the disease is more frequent
on the left than on the right side.

There does not seem to be any special association between
varicocele and varicose veins of the lower extremity ; indeed
their co-existence seems to be rather rare than otherwise, as
remarked by M. Landoury in a work on this subject. More.
over, varicocele is comparatively rare in old people, except as a
legacy from youth: nine tenths, at least, of those who are the
100 VARICES OF THE LOWER EXTREMITIES,

subjects of this complain are young persons; and in many
M. Breschet believed it was traceable to self-pollution.

It would appear to be, in some instances, an hereditary
affection ; thus, M. Breschet mentions an instance in which a
father and several sons were all similarly affected with varicocele.
It is of much more frequent existence than is generally sup-
posed ; for the examining surgeons of conscripts declare that
a seventh, or even a fifth, of all who appear before them have
this complaint.

The symptoms by which this disease is characterised are, a
sense of weight in the scrotum and cord, and a lax condition
of the cellular tissue of these parts. Soon afterwards the
testicle with its coverings, on the affected side, hang lower
down than in health; the cord becomes bulky and nodulous,
especially after much walking or standing for any length of
time, and this particularly in hot weather and in warm cli-
mates.

The inconvenience gradually increases with the augmented
volume of the affected parts, and the veins become more dis-
tinct beneath the skin; they assume a dilated and plexiform
arrangement; but this varicose condition may specially pertain
to the cutaneous veins,as they leave the scrotum, and on the
left side more than the right; or these vessels may retain their
normal development, whilst those of the sphermatic cord and
epididymis, even up to the internal abdominal ring, become
distended, and impart the characteristic of extraordinary in-
crease in volume to the cord. It should be remarked that the
horizontal posture, and the local application of cold, have the
effect of dispersing the swelling for the time their influence is
in operation.

In the course of time the sense of weight extends upwards
along the cord into the abdomen, and even to the loins and
back. The upright posture and walking for any distance
oceasion much distress. The patient mechanically carries the
hand to the scrotum to afford the testicle some support. At
a later period, the slightest pressure occasions suffering ; and
not infrequently the pain is of a neuralgic character, and
extends upwards into the abdomen in the direction of the
coeliac plexus.

In one instance which came under the notice of M. Breschet,
AND VARICOCELE. 101

the neuralgic pain, which was excited by the slightest move-
ment, was so intense, that the patient begged that he might
‘be castrated to obtain relief. In other cases the same surgeon
has remarked the development of the disease, without the co-
existence of any suffering beyond the inconvenience consequent
on the weight of the gorged vessels.

When the disease has attained a certain stage, the varicosity
is most marked in the neighbourhood of the epididymis; and
then not only the origin of the excretory duct is enveloped
by the tortuous and dilated veins, but the body of the gland
itself, A superficial examination of the testicle at this period
would give an impression that it was increased in size; but
this is a mistake. A more careful investigation proves that
the testicle is in reality diminished in volume; and in some
instances this atrophied condition is very decided. This point
should be carefully noted and pointed out to the patient,
otherwise the surgeon may have the credit of having sacrificed
the organ by the treatment which he adopts for the cure of
the varicocele. Where this is the case, M. Breschet -has
observed that the varicosity commenced at the epididymis, and
that this part was diseased consequent on one or more attacks
of gonorrhea. But, as already remarked, there is no constant
correspondence between the side of the varicocele and the
attendant suffering. The pain may be extreme, though the
swelling is but moderate; whereas, in other cases, an excessive
dilatation of the vessels may be attended by little or no actual
pain.

The diagnosis of this complaint is so simple and easy, that
with a little attention and habit of observation it is difficult to
mistake it; and yet varicocele has been taken for hernia,
abscess, hydrocele, &c. Varicocele follows the direction of the
cord, as high as the inguinal canal; but sometimes it seems to
spring from the epididymis, and rises towards the ring; whereas,
at others, it appears to descend from the latter point towards
the testicle. Slow in its progress, the descending form of
varicocele is more surely accompanied by pain than the ascend-
ing. Exposure of the scrotum to cold air, the application
of cold, or the horizontal position, diminish or cause the
entire disappearance of the swelling on the testicle and cord ;
but warm applications, the upright posture and walking, re-
102. VARICES OF THE LOWER EXTREMITIES,

produce the distension of the vessels. The degree of sensibility
under pressure varies very much in different cases.

One remarkable circumstance associated with the history of
varicocele is the influence it exercises on the moral condition
of the patients affected with it. It is well known that diseases
generally of the genito-urinary system produce a very depres-
sing effect; but this is especially the case in the complaint
under consideration. Melancholy, tedium vite, tendency to
suicide, and even insanity are common attendants on this
disease; sexual power is diminished, and abstinence from
attempted intercourse is the consequence. These effects are
not constant, but M. Breschet has observed them, more or
less, in all instances; and these results account for the des-
pondency and shyness of patients, Many instances have come
under my notice at the Hétel-Dieu, some of which occurred
in medical students, where both moral and physical depression
were removed by the cure of the disease; and these facts are
worthy of the observation of those especially who direct atten-
tion to mental and nervous complaints. :

The prognosis in varicocele is not serious ; as it does not tend
in any way directly to shorten life.

Until recently the cure of this complaint has been regarded
as impracticable, and practitioners were satisfied with recom-
mending the use of palliative measures, such as cold and
astringent lotions of various kinds, ice, &c.; but these, it is
needless to observe, are of but temporary benefit. The use of
a suspensory bandage becomes irksome to the patient ;. and.
yet without this simple arrangement he is unable to walk.
Radical cure has, indeed, been accomplished, by castration ;
but this is paying dearly for the relief, and its recommendation
is not justifiable.

The older surgeons, for the radical cure of varicocele, had
recourse to cauterization of the veins, or they tied them or
removed the varicose plexus. But these dangerous proceed-
ings are condemned by all the celebrated modern surgeons of
England, France, and Germany; and after the unfortunate
experience of Delpech, it created some surprise that M. Breschet
called the attention of the Academy of Sciences to a new
method of radically curing varicocele. This process, however,
is not obnoxious to the same objections, inasmuch as it is
AND VARICOCELE. 1038

gradual and not sudden, in its operation; and thus the risk
of extending phlebitis is obviated. More than two hundred
cases have been thus treated successfully, without any un-
toward accident occurring. The following is the mode of
proceeding.

In order that no vein may escape, the patient is directed to
walk for some distance, or bathe the scrotum in hot water;
and the scrotum having been carefully shaved, the patient
stands up before the operator, who takes the scrotum in his
left hand, and separates the vas deferens, drawing all the veins
to the outer side. Great care must be taken not to exclude
a single vein, but to leave the vas deferens and spermatic
artery entirely isolated. An assistant then applies the upper
pincers or forceps transversely, and as high ‘as is compatible
with the security of the penis; the blades are then tightened
and firmly fixed by a screw, care being taken to leave a
pedicle of skin on the outer side, about two lines in diameter.
The second and lower pair of compressing blades is to be
similarly applied as low as is consistent with the safety of the
testicle.

The following case will serve as an illustration in point.

Varicocele of the left side; chronic urethritis ; operation
and cure. A. Dromer, aged 35, of feeble constitution and
nervous temperament, was admitted into the Hétel-Dieu, under
M. Breschet. He had suffered for six months from a wearing
sensation of weight on the left side of the scrotum, accompanied
by dull pains in the corresponding lumbar region. He was
also the subject of gleet.

. The patient had been for some years affected by epilepsy,
and fancied he had received some injury to the scrotum during
one of these attacks. It also appeared that he had been ad-
dicted, when a youth, to masturbation. 3

The varicose tumour in this case presented nothing peculiar.
At its maximum size it was about as large as a hen’s egg;
and the testicle of the same side was manifestly shrunk.

On the evening of the day on which the operation was
performed, the gleet assumed an active character, the discharge
becoming more abundant and darker in colour; at the same
time great pain was felt in the scrotum and groin, and the
patient could not make water without the use of the catheter.

On the following day the pain was less, but the testicle and
104 VARICOCELE.

epididymis were swollen. On the fourth day all the symptoms
were amended, except that it was still necessary to pass the
catheter.

On the thirteenth day, the compressing blades were removed,
and it was found that the lower section was complete, but
above the tissues were not quite cut through. -

Subsequently inflammation of the bladder and erysipelas of
the scrotum supervened, but yielded to appropriate treatment.
At the expiration of another month the cure was complete.
SECTION VI.

ON WOUNDS OF THE HEART, THEIR CAUSES,
SYMPTOMS, AND TREATMENT.

Onty a few years ago it was considered an incontrovertible
fact that wounds of the heart are instantly fatal, and many
theses have been read before the faculty in support. of this as-
sertion. Even now, notwithstanding the cases collected at the
Hotel-Dieu and other hospitals, the contrary opinion is far
from being generally admitted. It is, however, well ascer-
tained by post-mortem examinations, that injuries involving
the substance of the heart are not incurable, however deeply
the instrument may have penetrated, or whatever cavity may
have been implicated in the lesion. Plater has cited an in-
stance in which the heart of a pig contained a piece of stick ;
and balls or manifest cicatrices have been frequently observed
in the hearts of animals killed in hunting. The celebrated
Harvey found a bullet in the heart of a stag. Latour, in his
‘History of the essential and proximate causes of Hemorrhage,’
(vol. i., p. 75), reports a very singular case of a soldier, in
whom, six years after his cure, a ball was extracted from the
right ventricle, near to the apex of the heart, and partly co-
vered by the pericardium. Finally, individuals have recovered,
in whom there was every reason to suppose, from the symptoms,
that the heart had been wounded. These facts, and others I
shall adduce, prove that wounds of the heart are not instantly
fatal, and even that, under certain circumstances, they may be
cured. Indeed, this conclusion is generally admitted by edu-
cated surgeons, as regards wounds penetrating the ventricles
or auricles.

This remark is especially applicable where the injury is oc-
casioned by a pointed instrument. For instance, M. Searle
tried acupuncture of the heart, at, Warsaw, in cases of cholera ;
and the introduction of the needle was accompanied by scarcely
any pain, and followed neither by extravasation of blood nor
106 WOUNDS OF

inflammation. Doubtless such a finely pointed instrument only
separates, without otherwise injuring the fibres of the heart;
but the case is different where the injury is inflicted with an
instrument at once pointed and cutting; although instances
are on record, which demonstrate that even these serious lesions
are not so immediately fatal as is generally proved. The fol-
lowing cases will illustrate this assertion, and likewise prove
that death is not an inevitable consequence of even very serious
wounds of the heart. ©

Case I—Wound of the right auricle, proving fatal after the
lapse of several hours.—On February 13, 1830, when the Duc
de Berry was leaving the Opera, a man threw himself upon
him from behind, and seizing his left arm and shoulder, turned
him half round, and then pressing one hand on his back, plunged
a dagger into his breast a little below the right nipple. The
first sensation of the Prince was that he had received only a
blow; but immediately afterwards, on touching the part, he
cried out, “I am assassinated! I am mortally wounded! here
is the dagger !” s

Being conveyed to the interior of the house, he himself drew
the dagger out of the wound, and the blood which had till then
been retained, spirted out and covered his clothes—though not
in such profusion as might have been expected: syncope fol-
lowed.

The impulse of the first medical man who saw the Prince,
was to bleed him, to relieve the oppression which evidently
arose from effusion of blood into the chest; but a second sur-
geon thought it expedient first of all to try the effect of re-
moving the clot which plugged the orifice of the wound. This
was accordingly done, and the wound itself slightly enlarged
below ; after which, a small quantity. of dark blood came away.
This afforded scarcely any relief; aud some veins were then
opened, which, however, yielded very little blood. Cupping-
glasses were then sent for, and suction in the mean time was
resorted to. When the cupping-glass was applied over the
wound, there was a larger discharge of dark blood which af-
forded evident relief. The patient was then conveyed to an-
other apastment, and the cupping-glass was again employed ;
the relief thus gained was such that colour returned to the face,
THE HEART. 107

the pulse became stronger, respiration and articulation were
easier, and the opened veins yielded six or eight ounces of
blood.

This improvement was, however, but transient; and when I
arrived, the oppression and other symptoms indicated imminent
danger. I examined the dagger, and found it to be about six
inches long, pointed, flat, and with cutting edges, but very rude
in coustruction. It had evidently been thrust deeply into the
chest. When asked where he felt the greatest pain, the Prince
directed attention to the lower part of the chest, and said that
the weapon had penetrated to his very heart.

We then examined the region of the heart: its beat was
imperceptible to the touch; the pulse was small, feeble, and
rose and fell at intervals, On percussing the chest, the left
side was found to be distinctly resonant; but the right side,
which corresponded with the wound, presented around this spot
a fluctuating elevation of the skin, caused by extravasated
blood, and yielded on percussion a dull sound, such as would
be elicited by striking the thigh. As there had been no
previous affection of the lung, the abnormal condition was attri-
buted to effusion of blood on this side—a conclusion which the
issue justified.

But a natural question arose, as to what was the source of
this extravasation; it might be from a wounded intercostal
artery ; or was it from the lung, from the heart itself, or from
one of the neighbouring large vessels? The dark colour of
the blood which flowed from the wound excluded the first idea,
and the absence of hemoptysis and emphysema, rendered the
second at least very doubtful. It was surmised by some that -
one of the large venous trunks of the chest was opened ; but
of this there was no certain indication, inasmuch as all the
symptoms present might be as reasonably referred to a wound
of the heart itself.

It was evident, however, to all, that something must be done,
and that promptly, if life was to be prolonged. The alter-
natives presented were, to close the wound and thus arrest
the hemorrhage, to wait for fresh symptoms, or to facilitate
the escape of the blood, the continued accumulation of which
threatened a speedy and fatal issue. The urgency of the
dyspneea led to the adoption of the last of these alternatives.
108 WOUNDS OF

With the view of affording the required relief, an incision
was made through the skin, and the finger, being guided by the
track of the wound, reached the point at which the dagger had
pierced the intercostal muscles. The weapon had penetrated
the fourth intercostal space, and had been plunged in with
such violence as to notch the opposed margins of the two ribs
between which it entered. Thus it was evident that a deep
wound had been inflicted, but we were still in the dark as to
what parts were involved in the injury.

As soon as the wound was extended, a considerable quantity
of dark blood flowed from it, and saturated the linen with
which I covered it, to prevent the access of air. The breath-
ing became easier and less painful; and no air escaped from
the wound.

Again, a question was raised whether leeches or bleeding
from the arm should be tried; but-the feebleness of the patient
forbad this. And the suggestion that the wound should be
exposed to the air was rejected as dangerous. Ultimately, it
was decided that the best course was not to disturb the patient,
to keep the wound covered, and to favour the escape of the
extravasated blood, by inclining the body towards the right
side ; awaiting the occurrence of other symptoms which might
lead to a variation in the treatment.

Soon, however, extreme thirst supervened, accompanied by
intense pain in the epigastrium, the back of the head, and the
bowels. Vomiting and purging followed; and the heart’s
action and respiration became more and more feeble. The
fatal instant was accelerated by a change of posture. ‘Turn
me,” exclaimed the Prince, “I cannot bear my present posture
any longer.” A vain attempt was made to dissuade him from
this change; his only reply was, “turn me.” Up to this mo-
ment he had been resting on the right side, so that the left
and sound lung had been left free and uncompressed, and had
thus sufficed, alone, to support life. But immediately the pa-
tient’s wish was complied with, he became insensible, and death
speedily ensued.

When a wound of the kind just described does not involve
parts essential to life, it may nevertheless prove fatal in various
ways. But it is usually not till after the lapse of several days
that dangerous inflammatory symptoms occur. On the contrary,
THE HEART. 109

when such vital organs are involved, death is the almost imme-
diate consequence.' It was thus that Henri IV lost his life.

On examining the body of the Duke, the following appear-
ances presented themselves. The dagger had entered the chest
between the fifth and sixth ribs on the right side, and passed
through the anterior part of the right lung; it subsequently
penetrated the pericardium and traversed the right auricle of
the heart, stopping short at the central tendon of the diaphragm.
Two pounds of blood were extravasated into the right side of
the chest.

A natural question arises, how life could be at all prolonged
with so serious a wound of the heart. Probably, the fact of
the right or venous side of the heart having been the seat of
the lesion may afford some explanation of this apparent anomaly.
In the case of Henri IV, who received a similar wound, the
monarch expired without giving utterance to a single word.
The weapon had taken a similar direction, that is, it had pierced
the lung and auricle; but the blow being struck on the left
side, it was the left side of the heart that was wounded:
whereas, in the Duc de Berri, the right auricle was opened.
This circumstance probably accounts for the speedy issue in the
one instance, and the prolongation of life in the other.

In my lectures on gun-shot wounds, I have narrated the
case of a man named Géray, in whom the left ventricle of the
heart was pierced to the extent of 33 lines; but who, never-
theless, survived for eight days, and would probably have
recovered, had not softening of the left hemisphere of the
brain supervened. In this instance there was no inflammatory
effusion into either chest or abdomen, and. the blood extrava-
sated into the chest did not appear to be. of much importance ;
therefore, taking these circumstances into consideration, in con-
junction with the hemiplegia and disturbed mental functions
of the brain, it is difficult to evade the conclusion that the fatal
issue was due to the cerebral lesion. In another part of my
lectures, on: “ Traumatic Emphysema,” I mention a case of
laceration of the pericardium, accompanied by penetrating
wound of the right ventricle of the heart by a fragment of a
fractured sternum ; here death did not ensue until the twelfth
day. we: A

! Such, at least, was the general opinion at that time.
110 WOUNDS OF

The case of a man named Sénart, published by M. Ferrus
in the Répertoire général d’ Anatomie et de Physiologie, is closely
allied to the preceding. The patient, who was the subject of
habitual melancholy, attempted to commit suicide by thrusting
a long, thin, and sharp instrument into his left side between
the fifth and sixth ribs: the weapon remained in the wound.
The wound healed, and the patient survived till the twenty-
third day after the infliction of the injury. On examining the
body, a stiletto was found fixed in the front and lower part of
the left ventricle; it had penetrated to the depth of 18 lines
from the surface of the heart, transfixing the left ventricle and
ventricular septum, and projecting into the right ventricle.

Thus, it is evident that these wounds of the heart are not
necessarily and immediately fatal, and may even be cured.
Nevertheless, in calculating the chances of a cure, it is essential
to bear in mind the depth to which the weapon has penetrated,
the direction which it has taken, and the thickness of all the
tissues involved in the wound; the form of the weapon, and
its retention in or removal from the wound should not be lost
sight of.

Let us consider these various points more in detail. Wounds
of the heart differ in regard to their extent and position: they
may be superficial or deep. The former involve only a part of
the thickness of the walls of the heart, whereas the latter com-
pletely perforate them. There are some cases on record where
the wounds have implicated the parietes of more than one of
the cavities.

The direction of the lesion may be such as to divide trans-
versely the greater number of the fibres through which it
penetrates, or the reverse may be the case ; and the tendency of
the wound to gape, more or less, will depend on this circum-
stance. Thus, when the division of the fibres is transverse,
the separation of the edges is more considerable, and the risk
of extravasation of blood is much greater, than when the wound
is parallel to the course of these fibres. But, as the heart
consists of several layers of fibres taking different directions, it
is evident that, in perforation of the cavities, the tendency to
separation of the lips of the wound in one part is counterbalanced
by an opposite condition in another. Thus, if the left ventricle,
for example, be perforated, and the wound extend from the
THE HEART. 111

anterior wall of the cavity obliquely towards the left side of
the heart, three planes of fibres would be implicated. The
superficial and middle are directed downwards and towards the
left side; the deepest, which exceeds the other two in thick-
ness, crosses them at right angles; and the penetrating weapon
which has cut transversely the deepest plane, has only separated
in its passage the other layers which are parallel to the wound
inflicted,—a _ circumstance which, of course, constitutes an
obstacle to the risk of extravasation, and greatly increases
the chance of a permanent closure of the wound.

The magnitude of the wound, again, has an important
influence on the issue of the case; and this depends on the
size and form of the instrument with which it is inflicted,
and on the force with which the blow is given. Thus, a ball
makes a round wound; a sharp, flat and cutting weapon, a
linear wound ; or the parts involved may be torn by the pene-
tration of an angular or irregular body. Every part of the
heart may be wounded ; but the left cavities are less obnoxious
to injury than the right. Again, the right ventricle is more
frequently opened than the corresponding auricle; and the
same observation applies to the left side of the heart. The
anatomical relation of these several cavities accounts for these
facts. Sometimes the wound is found in the groove lodging
the coronary arteries, both anterior and posterior; and the
hemorrhage, in such case, is most serious. The thickness of
the walls of the left ventricle renders this cavity less liable to
be opened than the others; and if implicated, supposing the
extent and direction of the wound and other circumstances to
be the same, there is a better chance of the aperture being
closed by approximation of its lips.

Wounds of the heart may be complicated by accidental
concomitants, such as division of .an intercostal artery, lesion
of one of the large vascular trunks, a large opening into the
chest, or wound of the lungs, diaphragm, or some one or more
of the abdominal viscera. Moreover, we should not Jose sight
of the moral condition of the patient at the time of the inflic-
tion of the injury, his age, constitution, &c.

It cannot, however, be doubted, that wounds which implicate
the substance of the heart, are, in general, very serious. Im-
mediate or secondary hemorrhage, from various sources, may
112 WOUNDS OF

prove fatal; or this consequence may result from inflammation
of the heart, or pericardium, or Of some neighbouring organ, or
even from sudden cessation of the heart’s action. It is not
essential that the walls of the heart should be entirely divided
to cause death ; an incomplete, and even very limited, division
may suffice to entail this result, as is proved by the autopsy of
the famous Latour-d’Auvergne. But, whatever may be the
nature of these lesions, it is certain that, in many instances,
death is not instantaneous ; in others, the nature of the injury
may be overlooked ; and in some cases, there may be even
recovery. The following cases illystrate, in a very interesting
way, some of the preceding remarks.

Casz Il.—Wound of both ventricles. Death after the lapse
of twenty-five days. A man, 40 years of age, of large frame
and dark complexion, who had been reduced to a state of great
misery by misfortune and misconduct, determined on self-
destruction. Having been thwarted of his intention to drown
himself, and subsequently thrown into prison, his despondency
prompted him to cut off his penis with a blunt knife, with
which he had provided himself, close to its root. The hemor-
rhage was not considerable ; but when he was discovered to be
bleeding he was brought to the Hétel-Dieu. Ligatures were
applied to all the bleeding arteries, and the wound was simply
dressed, a catheter being introduced into the bladder.

The patient was carefully watched, as his apparent tran-
quillity was suspected to cover a determination to renew the
suicidal attempt.

After some days the calm was succeeded by delirium. The
patient rose from his bed, tore off the dressings, and ran about
the ward. He was bled in the foot, and had administered an
opiate injection and a gentle laxative. Still the delirium con-
tinued; his face became ‘pinched, aud his strength rapidly
diminished. Pulse generally slow; extremities cold; respira-
tion free, and attended by neither cough nor expectoration.
The urine passed freely, and the wound seemed healthy. The
symptoms of cerebral excitement increased during the last
three days of his life; and he died, comatose, three weeks
after this self-mutilation.

Necropsy.—The membranes of the brain were loaded, and
THE HEART. 118

the brain itself injected and firm. On raising the sternum, a
large patch of ecchymosis was observed on the pericardium ;
and the bag itself was found half filled with fluid blood. On
seeking whence this blood came, several small wounds were
perceived on the anterior surface of the ventricles, plugged
with dark fibrinous clots. This led to a suspicion of the truth,
which was placed beyond doubt by a further examination. In
the centre of the ecchymosis, which occupied the front and
upper part of the pericardium, two minute penetrating wounds
were discovered, partly obliterated by false membrane. On
directing attention to the front of the chest, a small cicatrized
wound was found between the second and third ribs of the
left side; it was nearly round, and not more than a line and
a half in diameter. Beneath the skin, and between the inter-
costal muscles and pleura, a large ecchymosis was discovered,
extending downwards and forwards. The opening in the
pleura was indicated by a reddish-brown spot, surrounded by
false membrane. The anterior border of the lung had not
been implicated in the wound.

The small wounds in the heart itself were five or six in
number, and chiefly in the right ventricle into which they
evidently penetrated. One of these could be traced into th
ventricular septum, and another into the left ventricle, which,
however, it did not penetrate. The substance of the heart
was pale, and readily broke down under the pressure of the
fingers. The ventricles contained some dark fibrinous clots.

The whole of the gastro-intestinal mucous membrane was
the seat of chronic inflammation; and there were several
patches of ulceration in the neighbourhood of the ileo-czecal
valve. The mucous membrane of the bladder was red,
thickened, and granular. The other organs were healthy.

On inquiry, it was learned that, when this man was found
mutilated in prison, in addition to the knife with which the
mutilation was accomplished, he had in his possession a long
needle, such as is used in his occupation of a saddler. This
was taken from him, and he had afterwards no opportunity of
providing himself with a similar instrument. It was therefore
indubitable that this attempt at suicide must have been made
at least twenty-five days before his death; and the condition
of the external cicatrix entirely agreed with this calculation.

8
114 WOUNDS OF

The instrument, which was fine and very sharp, must have
been pushed in vertically, and directed towards the heart ; and
on reaching this organ it must have been plunged at various
points into its substance, as the appearances presented would
seem to prove. The minuteness of these wounds did not
allow of the escape of blood from the cavity of the ventricle ;
but that which was found in the pericardium (about three
ounces) escaped, I apprehend, from the substance of the heart
itself,

This patient’s pulse, which was often felt, presented nothing
remarkable ; and the heart’s action was natural, as were the
sounds. There was neither fainting nor dyspnoea, nor indeed
any symptom which could lead to the suspicion that the
circulating centre had been the seat of any lesion whatever.

The peculiarities of this case suggest to me some remarks
on the form of self-mutilation practised by the unfortunate
subject of it. These voluntary mutilations of the genital
organs are of not infrequent occurrence; and they constitute
a very singular variety of suicidal monomania. The individuals
who commit the act are usually of an erotic disposition; and
are under the impression that any serious injury of these parts
must be fatal. All the authors who have treated of madness
have alluded to this form of attempted suicide, and agree that
these mutilations are not, in themselves, dangerous. Such
maniacs require close watching, as they generally succeed in
ultimately destroying themselves. Many have been known to
attack others with the same blind rage with which they have
attacked themselves. It would appear that the sensation of
pain is weakened, if not actually annihilated. An indifferent
knife, with an edge more like a saw, must inflict, one would
suppose, horrible torture; yet nothing seems to stop them
from accomplishing their purpose. The arteries thus lacerated
do not bleed freely, and the retraction of the parts aids in
arresting what hemorrhage there is; or, perhaps, the patient
faints. In many instances the cure is purely spontaneous.
Every variety of mutilation may occur, including either par-
tially or completely all the external organs of generation.
Thus, I have seen one case in which the wound was inflicted
at the base of the scrotum and penis, which were divided
through two thirds of their extent. The parts were brought
THE HEART. 115

together with points of suture, and the patient recovered, with
one corpus cavernosum obliterated. In another instance, com-
plete obliteration of the anterior part of the corpora cavernosa
followed the tight application of a ligature around the penis.

Jealousy is one of the most common exciting causes of these
mutilations. A monomaniac of this class came under my
notice, who entirely cut off both testicles with the scrotum.
He quickly recovered ; but afterwards drowned himself. It is
difficult to conceive what can be the motive impulse to such
an extraordinary act, under these circumstances. But, to
return from this digression, I will now narrate a case very
much resembling the preceding, but in some respects still more
interesting.

Cast I1I.—Wound of the left ventricle terminating fatally
after three days.—A man, about 30 years of age, determined,
in a fit of jealousy, to destroy himself; and the instrument he
used for the purpose was a file, which he had sharpened at the
point, and with which he stabbed himself six or seven times,
principally in the precordial region. The patient lost blood
by the mouth, but much more by the wounds. When brought
to the Hétel-Dieu, on March 8th, 1832, it was observed that
a quantity of air escaped by the wounds, a circumstance which
left no doubt of the chest having been penetrated. His
breathing was short and feeble, his pulse small and irregular,
and the patient was altogether so prostrated, that it was out of
the question to bleed him at that time. When reaction took
place, he was bled; and this operation was repeated each time
that an exacerbation recurred.

Thirty-six hours after the injury was inflicted, a remarkable
circumstance occurred. The patient began to spit up a thick
expectoration of mingled pus and blood. I thought it advisable
to dress the wound, with a view of thereby preventing the
ingress of air and of stopping the bleeding. In so doing I
acted upon the principles which M. Larrey had some years
before laid down; and I cannot say that this step had the
effect of increasing the dyspnea; but, on the contrary, the
patient seemed to be going on pretty well under the treatment
adopted. But this favorable appearance was not of long dura- .
tion, for the unhappy man died after the lapse of three days
116 WOUNDS OF

from the receipt of the wounds. JI was never deceived as to
the very serious nature of the case; but I have no doubt that
the fatal issue was hurried by an interview with his mistress
and a commissary of police, about three or four hours before
his death.

Autopsy.—The integuments over the precordial region were
pierced by five triangular wounds, corresponding in form to
the instrument with which they were inflicted. In noticing
this point I would observe that, in a medico-legal point of
view, we ought not to lose sight of the fact that a round
instrument may produce wounds of a similar form. In pur-
suing the examination, two of the wounds were found to be
above the nipple, and three below it. All of these were
regular, with one exception ; a fact which proves that each was
made by a single blow. This is not always the case; for
sometimes the determination of the suicide to accomplish his
purpose induces him to plunge the weapon again deeply after
partially withdrawing it; by which an irregular wound is
produced, or the internal wounds may be more numerous
than those which implicate the integument only.

The highest of these wounds appeared to have been inflicted
with more violence than the others, for it involved a part of the
adjoining rib, and then penetrated the intercostal space. There
was a considerable quantity of blood extravasated into the
pleural cavities. On the left side there was air mingled with
blood, partly in a fluid state, partly coagulated ; and this effu-
sion, including what had escaped by the wound, might be com-
puted at three or four pounds. This blood would, no doubt,
have all found its way out, if the wound had been left open,
instead of being closed. As it was, the lung, being encroached
upon from all sides, was compressed and no longer permeable
to air, as occurs in emphysema.

The left side of the pericardium exhibited three or four aper-
tures, and its interior contained about a table-spoonful of blood
mixed with pus, the product of inflammation. The instrument
had pierced through the left ventricle in three places.

Was the left lung wounded? It was my impression that it
must have been so; and in order to ascertain the fact it was
inflated, and the air escaped at three several points, correspond-
ing exactly with the external wounds.
THE HEART. 117

The right ventricle contained some clots of blood, but was
unwounded.

I now proceeded to examine the interior of the left ventricle
to discover, if possible, the exact points at which the weapon
had entered the cavity. I was guided in this difficult search
by a clot of blood, evidently formed during life, which adhered
to the side of the cavity; and by introducing a probe from
without, the internal orifices of three penetrating wounds were
discovered.

These various lesions, together with the evidences of pleuritis,
were sufficient to account for death. But here another ques-
tion presented itself. From what source was the blood supplied
which had escaped from the wounds, and which had been found
in the chest? The lungs had not furnished it, but it had been
derived from the wounded intercostal artery.

The foregoing case confirms the opinion that wounds of the
heart are not necessarily fatal. The patient had lived upwards
of seventy-two hours, although he was the subject of three
penetrating wounds of this vital organ. The preceding cases
prove that life may be protracted for even a much longer

‘period. A multitude of other instances might be cited to show
that penetrating wounds of the right ventricle may be survived
two, three, four, five, six, and even fourteen days. Other cases no
less remarkable, and also noticed in M. Alph. Sanson’s thesis,
prove that penetrating wounds of the left ventricle have been
survived five hours; and that in others, where both ventricles
have been involved, the patients have lived for five, or even
twenty days.

In the face of so many and such authentic instances, it can-
not be asserted that wounds of the heart are immediately or
necessarily fatal. The case of the soldier, which was cited at
the commencement of this article, is’ still more conclusive, as it
leaves no doubt as to their curability. Ido not mean, how-
ever, to imply that these injuries are otherwise than extremely
serious ; all I mean to affirm is, that they are not altogether
hopeless.

The symptoms of wounds of the heart are not all of equal
moment; some are of doubtful import, ‘whilst others are more
characteristic. The uneasiness which would be excited by the
existence of wounds in the precordial region, would be enhanced
118 WOUNDS OF THE HEART.

by the occurrence of symptoms of hemorrhage, such as general
prostration, syncope, a small pulse, pallor, cold extremities,
vomiting, cold sweats, anxiety, sleeplessness, oppression, and a
sensation of great weight on the diaphragm. Other symptoms
have been enumerated as characterising wound of the heart ;
these are, a peculiar tremor of this organ, an unequal and feeble
pulse, violent fever, &c.

The diagnosis of wounds of the heart is by no means easy,
because the symptoms which distinguish them are rarely met
with in combination, and it is the doubt which hangs over such
cases which has led, probably in a considerable number of in-
tances, to the cure of penetrating wounds in this organ being
overlooked. Nevertheless, there is no doubt as to the fact of
such cures having been effected; it may, therefore, be laid
down as a general rule of practice, that wounds of this nature,
however serious, should be treated as if they did not penetrate
the substance of the heart.

The treatment to be adopted, under these circumstances, is
such as would apply to all deep wounds of the chest, accom-
panied by lesion of some one of the great vessels in this cavity.
Bloodletting, rest, a simple dressing of the wound, so as to
prevent the escape of blood and the ingress of air; sometimes
enlargement of the wound or tapping, and the émployment of
cold, and exhibition of acidulated drinks.

The abstraction of blood should be accommodated to the
power of the patient and the dypncea of which he is the subject;
and we may hope thereby also to combat the inflammation
which may affect the pericardium, the heart itself, or any other
wounded organ. Great caution should be enjoined as to diet
and exercise, until a considerable time has elapsed, in order to
avoid the risk of detaching a loosely adherent clot, or tearing
open a fresh cicatrix.
PART II.

ON DISEASES OF THE RECTUM.
PART II. ‘

ON DISEASES OF THE RECTUM.

SECTION I,

ON THE EXCISION OF HEMORRHOIDS.

THE lower extremity of the rectum is, in a great many
persons, the seat of vascular swellings, to which the name of
Hemorrhoids has been given.

These tumours may exist during the entire life-time of the
subject of them, without being the source of any considerable
inconvenience; but not infrequently they give rise to more
serious consequences, involving even a fatal issue, if not
attended to and relieved. Thus, the celebrated Copernicus
and Arius died of hemorrhage consequent on a rupture of
hemorrhoids; and many similar fatal cases are recorded by
various authors. The risk of such a termination was also
known to the ancients, who proposed various modes of treating
the disease, and amongst others the ligature. Thus, Hippo-
crates recommends the employment of a strong ligature, with
which all the hemorrhoids but one should be tied. “ You must
not cut them,” adds this author, “ but you may hasten their
separation by appropriate local applications.” Paulus Aigineta
gave the same advice. Celsus thinks that the nail or scalpel
should be used to assist in the detachment of the tumours when
tied. I cite these opinions simply to prove that the ancients
122 EXCISION OF

were aware of the dangers attending these hemorrhoidal af-
fections.

Before passing in review the various modes of treating these
diseases, it is desirable to say a few words respecting their
nature and anatomical structure, and to point out the class
of cases in which the treatment I am about to speak of is
applicable.

As regards their nature, a great variety of opinion exists.
Some suppose the disease to have its seat in the capillary
vessels, without involving either arteries or veins. Others
again,—as Duncan, Le Dran, Cullen, &c.,—regard them as
cysts into which the blood is poured. Lastly, Stahl, Albertus,
Vesalius, Morgagni, Petit, and Boérhaave, consider them to
be dilated veins, true varices; and this is my opinion also.

If we examine the composition of these hemorrhoidal
swellings, we find that they are distinguishable into internal
and external.

Internal piles are covered by mucous membrane of a livid
hue, and form a sort of partition in the rectum ; they present
sometimes grooves in their intervals which facilitate their
isolation, but which at other times are absent in consequence
of being obliterated by inflammation. Even the tissue of this
membrane exhibits varices like the heads of pins, which, when
they are cut, allow of the exudation of venous blood, and thus
impart a spongy appearance to the diseased surface, On
raising the mucous membrane, an organized false membrane
is brought into view, or else cellular tissue. Lastly, the
muscular coat is external; and large arterial trunks are fre-
quently seen spread out over these coverings.

External piles, which arrange themselves in an annular form
around the anus, are constituted,—first, externally, in great
part by the rectum, and to a limited extent by the skin;
secondly, by the false membrane which often exists in connec-
tion with internal piles, or by the filamentous investment
which appears then to be continuous with the superficial
fascia; thirdly, by the dilated veins themselves; fourthly, by
the sphincter muscle, which embraces the pedicle, and spreads
over the surface of the tumours; fifthly, by nervous filaments
which creep over their surface; and lastly, by fat, which is
sometimes interposed between them and the superjacent skin.
HEMORRHOIDS. 123

There is no doubt that age and sex exercise an influence
over the production of hemorrhoids. By some authors, they
have been described as belonging exclusively to the adult
period and commencing old age; and that they are never met
with in early youth, though partial prolapse of the rectum has
been mistaken for them. Others, on the contrary, have recorded
cases even in very young children. Again, some affirm, and
others deny, that the displacement of the uterus during preg-
nancy, and a constipated state of the bowels, specially dispose
women to this affection.

But the practical question is, which cases are we to leave
alone, and which to attempt the cure of by surgical measures.

It is clear that we have no business to meddle with hemor-
rhoids in individuals who are prostrated by organic disease of
the bowels, liver, or, above all, of the lungs. It is, indeed, an
ascertained fact that, in certain subjects, in whom the phthisical
tendency is more or less developed, the progress of this disease
is suspended for a longer or shorter time by the presence of
hemorrhoids ; and that their ill-timed suppression has stimu-
lated the organic affection to resume its destructive inroads.
Hemorrhoids make their appearance, in pregnant women,
often towards the period of their confinement, or as a conse-
quence of labour; but, in such cases, the cause is evident, and
the effect ceases with its removal.

I may further remark that, so long as piles do not exhibit
degeneration in their tissue, and are not the source of hemor-
rhage or copious sero-purulent discharge, by which the patient
is thrown into a marked and characteristic state of anemia, sur-
gical interference is not justifiable, as antiphlogistic measures
are alone sufficient to relieve the annoyance they occasion.
But, where serious inconvenience attends this complaint, and
life itself is threatened, then more decisive measures must be
adopted for the removal of the degenerated hemorrhoidal
excrescences.

Internal and external hemorrhoids may be met with either
separately or in combination, and present the appearance of
tubercular projections arranged around the lower extremity of
the gut, either within or without the anus. Externally, they
are characterised by their rounded prominence and cover-
ing of dark skin; whilst, mternally, they are invested by a
124 EXCISION OF

covering of bright-red mucous membrane. In the former
position, they rarely ulcerate; but in the latter, frequently:
and the consequence of such ulceration is loss of blood, and
the discharge of serum and pus, by which the patient is much
worn and prostrated.

Internal piles, which are situated entirely above the anus,
are often strangulated by the sphincter muscle, in consequence
of their turgid condition and the prolapse of the lining mem-
brane of the bowel; they likewise present the same external
character derived from their mucous investment, and also yield
blood or pus from their surface when the seat of ulceration.
As I have already remarked, in some instances both forms of
hemorrhoids coexist in the same subject.

Individuals afflicted with this complaint walk with difficulty :
they may be seen carrying the hand to the seat of suffering,
or sitting down to aid thus in returning the protruding mass.
But the relief obtained is only temporary, and the suffering is
renewed as soon as the turgid vessels again descend.

The debilitating effect of the discharge accompanying these
swellings is evidenced by the emaciation of the patient, and the
wan, discoloured, and wax-like tint of the skin. In two indi-
viduals in the Hoétel-Dieu, a bellows-sound was distinctly
audible when listening to the heart; and in one of these
patients this sound could be traced upwards in the course of
the carotids. Such persons have the aspect of patients suffer-
ing from other forms of hemorrhage, or worn down by exces-
sive suppuration: their spirits become painfully depressed,
their intellect is weakened, and a tendency to commit suicide is
induced. As the local complaint advances, the lower part of
the bowel assumes a scirrhoid character, and death finally
ensues if measures be not adopted to arrest the disease.

Under such circumstances an operation affords the only
prospect of relief: but what should this operation be? For
the radical cure of hemorrhoids, compression, cauterization,
the ligature, or the knife, have been recommended and em-
ployed. I will refer, in succession, to these different plans of
practice.

There can be no doubt about the possibility of obliterating
these diseased vessels by pressure, if it could be effectually
applied: but this is the difficulty; and therefore this attempt
HEMORRHOIDS. 125

has been abandoned. The ligature, as I have mentioned, has
been recommended and adopted for a long time past ; and this
mode of treatment is attended with great risk, on account of
the inflammation which it engenders, and the excessive suffer-
ing it entails. Sometimes even a fatal result follows its use,
as in a case recorded by J. L. Petit. Cauterization has been
frequently had recourse to. Although of undoubted value as
an adjunct to excision, it is both excessively, painful and dan-
gerous when employed alone on tumours of large extent, which
cannot be dealt with except by the prolonged action of the
heated iron. Shaving off or clipping the tumours with scissors
has had its advocates. But this partial proceeding is attended
by the risk of hemorrhage and inflammation, whilst the disease
is not eradicated ; and therefore I do not consider it justifiable.
Excision of the morbid mass is the mode of treatment to which
I give the preference ; and I now proceed to describe how this
ought to be accomplished; and subsequently I will mention
the difficulties and risks attending it, and point out how they
are to be met and combated.

When the operation is decided on, I make the patient lie
down at the edge of his bed and on his side, or on his elbow
and knees with the leg extended, or, better still, with one of
the legs completely bent on the thigh, and the other extended.
If the pile is external, I direct him to strain violently as when
at the water-closet, and in this way it is forced out. The
tumour is then seized with a strong pair of forceps, whilst an
assistant separates the nates, and with a long pair of scissors,
curved on the flat, the tubercles are excised with very little
difficulty. I make it a rule to remove only a portion of the
tumour which projects; for, if the whole be taken away, there
is risk of serious hemorrhage, and subsequent constriction at
the anus. In proceeding as I have described, there is, in ap-
pearance, a very considerable mass left at the orifice of the
bowel, which would give the impression that a sufficient quan-
tity had not been removed; but when the part heals, that
which is left assumes its normal position, and the anus regains
its natural state. In fact, the same result attends this opera-
tion as that which follows a similar one on the tonsils.

When the pile is internal, its excision is attended with rather
more difficulty. In order to procure its extrusion so as to be
126 EXCISION OF

able to remove it completely, it is requisite, in the first place,
that the patient should sit down in a hot bath, and make every
effort in his power to force down the bowel. As soon as this
is effected, he must place himself quickly in the posture I have
described, and the operator must lose no time in seizing and
excising the diseased portion with the scissors.

Before the operation, it is my custom to administer a mild
purge and an injection. I shall presently notice why I con-
sider this precautionary measure essential.

The excision of hemorrhoids is not free from some incon-
veniences, and even danger; but the latter can happily be
surmounted by the adoption of suitable measures.

The danger to which I refer is that of hemorrhage. In exter-
nal piles the bleeding is likewise external, and, being readily
discovered, may be as speedily arrested by the employment of
the actual cautery. ‘The same course must be pursued where
the hemorrhoidal tumour is internal; but in this case the
employment of the remedy is not so easy, and the bleeding
may go on without being detected. When there is good
reason to believe that the patient is bleeding internally, he
must be directed to empty the bowel of the blood by the same
effort as he makes in having a motion: a cold injection is then
to be administered. The patient’s straining will bring the
bleeding wound into sight, and then the cauterizing iron,
heated to a white heat, must be applied to it. This is effec-
tual; and I have never seen any dangerous consequences follow
its employment. I always make it a practice to leave an intel-
ligent assistant to watch the patient, and to apply the cautery
as soon as it is needed, should. hemorrhage arise.

I have been asked whether it is not better, in every case
and immediately after the operation, to cauterize the part,
rather than wait till hemorrhage occurs. J am disposed to
think it is, inasmuch as in the numerous cases on which I have
operated, both in public and private, about two fifths of the
whole have suffered from bleeding afterwards when the cautery
was not used; whereas, I have never known this consequence
where the part was cauterized at the time. The question,
therefore, resolves itself into an estimate of the danger attend-
ing, severally, hemorrhage and the use of the cautery. But I
am of opinion that the risk of the latter bears no comparison
HEMORRHOIDS. 127

to that of the former ; for the inflammation and swelling follow-
ing the cautery, and the sympathetic irritation of the rectum
and urinary organs, generally yield to simple measures, and
never lead to serious consequences; but internal hemorrhage,
on the contrary, frequently imperils a patient’s life. Further,
as it is impossible to ascertain, @ priori, whether a patient will
bleed or not, I am disposed so far to modify the practice I have
generally pursued, by adopting and recommending the use of
the actual cautery in all cases where the operation of excision
is performed.

Another, but less certain, mode of stopping the bleeding,
consists in the introduction of a pig’s bladder into the rectum :
this is then stuffed with charpie. Although this plan suc-
ceeded the first time that I had recourse to it, I cannot recom-
mend it, on account of the inconvenience it occasions to the
patient, and the risk of its being almost certainly expelled in
the involuntary efforts which are provoked by its presence.

The other accidental concomitants or sequences of excision
are far less important. There is always considerable swelling
of the adipose and cellular tissue about the anus. The chief
inconvenience of this tumefaction is the irritation Fhich it
excites in the rectum, in consequence of which patients are
unable to empty the bowel for the succeeding four or five days.
And here the object of the aperient prior to the operation
becomes manifest; for, the previous free evacuation of the
bowels, together with the spare diet allowed afterwards, render
it unnecessary that they should be disturbed for the first few
days. Again, this swelling may occasion retention of urine ; this,
however, may be readily relieved. As to the tumefaction itself,
leeches, fomentations, &c., may be had recourse to if necessary.

As to the pain accompanying this operation, it is sharp but
momentary, and is of very little importance as contrasted with
the previous suffering of the patient, and the purpose accom-
plished by the surgical interference.

Other circumstances, less directly consequent on the opera-
tion, demand the attention of the surgeon, and should not be
lost sight of. I have observed that patients suffering from
the continuous drain of blood, serum and pus, which severe
hemorrhoids entail, become reduced to a miserably asthenic
and anematous condition. Now, such discharge, where it has
128 EXCISION OF

been of long continuance, cannot be suddenly arrested without
a morbid reaction on the animal economy, producing a general
state of artificial plethora, congestion in the lungs, liver, or
brain, and consequent disease in one or other of these organs.
Sometimes patients are attacked by fainting fits, spasms, and
even insenasibility ; and the arteries beat with such violence, as
would lead to the suspicion of the existence of an aneurismal
diathesis, were it not for the constantly changing character and
seat of these pulsations. ® And, which is remarkable, this state
of plethora coexists with a pale, or rather a yellow, earthy tint
of the skin, and especially of the face, together with marked
debility in the patient.

The repeated application of leeches, for some time and at short
intervals, is desirable when the patient is young and vigorous,
and where the discharge has been of a sanguineous nature ; or,
where it has been of a purulent character, an artificial drain
should be established ; or even the two may be combined, where
the case seems to call for it: these remedies, together with mild
laxatives often administered, constitute the most rational treat-
ment to prevent the ill effects of a plethora which might other-
wise préve seriously dangerous.

When the excision of an external pile has been accomplished,
the resulting cicatrix, which is dependent on the constriction
of the sphincter itself or of the anal integument, suffices, in
the great majority of cases, to oppose the descent of any in-
ternal hemorrhoidal tumour; and in that case a similar ope-
ration upon the latter may be dispensed with. As regards
internal piles, excision is equally efficacious, and the patients are
permanently cured by it.

Excision may, however, be followed occasionally by too great
constriction of the anus. J. L. Petit records a case where the
narrowing was such that the pipe of a syringe could scarcely
be introduced. Such an accidental result may be obviated by
keeping the aperture dilated as long as may be needful.

I will now illustrate the principles I have laid down, by the
selection of a few from amongst the numerous cases I have
treated, both in private and in tke hospital, in this way.

Casz I.—Ezxcision of hemorrhoids, followed by hemorrhage.
—Melleville, aged 36, a shoemaker, of pretty good constitution,
HEMORRHOIDS. 129

had been the subject of hemorrhoids for twelve years. He
ascribed their origin to a residence in Champagne, where he
had freely indulged in the wine of the country. He then
came to Paris, where he worked hard at his trade, sitting of
course almost all day long. The hemorrhoidal flux had for
some time been periodical, returning every month, or even
every fortnight, and lasting for some days; so that the loss of
blood in large quantities and the abundant discharge of mucus
seriously affected his health, reducing him from a robust, hale
man, till he became pale and emaciated. Latterly, all his
symptoms had become aggravated; the hemorrhoidal tumours
had acquired an immense size, and there was acute inflamma-
tion of the anus, accompanied by obstinate constipation and
retention of urine. He had been twice bled at home, but with
scarcely any relief, and then he presented himself at the Hétel-
Dieu.

When admitted, he could scarcely walk, on account of his
weakness and acute suffering. On examination, a large he-
morrhoidal swelling, of the size of a hen’s egg, tense, and of a
livid red hue, was found protruding and, as it were, strangu-
lated by the anus; it appeared to be bordering on gangrene.
The patient’s abdomen was, moreover, tense and tender; there
was retention of urine, intense fever, and an anxious coun-
tenance.

The first care was to place the patient in a bath, and to
employ opiated applications to the anus; some relief was thus
obtained, and he was able to puss his water, though but
little impression was made on the swelling ; I therefore pro-
posed the operation of excising the diseased mass.

There is no doubt that, under these circumstances, the ex-
isting crisis might have been surmounted by leeching, fomen-
tation, injections, rest, and appropriate diet ; yet neither can it
be denied that such treatment can only be regarded as palliative,
and that a recurrence of all the distressimg symptoms must
certainly be looked for sooner or later. But, it may be asked,
why not have recourse to similar palliative measures at each
return of the attack? This plan is adopted by many surgeons,
and is preferred by a great number of patients who dread the
knife; it is true that, in some instances, these palliative mea-
sures defer the attacks and render them less frequent; but

9
130 EXCISION OF

more often they increase both their intensity and frequency,
and thereby more rapidly impair the patient’s health. What-
ever value may be attached to such temporising treatment, the
risks attending the persistence of the disease far outbalances
the apparent advantage. For hemorrhoids, both external and
internal, may assume a scirrhoid character; or the latter may
extend so far up the rectum as to get beyond reach, and thus
the process of degeneration involves more and more of the in-
testine. These local, in addition to the constitutional, effects
of the disease, remove all hesitation in my mind as to the
proper course to pursue in these cases.

But let me guard my readers against inferring that I intend
to recommend the operation of excision indiscriminately in all
cases; I have already pointed out the circumstances under
which the disease should be removed, and those which indicate
the propriety of not meddling with it.

To return to the case. The patient having assented to an
operation, he was placed on a bed, with his abdomen supported
by a pillow. The hemorrhoidal tumour, which was already
very prominent, became more so when the patient was directed
to strain. Two rows of hemorrhoids were then very distinctly
brought into view; one set external, invested partly by skin
and partly by mucous membrane, the other internal and having
their seat entirely within the bowel. The excision of these
tumours was accomplished with a pair of scissors curved on the
flat, care being taken in the removal of the external portion
not to cut away too much integument, lest the anus should be
thereby too much contracted when the part healed. There
was some surface bleeding, but as it seemed to stop sponta-
neously, the part was not cauterized.

I was desirons in this case to avoid increasing unnecessarily
the inflammation in the rectum, and therefore I did not at the
time employ the cautery, as indeed then it did not appear requi-
site. Moreover, I may remark that there is something very
alarming to patients and their friends in the heating and em-
ployment of the canterizing instrument. Nevertheless, I had
my misgivings that hemorrhage might supervene, and therefore
left a competent assistant with the patient, instructing him
how to proceed in case of necessity. I may also remark that,
in such cases as the present, I do not apply any dressing to
HEMORRHOIDS. 131

‘the wound at first, as it would tend only to confine the blood,
if any escaped, and thus to mask the real state of things. Ex-
ternal hemorrhage is easily dealt with; but the heat of the
bowel naturally favours internal bleeding, which is therefore to
be much more feared, both on this account and because it is
so insidious and more difficult to control.

In the present instance, bleeding of this kind occurred. It
was characterised by the following symptoms, exhibiting them-
selves about an hour after the operation: a tendency to drow-
siness and stupor, tingling of the ears, heat and tension of the
abdomen, especially in the left iliac fossa, tenesmus, and fre-
quent desire to evacuate the bowels, without the ability to do
so. Presently other and more marked symptoms supervened ;
a deadly paleness overspread the patient’s face ; he had rigors
and frequent fainting fits; the pulse became almost impercep-
tible, and a cold, clammy sweat bedewed the skin. Such in-
dications it was impossible to misinterpret ; there was hemor-
rhage going on within the bowel, and to such an extent that
it must speedily prove fatal if not arrested.

With this view two injections of cold water were adminis-
tered, to stimulate the rectum to part with its contents. This
end was satisfactorily accomplished, and a large quantity of
clotted blood was discharged. At the same time the bowel
was sufficiently forced down to bring the bleeding surface,
which was near the anus, into view. The red-hot iron was
then applied to this part. The pain attending its employment
was very acute, but the bleeding was immediately arrested.
Warm clothing and sinapisms to the legs restored the patient,
and he soon felt much better; but the smarting pain continued,
accompanied by constipation and retention of urine.

All these symptoms gradually subsided. The pain dimi-
nished under the employment of emollient applications ; consti-
pation was relieved by the use of castor-oil; and though the
first motions occasioned suffering, they did not cause any bleed-
ing. The retention of urine, which resulted from an extension
of the inflammation from the rectum to the neck of the blad-
der, required for some days the use of the catheter; but this
also subsided, under the use of tepid baths, fomentations, &c.

The present case affords a good illustration of all the symp-
toms characterizing the disease and accompanying the treat-
132 EXCISION OF

ment adopted for its relief. The latter must be met and
combated as I have described, taking care that the bladder is
regularly relieved, and the rectum likewise assisted after the lapse
of the first few days, but not earlier; on the sixth day after the
operation the patient was able to evacuate the bowels without
either pain or risk of laceration. In the course of a fortnight
he was nearly well; and the piles which had been left inten-
tionally around the anus were gradually shrinking. The pa-
tient was advised to be on his guard against general or local
plethora, and to lose blood, if requisite, from the arm or the
anus, as the symptoms might indicate.

Casz II.— Hemorrhage dependent on internal piles, relieved
by operation.— About fifteen years ago, a very rich banker,
about 45 years of age and of bilious temperament, consulted
me on account of piles, which were the source of constantly

‘recurring attacks of hemorrhage. He was much reduced and
anematous from this repeated drain, and was unable to attend
to his business, for the slightest effort exhausted him. I ex-
amined the rectum, and discovered an internal hemorrhoid,
which I proposed to excise. The operation was gladly acceded
to, and I proceeded in the following way.

Having washed out the bowel with an injection, and removed
the patient from a hip-bath to the side of his bed, the nates
were separated, and he was directed to strain so as to force
down the tumour. ‘This was effected, and with some difficulty
the hemorrhoid was excised with the curved scissors. There
was no bleeding externally after the operation. I did not, how-
ever, leave this gentleman; and in the course of a quarter of
an hour I observed all the signs of alarming hemorrhage, as
detailed in the last case, making their appearance. Especially
he complained of a sense of internal heat in the abdomen,
which kept extending higher and higher. I immediately
directed the patient to empty the bowel. This was done, and
a large quantity of blood was discharged. I then threw in
cold water, but the bleeding still continued. I therefore had
recourse to the pig’s bladder, which was introduced into the
rectum and stuffed with charpie. This was entirely successful,
though there was much difliculty in keeping it in its place in
consequence of the violent straiming which it excited, and by
HEMORRHOIDS. 133

which it was actually expelled several times. Doubtless in
this case a fatal result must have speedily ensued if prompt
assistance had not been rendered. The patient made a speedy
and perfect recovery.

Case III.—Ezcision of hemorrhoids, followed by internal
hemorrhage.—The banker, whose case I have just described,
had a brother at Berlin, who was suffering much in the same
way ; and having heard of the cure which had been effected,
he wrote to me on the subject. According to the enclosed
report of the eminent Berlin surgeon who was in attendance
on the case, I had not any doubt of the similarity of the two
cases, and advised the removal of the internal pile. But,
warned by the danger incurred in my own case by the serious
internal bleeding, I suggested that the part should be caute-
rized after the excision was effected, should hemorrhage occur.

The Berlin surgeon paid no attention to this advice. Im-
mediately after the operation he left his patient, and soon
afterwards symptoms of internal hemorrhage became apparent.
A younger brother, who had witnessed the first operation,
recognized these indications, and ascribed them to the right
cause. The surgeon was sought in vain, and the danger
appeared imminent, when the young man had the presence of
mind to follow the example I had set him, by procuring and
introducing a bladder into the rectum, which he stuffed with
charpie; and in this way the bleeding was arrested. But the
loss of blood had been considerable, and it was a long time
before the patient’s health was re-established.

The next case I shall narrate is interesting for several
reasons. The hereditary nature of the disease was exhibited
in a very striking manner, as it had affected three generations
successively. The form in which the hemorrhoids presented
themselves was also very singular; like the catamenial dis-
charge, the bleeding recurred at monthly intervals, lasting for
three or four days, and ushered in by precursory symptoms.
As soon as the discharge commenced, there was remittance of
the pain in the head, with which the patient had been afflicted
for several years. The efforts at defecation caused prolapsus
of the rectum, which is a not infrequent complication of the
disease. The mode in which the patient returned the piles
134 EXCISION OF

is characteristic; and the cure, which was accomplished after
twenty-five years of suffering, is a point well worthy of
remark,

Case 1V.— Excision of large hemorrhoidal tumours of twenty-
five years’ standing —G. P. Chalot, aged 45, a broker, presented
himself at the Hétel-Dieu, with hemorrhoids, from which
disease his grandfather and brother had also suffered, and his
son began to complain of the same. Of a lymphatic tempera-
ment and rather feeble constitution, he had nevertheless en-
joyed pretty good health until he was about five and twenty,
with the exception of violent headache, which was also here-
ditary in his family.

At the above age he began to experience heat and smarting
about the anus, and soon afterwards he perceived several small
piles. For two years they remained nearly stationary, and
gave him very little inconvenience. During the third and
fourth years they grew rapidly, which he ascribed to hard
work and irregular living. A gonorrhcea which he contracted
at that time appeared also to aggravate the symptoms; and
he began to lose blood: then his headache, from which he
had suffered from infancy, ceased.

The tumours gradually increased, together with the symp-
toms to which they gave rise. The bleeding, which was at
first irregular in its return, afterwards assumed a strictly peri-
odical type, recurring every month, and lasting for two or three
days; these attacks were always preceded by general uneasi-
ness and painful swelling of the hemorrhoids. He married ;
but the more regular life he then led was not attended by any
amelioration in his symptoms. When his sufferings were
extreme, he took baths and applied leeches, which afforded
him some relief. For a twelvemonth the hemorrhoids did
not descend, and then he was afflicted with a painful affection
of the nose, which lasted several months, and which was so
distressing to him that he regretted the confinement of the
piles within the bowel, to which he attributed this new
symptom.

After a time, however, the hemorrhoidal tumours again
made their appearance, even larger and more painful than
before. Every time he had a motion, which always caused
HEMORRHOIDS. 135

him violent straining, the diseased parts descended in a mass,
dragging with them a part of the mucous membrane of the
rectum ; and then the contraction of the sphincter produced
strangulation, and entailed excessive suffering. When he was
walking they came down every quarter of an hour, and he had
reeourse to the following expedient to procure relief. He
would select a narrow post, on which he placed his handker-
chief tightly rolled up, and then, sitting down on it, he would
press his nates firmly together, and moving about in this
position, would thus contrive to force the piles up. This
manceuvre would afford him temporary relief, and he was
enabled to continue his walk until obliged, by a renewal of
his suffering, again to have recourse to the same expedient.

When he had been to the water-closet, he was unable to retain
the tumour for some time; therefore, he always deferred this
act, when practicable, till the evening: for, if obliged un-
fortunately to evacuate the bowels in the morning, he was unable
to leave the house for the rest of the day. In the meanwhile, the
irritated hemorrhoids grew apace, and at last became irreducible,
presenting, around the anus and within the bowel, an irregular
and hardened mass about two inches in diameter, and dis-
charging, from numerous ulcerated points, a sero-purulent and
sanguineous fluid. The patient became daily more feeble, and
even rejected food, that he might have the less to pass off by
the bowel.

Such was the deplorable condition of this man when he
applied to me; and it was evident that he could not long sur-
vive unless something were done for his relief. Indeed, the
tumours would soon assume a cancerous character, if such were
not already the case. As he was satisfied how nugatory all
palliatives had proved, he readily assented to an operation for
their removal.

The patient was prepared, as in the preceding cases, and
placed in a favorable position to allow of excision. This was
effected with the curved scissors; but, as the mass was large
and very vascular, I removed it at four different cuts, applying
the actual cautery after each.

For the first four-and-twenty hours he suffered but little,
and lost no blood. He then had difficulty in passing his water,
and required the catheter. On the fourth day, the constitu-
1386 EXCISION OF

tional excitement was allayed. On the fifth, he had a painful
motion, streaked with blood. On the eighth day, the urine
was passed without assistance. On the ninth, the sloughs
began to separate, and the circumference of the anus was red
and very tender; soothing applications relieved this.

When the sloughs had separated, a large and continuous
granulating surface was exposed, which made me anxious lest
the contraction at the orifice of the bowel should exceed what
I desired. To counteract this tendency, I introduced a plug
covered with ointment, and gradually increased its size. The
wounds healed slowly, and were quite closed at the end of a
month. He ultimately recovered his health, and resumed his
usual occupations, I advised him to lose some blood, that he
might not suffer from the suppression of the discharge to which
he had been so long habituated.

Case V.—Internal hemorrhoids, treated by excision. Mr.
Ex——, a Scotch cavalry officer in the British service, aged
40, and of sanguine temperament, had suffered severely for
three years from internal piles, which descended on the slightest
attempt to evacuate the bowels. He was operated on, as in
the preceding cases; three tumours of small size being suc-
cessively removed. As the bleeding was very trifling, I did
not think it necessary to employ the cautery. An assistant
was left to watch the patient.

Five days elapsed before anything attracted attention, and
then unequivocal signs of internal hemorrhage declared them-
selves, such as I have noticed in a previous case. The extreme
tenesmus ‘led to an effort to empty the rectum, and a large
quantity of blood was evacuated. A cold enema was then
administered, and, when returned, it was followed by another.
Temporary relief was obtained ; but, after the lapse of an hour,
the symptoms returned with more intensity than at first.
The cautery was then resorted to, and applied with the aid of
an open speculum ; the bleeding spot being detected by these
means, and the curved point of the heated iron applied to it.
There was no more hemorrhage ; the local irritation consequent
on the operation speedily subsided, and the patient was quite
well in a few days.
HEMORRHOIDS. 137

Cast VI.—lInternal and external hemorrhoids treated by
excision. A man of low stature and sanguine temperament,
about 47 years of age, was admitted into the Hétel-Dieu with
hemorrhoids, which he had suffered from for fifteen years. The
pain he endured was so great, that he was able to exert him-
self very little; and the internal piles readily descended, and,
being fretted by his dress, the excoriated surface bled and dis-
charged sero-purulent matter. The act of defecation was torture
to him.

This patient was carefully prepared for the operation by being
bled and having a blister applied to his arm, to obviate the ill
effects attending the sudden suppression of an habitual dis-
charge; the rectum was also cleared out by a purgative,

The piles were both internal and external, and each consisted
of seven or eight subdivisions or tubercular masses ; the external
being dark in colour, the internal of a bright, rosy hue. These
were each dissected out, and immediately afterwards the cautery,
at a white heat, was applied to the bleeding points.

A small plug was introduced into the rectum, but could not
be borne. On the following day there was much febrile excite-
ment, and severe colic accompanied the swelling and pain
around the anus; there was also retention of urine. He was
bled from the arm.

Gradually, these symptoms subsided; and, the bowels not
having acted, on the seventh day an ounce of castor-oil was
administered. This acted very freely and afforded great relief,
though the act of defecation was very painful. On the twelfth
day the colic again increased, and was followed by purging.
This lasted for two days, without any assignable cause, and
then left him. After this he speedily recovered, and was dis-
missed quite well.

Of the various risks entailed by excision of hemorrhoids, I
have pointed out that hemorrhage is the most frequent and
serious. Independently of the characters common to all
internal hemorrhage, that from the rectum presents peculiari-
ties by which it may be distinguished from all others. our or
five hours usually elapse after the operation before the symptoms
declare themselves. The patient becomes agitated and restless ;
he is sometimes conscious of a sensation of heat, extending
upwards along the bowels; or perhaps he has colic; but there
- 138 EXCISION OF

is also a painful sort of tenesmus present. The belly becomes
sensitive, especially in the left lumbar and iliac regions. The
respiration is hurried and difficult. The pulse, at first inter-
mittent or irregular, becomes small and frequent. The surface
becomes pale, and the face is bathed in cold perspiration. The
restlessness of the patient is soon succeeded by feelings and
expressions of despair; and very often nausea or vomiting,
with vertigo and convulsions, supervene. If the intestine is
relieved of its contents, a sense of general ease is the imme-
diate consequence, and the most marked remaining symptom
is that of extreme prostration. This is the moment the surgeon
should avail himself of to arrest the bleeding, or the symptoms
will reappear speedily, and more alarmingly than before. The
depression which then ensues is such that the patient almost
covets death to relieve him; and it requires great presence of
mind and firmness in the operator to insist upon and employ
the appropriate remedies. These are either compression or the
actual cautery.

J. L. Petit employed a double plug, and with good effect.
In excising internal hemorrhoids, when the tumours were
forcibly extruded, he introduced, by the anus, his first plug;
and then, after he had cut away the piles, he inserted the
second plug, fixing them together and making all secure by a
bandage. By this arrangement, he considered his patient safe
against hemorrhage.

Desault and Boyer have since simplified and improved upon
this mode of treatment; but it is obnoxious to these two
objections. In the first place, the anus being plugged, internal
bleeding may go on without being detected ; and further, it is
necessary to remove the apparatus to allow of the evacuation
of the bowel. But, it may be remarked that all methods of
applying compression, by plugging the bowel or otherwise, are
obnoxious to the objection that the part acted upon is yielding
and distensible to an almost indefinite extent; as proved in
some instances by the immense accumulation of feces which
the rectum will contain. The actual cautery is, therefore, the
most secure and trustworthy method of arresting hemorrhage
in such cases.

Again, it may be observed, the risk of hemorrhage is by
no means necessarily proportioned to the size of the tumours
HEMORRHOIDS. 139

removed; nor must the surgeon presume upon the absence of
bleeding at the time of excision, as an indication of security ;
for, spasmodic retraction of the bowel may close the vessels
for a period, and several hours may elapse before the symptoms
of loss of blood manifest themselves. A watchful superinten-
dence of an operation of this nature ought, therefore, never to
be neglected.

Bleeding after excision of external piles is readily manage-
able, from the accessibility of the affected part. But, when
internal piles are the seat of operation, it may be necessary
to make use of a speculum, the blades of which open widely,
whereby to discover and cauterize the source of hemorrhage.
If very deeply placed, I think the best course is, under any
circumstances, to employ the cautery immediately after the
excision is performed.

One of the inconveniences consequent on excision of he-
morrhoids is, possible constriction at the anus. In a case of
this sort Boyer was obliged to extend the outlet by incisions
right and left. A bougie or plug of suitable size, worn in the
rectum during the healing process, will suffice to obviate this
troublesome consequence, should there be a tendency to it.

I would remind the practitioner of another important point,
which should be borne in mind in deciding on the operation
of excision; viz.—that prolapse of the rectum is sometimes
associated with hemorrhoids ; as the removal of the latter will
often suffice to cure the former.

I will close this division of my subject by the narration of
one more case.

Case VII.—Excision of hemorrhoids of long standing ;
cure.—P. J. Pasquier, aged 47, a market-porter, was admitted
into the Hétel-Dieu, in 1825, to be treated for piles from
which he had suffered for many years, and which had become
external fifteen years previously. The descent of these tumours
had been caused by the efforts to evacuate the bowels ; they had
been returned by pressure, but had continually re-appeared
during the act of defecation, and had become a source of
constant suffering and inconvenience to the patient. The
irritation occasioned by walking, the friction of his clothes,
&c., caused the discharge of a varying quantity of bloody
140 EXCISION OF HEMORRHOIDS.

mucus or of blood. In such cases I have found leeches and
anodynes relieve the suffering; but astringents are almost
always mischievous. I may remark that, sometimes, hemor-
rhoids shrink in old age: but, as I have already observed,
excision is the best remedy: care being taken to supply the
place of the habitual drain which they entail, by the employ-
ment of leeches, or the general abstraction of blood in small
quantities.

In the present instance the hemorrhoidal tumours sur-
rounded the verge of the anus, consisting partly of internal,
and in part of external, piles. The whole mass was excised,
as in the former cases, with curved scissors, the diseased part
being firmly held with a pair of forceps. At the moment of
excision a small quantity of blood escaped,—not from the
open mouths of vessels, but from a sac in connection with one
of the veins, which contained some clots. It would appear
that these cavities are sometimes dilated veins, but at others
they appear to be accidental, when the piles are lacerated.
When carefully examined, they are found to contain distended
veins filled with coagulated blood, and present spaces lined
with a membrane analogous to that of veins; they commu-
nicate with these vessels by orifices of varying diameter.

In this case there was no bleeding. A little swelling and
inflammation followed the operation; and in a fortnight the
patient left the hospital quite well.
SECTION II.
ON PROLAPSE OF THE RECTUM.

Surgical diseases so generally entail the shedding of blood
and suffering in their treatment, that an important step is
taken when any operation is simplified. Some years back,
M. Boyer demonstrated that fissures of the anus may be cured
by incisions. But prolapse of the mucous membrane of the
rectum—a very troublesome if not a serious affection—has
been treated hitherto in a most inefficient manner ; in fact, all
that has been done may be regarded as simply palliative. I
have succeeded in completely curing this complaint by an
operation, which is simple and easy of execution and certain
in its results. This complaint is more common in infancy and
old age than in middle life, and consists in a descent and
eversion of the bowel, the upper part becoming invaginated in
the lower, down to the level of the anus; this extrusion of the
bowel varies from two to even six inches. In general this
prolapse occurs every time the bowels are evacuated; and in
some persons the erect posture, maintained for any length of
time, induces it. This tendency often co-exists with hemor-
rhoids, and is usually met with in persons of feeble constitu-
tion and lax tissue.

A simple and natural mode of proceeding in these cases is,
to return the bowel whenever it descends; and this is, in
general, easily accomplished. But occasionally the swelling
is so great, and the spasm of the sphincter so firm, that the
extruded part becomes strangulated, and great difficulty is
experienced in restoring it to its normal position. In fact,
the symptoms become so urgent, that gangrene may supervene
if there be not speedy and effectual relief. The best method
of reducing the strangulated part is, to place the patient on
his belly, and to raise the pelvis with a couple of pillows. The
whole surface of the exposed bowel is then to be surrounded
by damp cloths, and a compress placed on the centre of the
142 PROLAPSE OF

protruding part; pressure is then to be made on the base of
the prolapsed portion, and by gentle manipulation the reduc-
tion must be effected. In this way the bowel is returned, hy
commencing with that part which was last forced down.
Scarifications have been recommended by some practitioners ;
but they should be avoided if possible, as they give rise to
inflammation, and leave wounds which are troublesome to
heal. This remark applies also to the employment of leeches ;
indeed, I have known hemorrhage and ulceration of the in-
testine follow their application. At best, this proceeding can
be regarded as only palliative ; for the disposition to prolapse
is not thereby relieved.

Cold lotions and bathing have been recommended ; and they
are useful sometimes, but require time and perseverance; and,
moreover, they give rise to such disagreeable sensations, that
many patients will not continue their use long enough to be of
any service. Astringents, and pressure made with a sponge,
and maintained by a T bandage, are serviceable in children ;
and so are various suppositories: but these remedies usually
fail in adults and old persons. Failing other remedies, it has
been proposed to excise a portion of the protruding bowel and
of piles which may present themselves on its surface. But this
operation of excision, which has been lauded by many practi-
tioners, and amongst them Sabatier, is attended by risks, and
especially that of hemorrhage, which may be serious, and has
been, in some instances, even fatal. But should this danger
be averted by the use of the actual cautery, then a fresh source
of trouble is entailed, in the violent inflammation which may
follow, involving the intestine, and even the neck of the bladder
in its mischievous effects.’

Before describing the plan I have adopted in the treatment
of these cases, J will say a few words on the anatomical ar-
rangement of the parts around the lower part of the rectum.

The skin covering the circumference of the anus is thinner

[' It can scarcely fail to strike the reader that there is an inconsistency between
these remarks and the tone of those which accompany the cases in the preceding
section. The risk of hemorrhage in extensive excision of internal piles, and that in-
volved in the use of the cactual autery to the bleeding surface, are probably more
correctly glanced at here than in the last section. Few surgeons would draw a
parallel so unfavorable to the ligature, as Dupuytren.—T.]
THE RECTUM. 143

and of a different colour from that in other parts. It is rich
in mucous follicles, which secrete an oily matter with a pecu-
liar odour. This skin is arranged in folds, with intervening
furrows, which converge towards the anal aperture and are
lost in it, their number, prominence, and depth corresponding
to the degree of contraction of the sphincter muscle; these
folds disappear or are effaced when the anus is dilated, and
are thus subservient to the mechanism of defecation. Beneath
the integument is a layer of fibro-cellular matter, and likewise
the sphincter muscles, external and internal.

My operation is performed in the following way : the patient
is placed on his belly, with the head and chest low, whilst the
pelvis is well raised by pillows, and the thighs are widely
separated so as to bring into view the parts to be operated on.
The operator then seizes, with a pair of large dissecting forceps,
the radiating folds, and excises them with scissors curved on
the flat. Two, three, or more of these folds or plaits are thus
removed on either side, in front and behind, the excision being
prolonged quite to the margin of the anus, or even within it if
the relaxation is considerable,—the extent of excision, in fact,
bearing a relation to the laxity of the surrounding skin.

Ordinarily the operation occasions but little suffering, and
is almost unattended by hemorrhage; though there may be
some bleeding if the excision is carried deeply.

The object of this operation is very simple. There is an
abnormal or excessive dilatability about the anus. By the
removal of the superabundant tissues, this condition is cor-
rected, and the parts within are thus shut in and prevented
from becoming prolapsed, partly by curtailing the redundance
in question, and in part by the contraction of the neighbouring
tissues, resulting from inflammation and the cicatrization of
the wounds ; the new integument being much more firm, close,
and adherent to the deeper textures.

No dressing is needed. The pain occasions immediately a
strong contraction of the sphincters, to which and the neigh-
bouring areolar tissue the inflammation speedily extends.
Usually the bowels do not act for the first few days; the
inflammation subsides, but the sphincters still contract on the
slightest effort. In a short time the wounds heal, the aperture
is permanently diminished, and the cure is complete. For
144 PROLAPSE OF

several years I have been in the habit of performing this ope-
ration, and with uniform success, except in one instance, where
the patient, a child, interfered, by his resistance and cries,
with the completion of the requisite steps to ensure a cure. A
somewhat similar operation has been performed by Hey (de-
scribed in his ‘“ Practical Observations’’) ; but here the patient
was the subject likewise of hemorrhoids, and the mode of
proceeding. differed, im many essential particulars, from that
which I have described ;—the peculiarity of mine consisting
in the remedy being applied to the cure of prolapse, uncom-
plicated with piles.

Casp I.—Prolapse of the rectum; operation and cure—
G. Brionde, a child of three years of age, was brought home
from nursing when twenty-one months old. The mother soon
perceived that, whenever the intant had a motion, the bowel
came down, and formed a bulging swelling around the anus.
‘When the nurse was interrogated as to how long this state had
existed, she pretended to know nothing about it, and that
she had never perceived it whilst the child was under her care.
The bowel did not entirely return spontaneously ; but, at this
time, a very slight effort sufficed to replace it. The prolapse
became, however, more intractable afterwards, and then the
child was brought to the hospital.

The little patient was well-formed and healthy; but every
time that he went to stool, or coughed rather violently, or
otherwise exerted himself, the bowel descended, and formed a
livid tumour between the nates of the size of a pullet’s egg.
The protruding mucous surface poured out a viscid secretion
slightly tinged with blood. The bowel was easily reducible,
but could not be kept in its place. As the child was in good
health, I did not hesitate to operate at once.

The little patient was placed on a bed, and the nates were
well separated. I then reduced the prolapsus, and seizing a
portion of the integument around the anus, I excised it with
scissors, in the way described above. This operation was re-
peated four times, and in this way a segment of ‘skin was
removed in front, behind, and on either side of the anus, the
excision extending even to the mucous membrane of the rec-
tum. There was very little pain felt, and no bleeding. A
THE RECTUM. 145

light dressing was applied, to prevent the descent of the
bowel, and the child was taken back to bed, where he was as
cheerful as usual. He slept well; and on the following day a
solid motion passed from the bowels, without prolapse occur-
ring. On the third day there were two motions, and still the
rectum retained its position. Very little inflammation ensued ;
indeed, so little, that the child did not complain of pain when
the bowels acted. In the course of a week he was dismissed
well.

A fortnight afterwards I saw this little patient again; and
though he had been suffering from diarrhoea for several days,
still there was no prolapse of the bowel.

Cast II.—Prolapse of the rectum; operation and cure.
Prolapse of the womb.—Auger, a water-carrier, aged 58, was
admitted into the hospital, February, 1833. She had been
regular, and the catamenia abundant, up to the age of 50.
She had never been pregnant; but appeared to have been
the subject of attacks of chronic gastro-intestinal inflammation,
and several times had suffered from diarrhea, which continued
even for’ many months. Eight years ago she was in the
hospital for one of these attacks, and then perceived, for the
first time, that the rectum came down whenever the bowels
were evacuated, but returned very soon and spontaneously.
Gradually the extent of the prolapse increased, and at the
same time the difficulty of returning the bowel was augmented.
When cured of the diarrhoea, she was transferred to a surgical
ward, and there had some folds of integument removed from
the circumference of the anus, and left the hospital well.

For eight months the intestine retained its normal position,
and did not come down even when the patient went to stool,
or used any violent exertion; but after that time she again
began to be troubled, the prolapse occurring about every fort-
night, and being difficult to reduce. She was then (February,
1833) again admitted into the Hétel-Dieu, and came under my
notice for the first time. She was a short, spare woman, of
sanguineous temperament. Between the nates was a rounded
tumour, the size of a pullet’s egg, and of blood-red colour,
shining at its lower part, and presenting a cleft, directly from
before backwards, in its centre. A muco-sanious secretion

10
146 PROLAPSE OF

exuded from its surface. The finger could not penetrate into
the bowel, being arrested by the cul-de-sac. The patient told
me that, for seventeen days the bowel bad been down without
her being able to reduce it; nevertheless, she had motions,
there was very little tension of the tumour, and it was not
strangulated. There was neither fever nor vomiting; and I
found very little difficulty in reducing the prolapsed in-
testine.

Under these circumstances I did not hesitate to recommend
a repetition of the operation, which had failed on the previous
occasion, probably, in consequence of the excision having been
insufficiently performed. Four folds were, accordingly, re-
moved, as in the last case; the excision extending quite to the
mucous membrane of the rectum. For two days nothing
occurred calling for remark. On the third day the bowels
acted with scarcely any pain, and without prolapse. In a
fortnight the wounds had healed, and the cure was complete.
For the prolapsed womb a pessary was recommended.

When prolapsus recti is complicated with hemorrhoids, ex-
cision of the latter is sometimes sufficient to cure both affec-
tions ; but if it fail, then recourse must be had to the further
operation of removing a portion of the surrounding integu-
ment,

Case III.—Prolapse of the rectum accompanied by hemor-
rhoids, and cured by their excision—F. Chatrane, aged 23,
mathematical-instrument maker, of lymphatic temperament,
had been the subject of hemorrhoids around the anus for
eighteen months, which, as they increased in size, became
painful, and bled at each action of the bowels. Soon after
the first appearance of the piles, the patient perceived that the
rectum became prolapsed; at first it returned spontaneously,
but afterwards he was obliged to employ pressure with the
hand to complete the reduction. He had also suffered from
habitual diarrhoea.

There were five or six hemorrhoidal swellings within the
anus, forming a tumour which narrowed the outlet, and forced
out the mucous membrane whenever the patient had a motion ;
the portion which became prolapsed represented a cylinder
about four inches long, girt above by the sphincter, and sur-
THE RECTUM. 147

rounded by the hemorrhoids. The aperture of the intestine
was at its lowest part, and the mucous surface was red.

I had it in contemplation to excise some portions of the
mucous membrane of the protruding bowel, in the hope that
by the adhesion of the contiguous textures, an obstacle would
be opposed to the descent. But,on tracing back the disease
to its probable origin, I thought it better first to remove the
piles, reserving the ulterior step of excision, in case of failure
in the first operation. This simple expedient was entirely
successful. The portions of excised hemorrhoids contained clots
of blood; the wounds soon healed; the diarrhoea ceased, and
the bowel never once came down after the operation was per-
formed.

I may here remark that, when I first performed the opera-
tion for prolapsus of which I have given instances, I used at
the same time to remove more or less of the mucous membrane
of the rectum. But this plan I afterwards abandoned on
account of the consequences, which were sometimes trouble-
some. Hemorrhage is very rare; but should it occur, I prefer
the use of the actual cautery to plugging, for reasons already
mentioned. Usually no dressing is required to the wound,
which heals in less than a fortnight.
SECTION III.

ON FISSURE OF THE ANUS.

The diseases which affect the anus and surrounding parts
demand the careful attention of the practitioner, both on ac-
count of their frequency, and the serious consequences which
may result from an error in diagnosis.- Fissure of the anus is
not a dangerous complaint, but it is one accompanied, in
general, by such severe suffering, that it is of great importance
to afford as speedy relief as possible. The pain is characterised
by this peculiarity, that it increases gradually and lasts a long
time after defecation, and is either of a sharp cutting or burn-
ing character, and so acute that the patients are at a loss to
find words sufficiently expressive to depict their suffering.
Usually they compare the pain to that which would be pro-
duced by the introduction of red-hot iron into the rectum;
and so much is the passage of the feces dreaded, that they
defer as long as possible the action of the bowels, and even
deprive themselves of food, in order to escape it.

These characteristics are peculiar to the disease in question;
and I may observe that, in studying diseases of the rectum, a
careful observation of the various kinds of pain in different
affections of the bowel will be found very valuable in deter-
mining their nature.

Fissure consists of a longitudinal and superficial ulceration
in the mucous membrane of the rectum near to the anus. On
separating the borders of this orifice, and directing the patient
to strain, a narrow cleft or fissure is brought into view, red at
the bottom, and with slightly swollen and callous edges. But
in order to ascertain the exact height to which it extends, it is
often requisite to introduce the finger into the rectum. It is
more often found at the posterior or lateral part of the bowel
than in front—a circumstance which is favorable for an ope-
ration, especially in women, in whom the anus and _ posterior
commissure of the vulva are separated often by only a narrow
FISSURE OF THE ANUS. 149

partition. This form of ulceration rarely involves the entire
thickness of the gut.

The gravity of this affection depends, therefore, principally
on the painful spasm of the sphincters of the anus, the fis-
sure being merely accidental; and this is shown by the exis-
tence of painful stricture without any fissure ; which latter,
according to some eminent surgeons, does not occur in one
case out of four. This spasmodic condition is such, that the
introduction of the smallest body is unbearable, even the end
of the finger, or a clyster-pipe producing extreme pain ; and re-
sistance of the anus to such invasion is another characteristic
of the affection.

This fissure, connected with painful spasm of the sphincters
of the anus, had been observed only in the anal region, until
M. Pinel Grandchamp remarked a similar condition of the
vulva, where the constriction was so firm that the marriage
rights could not be fulfilled. Feeling convinced of the analogy
of this case with stricture of the anus, Grandchamp made a
deep incision, dividing the commissure, the mucous membrane,
and the sphincter of the vulva, to the extent of two inches;
the contraction was cured, and the parts resumed their normal
condition.

There are many causes producing anal fissures ; such are con-
stipation and the consequent spasm; the evacuation of hard
feeces, which abrades the mucous membrane, and distends the
parts in an unnatural degree ; the awkward administration of
injections, especially when pointed or rough metal pipes are
used. They also occur in persons affected with hemorrhoids ;
the venereal virus, either deposited immediately on the verge
of the anus, in an unnatural connexion, or flowing from the
genital organs in women, as very often occurs, is frequently
productive of this affection.

The well-known insufficiency of almost every local applica-
tion in this most painful disease, has led to the abandonment
of nearly all the means which have heen considered either as
curative or palliative ; and now it is usual to resort to an ope-
ration, which is free from danger, it is true, as well as always
successful, but at the same time is so exquisitely painful, that
patients are unwilling to undergo it; I allude to incision of
the sphincter ani at one or more points of its circumference, as
150 FISSURE OF

may be required by the amount of contraction ; or cauterizing
the fissure with nitrate of silver in solution. The latter was first
recommended by M. Béclard, and I have used it with success in
some cases. The operation by incision is so simple, and so
well known, that it is unnecessary to describe it.

The discovery of some therapeutic means of cure would be
a real service to humanity ;"and, although the following has
uot been invariably successful, it has been sufficiently so to
warrant its trial before proceeding to an operation.

The spasmodic constriction of the sphincter is the true
source of mischief, the prolonged ulceration or fissure is but a
secondary condition ; for, in curing the stricture, the disease is
stopped. Under these circumstances, the application of bella-
donna would appear to be a natural resource, and I have used
it with considerable advantage combined with acetate of lead,
in the proportion of one part of each to six of lard.

A small pledget covered with this ointment is first used, and
the size of it is gradually increased till it attains that of the
forefinger.

The continued use of this ointment for several days, will
often completely remove all pain. The following case is one
of many that I could cite.

Cass I1.—Superficial fissure of the anus; application of bella-
donna ointment ; recovery.—A strong young woman, of good
constitution, confined four months previously, experienced great
pain at the anus for several weeks. It was very severe when
she went to stool, especially when the evacuated matter was
hard. At first this pain lasted only a few minutes, but this
period increased at last to some hours.

At the time of her entering the Hétel-Dieu, (December,
1828), the anus was carefully examined, and, on drawing out
the intestine slightly, a very superficial fissure was perceived.
There was considerable constriction at the anus, so that the
little finger could scarcely be introduced, and even that not
without great pain. The nature of the affection being clear,
and being desirous of saving the patient from a painful opera-
tion, I ordered the above-mentioned ointment to be applied.
Pledgets of lint covered with a thick layer of it were introduced
into the anus, and renewed several times during the day, and
THE ANUS. 151

this immediately eased the pain. The patient recovered com-
pletely in a fortnight, without the necessity for any operation.

This case clearly shows the propriety of not being over hasty
in operating or in the application of cautery, before trying
belladonna.

Even if it should not succeed in curing all fissures, it ought
nevertheless to be applied, for it will at least assuage the
pain, and the ulterior measures can but be resorted to at

‘last.

Before proceeding to the latter, I will first say a few words
on the difference of fissures arising from their position. Those
which are formed below the sphincter ani, affecting only the
cutaneous tissue, and not the anal mucous membrane, give
rise, ina greater or less degree, to pruritus, but they are of little
inconvenience in defecation, they occasion no constriction of the
sphincter, and consequently give but little pain. They are com-
monly due to venereal disease. Fissures above the sphincter affect
the mucous membrane; they are visible only with the assis-
tance of the speculum. On introducing the finger into the
rectum, a hard, knotty cord is felt, the pressure of which gives”
intense pain. When the patient goes to stool, there is a sen-
sation of distressing tenesmus, which, however, subsides imme-
diately after evacuation. The fecal matter is covered with
puriform mucus, and with blood on the side of the lesion.
These fissures are usually produced by the ulceration of in-
ternal hemorrhoids during the passage of hard fecal matter.
Finally, fissures opposite to the sphincter itself are far more
serious ; and it is in these that we meet with the painful con-
striction of this muscle, and the other symptoms already de-
scribed.

Fissures of the first and second class are often cured with-
out any operation ; some with simple cerate or cerate with
opium, mercurial preparations, &c., others by emollient and
narcotic lotions made with decoctions of marshmallow, of
poppy-heads, henbane, belladonna, or datura stramonium, and
by other means. In this way I cured a cardinal of this affec-
tion by injections, and another by the simple use of pledgets.

But in very painful fissures, accompanied by spasmodic con-
traction of the anus, and which have their seat on a level with
the sphincter muscle, the quickest and surest remedy is the
152 FISSURE OF

operation introduced by Professor Boyer, which is performed
with a common or a blunt pointed bistoury. This eminent
practitioner proposed a broad, deep incision, for which I have
substituted a simple incision of the bottom of the fissure com-
prising the thickness of the mucous membrane, the sub-mucous
cellular tissue, and the skin at the margin of the anus to the
extent of two or three lines. This is more simple, shorter, and,
above all, less painful.

Case II.—Very painful fissure, with spasmodic constriction of
the anus. Incision. Recovery—A man, 28 to 30 years of
age, had experienced pains at the fundament for four months,
which were considerably increased on passing his motions; so
that latterly he could scarcely bear the pain, which was greater
even after evacuation, and lasted for four or five hours, To such
an extent did this proceed that he resisted as much as possible
going to stool, which was thus deferred to intervals of three
or four days. He had submitted to various treatment, but
neither injections, fumigations, emollients, narcotics, nor castor
oil had had any beneficial effect, and he came at last to the
Hétel-Dieu.

He had a small excrescence at the anal orifice, and a spas-
modic constriction of the opening, with a fissure on the left
side. The excrescence was removed at once with the scissors,
and an incision was made into the fissure itself. A pledget
with cerate was introduced into the rectum between the lips
of the wound.

It is important to make the incision in the fissure itself, in-
stead of making it at a distance from it; for by thus freeing
the anus from constriction, the pain is immediately relieved,
the fissure cicatrizes freely, and recovery is certain. There is
one case, however, in which this cannot be done, namely, when
the fissure is in front near the urethra in men, and near the
vagina in women.

This affection, though in itself simple, may, from long stand-
ing, be complicated with local disorders more or less serious,
and with such disturbance of the constitution as to place life
in peril.

Cast III.—Old standing fissures, with hemorrhoidal excres-
THE ANUS. 153

cences. Incision. Recovery.—Angelique Delahaye, aged 24,
of good constitution, having had several children, entered the
Hétel-Dieu, to be treated for several fissures of the anus, with
anal excrescences. The mischief began many years previously,
and at its commencement produced very little inconvenience,
making but slow progress. At the time of her coming to the
hospital, the anus was contracted ; several fissures existed round
it, as well as a mass of excrescences, which, however, were of
a simple nature. The evacuations were at long intervals, and
accompanied with horrible suffering, which continued for several
hours afterwards. The pain was so severe that the patient
deprived herself of food, so as to decrease the evacuations.
The fecal matter was generally mixed with a large quautity of
blood and mucus,

The patient’s constitution was giving way; she was pale,
and bloated all over, especially in the face, and frequently had
fever. When asked as to the origin of the disease, she said
that she had never had any syphilitic affection, and had no idea
whence it originated.

After a preparatory treatment of two or three days, I cut
away the excrescences, and at the same time incised the fissures.
I took hold of each tumour with the dissecting forceps, and
removed it with one cut of a pair of curved scissors; then,
with a straight blunt-pojnted bistoury introduced into the rec-
tum, I made several incisions in various directions, three or
four lines deep. A pledget of lint about the size of the finger
was put into the anal aperture, to prevent the incisions from
uniting. Little blood was lost during the operation.

On the same day a copious evacuation took place, accom-
panied by a considerable quantity ‘of blood, but without any of
the excruciating pain which was experienced previous to the
operation. A fresh pledget was immediately afterwards placed
in the rectum, and the same treatment was observed daily, and
after every evacuation. She became quiet, gained flesh, and
twenty-two days after the operation she left the hospital quite
well.

Case 1V.—Fissure of the anus cured by incision of the
sphincter.—Nicole Lambert, aged 22, married, of sanguine
temperament, and good constitution, had been ill for eighteen
154 FISSURE OF THE ANUS.

months. At first, without any known cause, she felt slight
pain when she went to stool, which lasted only a few minutes,
and disappeared spontaneously; but as the affection became
worse, so did the pain likewise increase. After the lapse of
three months, the pain lasted for half an hour, and when she
came to the Hétel-Dieu, it extended over several hours after
every motion. She was habitually constipated, and dreaded
going to stool; she had been in the habit of constantly using
‘injections ; the fecal matter was always hard, and often streaked
with blood. The patient ate little, so as to avoid frequent
evacuations; her sleep was often disturbed, and she had become
very thin. A small hemorrhoidal tumour had appeared during
the last three months, at the verge of the anus, and internally
the outlet presented a fissure which extended forwards and
upwards into the rectum. The introduction of the finger was
so painful that the patient shrunk from it whenever it ap-
proached the part. On the 12th September I removed the
small tumour with a pair of curved scissors, and then intro-
duced a bistoury into the rectum, on withdrawing which I cut
pretty deeply into the sphincter, comprising in this incision
the fissure which was towards the right side of the anus. The
operation was a very simple one; a pledget was introduced
into the rectum between the lips of the wound, a little lint
was placed on the edges, and the whole was supported with a
T bandage. The patient was much surprised, on going to
stool the first time, to find that she suffered no more pain than
if she had nothing the matter with her, and on the following
days she felt no pain, either at the time of the evacuation, or
afterwards. The pledget was continued; the fissure and the
incision healed, the rectum retaining the dimensions given to
it by the incision; and the patient left the hospital quite
cured, on the 2d October, a week after the wound had com-
pletely cicatrized.
SECTION IV.

ON STRICTURE OF THE RECTUM.

Stricture of the rectum is a somewhat common disease, and
women are more subject to it than men. This is due to their
_ habitual constipation ; and sometimes also to unnatural coha-
bitation. On close questioning them, they almost all confess
that this was the origin of the mischief. I have many times
seen the same contraction in men addicted to this horrible
vice. It is easy indeed to conceive that such practice is suffi-
cient to produce simple inflammation, excoriation, laceration,
and ulceration, which give rise to thickening and a diminution
of the calibre of the intestine. When the poison of syphilis
is superadded, the lengthened duration of the affection, espe-
cially if it is misunderstood, is a still more certain cause of
contraction, which is also occasioned by scirrhous and cancer-
ous diseases.

I shall not dwell upon the symptoms of stricture of the
rectum ; but I will allude to one of them which has not been
noticed by authors. Most persons who are badly affected,
have an almost continual diarrhoea, and the fecal matter comes
away involuntarily, and without the knowledge of the patients.
It is a true overflowing, as observed in bad stricture of the
urinary passage: the cases are quite analogous.

The treatment of this affection offers some peculiarities
which are interesting. The dilatation of the rectum by means
of bougies introduced into the passage, and within the constric-
tion itself, is without doubt a very good means, since, by gra-
dually increasing their size, prompt and sensible relief is
obtained ; but, as in cases of contraction of the urethra treated
by dilatation, the cure is only temporary, so it is also in con-
tractions of the rectum; as soon as the use of the bougie is
discontinued, the affection soon returns.

When the contraction is very considerable, it sometimes
156 STRICTURE OF

happens that bougies cannot be introduced by any means into
the stricture; and no force should be used to overcome this
obstacle, the only way being to pass the bougie up to the
point. It will be seen in this case, as in vital dilatation of
the urethra, that the foreign body will in the end penetrate
and pass through the contraction. Patients are almost always
momentarily relieved by the action of dilating bodies, which
made Desault think that dilatation would cure cancer of the
rectum. I repeat, these bodies give relief, but they do not
effect a cure. The action of compression is to diminish the
congestion of the parts, but without removing the disease. By
compression, tumours developed in the breast often disappear
for a time; but the disease is subsequently re-produced, and
proceeds with more activity than before.

When there is a band, it must be divided, as in the follow-
ing case.

Case.— Annular contraction of the rectum an inch above
the anus. Cure.—A. S—, aged 35, a servant, was received
into the Hétel-Dieu, on the 5th June, 1824. This patient,
who was of sanguine temperament, and tolerable constitution,
was operated on six years previously for fistula of the anus;
since which he had contracted a gonorrhcea, which had con-
tinued for eighteen months. On his second entrance into the
hospital, he complained of pains in the belly, colic, and diffi-
culty in passing his feces, the weight of which towards the
bottom of the rectum gave him great uneasiness. His motions
came away covered with pus, and in the form of ribands.
He denied, as they all do, that this disease originated from a
degrading habit ; but the way in which he repudiated it almost
confirmed the suspicion.

On introducing a finger into the rectum, it was ascertained
that about an inch above the anus there was a circular con-
striction, formed by a sort of imperfect partition pierced in
the centre by an aperture, through which the finger could
scarcely pass, and not without giving pain. This septum was
of trifling thickness, and formed by bands, and was more déve-
loped posteriorly and at the sides than anteriorly. On the
11th June, I cut through the circular band in four opposite
directions, with a straight blunt-pointed bistoury. A bougie
THE RECTUM. 157

was inserted, but it only remained two hours. He had three
motions, occasioned by the presence of blood in the rectum.
On the following day he retained the bougie a much longer
time; a small quantity of blood came away with the stools.
The evening before he had some disposition to vomit; but he
soon got better, and I prescribed emollient injections. Sup-
puration was established, and on the 7th July he quitted the
hospital completely cured.

When syphilis is the cause of the contraction, and where con-
gestion and ulceration exist, which do not appear to be of
doubtful origin, it might be supposed that the application of
mercurial ointment would be appropriate, and that it would
wonderfully assist the general anti-syphilitic treatment. This
is, however, far from being the case; for mercurial ointment,
applied to the mucous membrane of the rectum, produces very
active irritation, and very commonly smarting and pain. In
these syphilitic diseases of the rectum, mercurial preparations
administered internally have a bad effect on the intestine, which
they irritate, and they rather retard than accelerate the cure.
In such cases I generally resort to mercurial friction, which does
not produce these effects. It is easy to ascertain the injurious
action of mercury on the rectum when administered internally.
When taken either in liquids or pills, it will be partly absorbed
in its course along the alimentary canal; it will be mixed with
the food and other matter, and accompany them in their course,
remaining occasionally a long time in the rectum, until the
unabsorbed portion is expelled with the feces; but during this
time the mercury irritates the rectum, and increases the evil
which it was intended to cure. These considerations have in-
duced me not to prescribe mercury internally for syphilitic
affections of the rectum. The local treatment is the same as
in cases of contraction originating from other causes.
PART III.

MISCELLANEOUS.
PART III.

SECTION I.

ON CONGENITAL HARE-LIP, WITH REMARKS ON THE
PROPER PERIOD OF OPERATING; AND ON ACCI-
DENTAL HARE-LIP.

Aut the vices of conformation, dependent upon arrested
development, are met with in the median plane of the body.
In some instances several of these fissures are met with in the
same individual. In this category may be classed congenital
hernia of the cerebrum and cerebellum; fusion of the two
eyes, constituting monopsy ; fissure of the hard and soft palate ;
cleft upper and lower lip; separation of the sternum; fissure
of the linea alba, open urinary bladder; epispadias; spina-
bifida, &c.

To arrive at a proper conception of the manner in which
this vice of conformation is produced, it is necessary to call to
mind the laws relating to the formation of the embryo. The
lateral portions of the body proceed from two primitive points,
and the development extends towards the centre; but before
these lateral parts, which converge towards each other, come
into contact, a third piece, composed of two nuclei, appears
between them. This constitutes the inter-maxillary bones of
the upper jaw in man and animals, the spinous apophysis for
the vertebral column, &c.

li
162 CONGENITAL HARE-LIP.

If we suppose that the development may have been arrested
by any cause whatever, it is especially near those parts where
the latest process takes place that a fissure will remain.

For this reason we frequently find, in newly-born infants,
openings in the bones of the cranium, the upper lip, the um-
bilicus, the pubes, the vertebral column, &c.

In hare-lip, when deep, and when the fissure extends to the
bones, we find a median tubercle on which teeth are formed.
This osseous tubercle is prolonged backwards, as well repre-
sented by Kerkringius, Albinus, Sandifort, and more recently
by Nicati. Breschet has deposited in the Museum of Patho-
logical Anatomy several sketches of foetuses and children
affected with hare-lip, in which may be seen the median piece
and its pedicle. This piece is separated into two, and each
forms an inter-maxillary bone.

The existence of these bones, which were previously shown
by Galen and Vesalius, and which are so carefully described by
Blumenbach in giving their differential characters in animals
and in man, is no longer doubted by anatomists.

Nevertheless it was believed that Vesalius and Galen had
only described these bones in man, to show an analogy between
the human species and animals, especially the monkey tribe.
Vicq-d’Azyr had in vain attempted to establish, not only an
analogy but an identity of arrangement in the palate and
upper jaw of man and animals. People were incredulous;
but they were converted by the words of a poet. The discovery
of the inter-maxillary bones in man has been attributed to
Goethe, who, when he printed his ‘Morphology’ in 1820,
repeated what he had written in 1786. Since that date, most
anatomists, and embryologists especially, have spoken of the
existence and arrangement of the inter-maxillary bones in man
and animals. Thus Spix, Soemmering, Autenrieth, Blumenbach,
Senff, Meckel, Beclard, Serres, have confirmed, by new observa-
tions, what was already known, but they have not added much
to our knowledge. One anatomist, little acquainted with the
splendid labours of comparative anatomy of our time, and
especially with those on embryology, has recently maintained
that the inter-maxillary bones have no existence in man;
which is simply an assertion made against all evidence, and
remaining a century behindhand,
CONGENITAL HARE.-LIP. 163

Hare-lip may be labial or palatine, or both. It may be
simple, or on one side only; or double, exhibiting itself on
both sides with a median tubercle. When simple it is never
in the median line, but a little on one side, generally on the
left. I have explained this difference by pointing out the
greater precocity of development of parts on the right side
than on the left, which accounts for their predominance and
preponderance in physiological action.

This precocity must be attributed to the blood from the
placenta being distributed in the liver, which lies rather more
to the right side than the left: this also accounts for the
earlier development of the right side of the vertebral column,
and thence for the deviation of the aorta to the left.*

Strictly speaking, it might be affirmed that hare-lip is
scarcely ever exactly in the median line of the body, because
it does not occur between the two inter-maxillary bones; but
the two bones, united, are pushed to one side or the other.
It may also be said that the median tubercle, formed by these
two bony parts, is not regularly developed, as one of them is
most frequently smaller than the other. MHare-lip may also
be complicated with a cleft palate, either with or without the
development of the septum nasi, or division of the velum
palati and the uvula, and even of the vertebral column. This
separation towards the base of the cranium is sometimes pro-
longed to the face, and produces a very singular condition of
the nose, fusion of the eyes, separation of the bones of the
cranium in the median line, and the division of the brain
into two lateral halves. It is known that, in the development
of the brain, the commissures are formed during the last period
of the evolution of this organ. The whole of these organic
deviations appear, therefore, to be in exact harmony with the
laws of the formation of the embryo. These considerations
are but a rapid analysis of what Breschet has communicated
to me.

The operation for hare-lip, which is very simple in most
cases, presents, however, two important and hitherto undecided
points : first, the most proper period for its performance, and
secondly, the treatment applicable to a complication hitherto
little noticed.

* The soundness of this reasoning may be fairly questioned.
164 CONGENITAL HARE-LIP.

The most opposite opinions have been started on the first
question, Many surgeons have been of opinion that it is
better to wait for the period when children could appreciate
the deformity ; founding their opinion on the. greater thickness
of the lips at this period, and on the requisite firmness of the
tissue to bear a suture. Many think that it is better not to
operate till towards the end of the third year, except in cases
where the defect interferes with suckling. The tissues, they
say, having become more solid, without having lost any part of
their extensibility, are capable of resisting the traction of the
pin. Children also are sufficiently reasonable to submit easily
to the precautions necessary to insure success.

Others have thought that they might operate on newly-born
infants, because the lips, being furnished with blood-vessels of
which a portion may in a short time be obliterated, heal more
promptly than at a later period. Moreover, such young infants
are less subject to agitation, and have not yet acquired the
habit of suction. But the operation is by no means certain
immediately after birth, because the flesh is too soft, and too
easily cut by the pin; and because the general mortality,
independently of every special cause, being much greater at
this age than at any other, it would be imprudent to increase
the chances of death to which infants are subject, by that
arising from the operation. These are the disadvantages ; let us
see what there is to balance them. Doubtless it is important
to operate early, that the infant may be able to take the
breast ; but this predisposition, this habit of sucking, is pre-
cisely one of the greatest obstacles to the success of the oper-
ation. If this could be avoided, it would be a powerful
argument in favour of the operation at birth; but an infant
sucks by instinct, even before it is put to the breast; the
obstacle is as great then as it would be at a later period.

This is not, however, the least convenient period; and it is
difficult to conceive how so many authors have given the pre-
ference to the age of 4 or 5, alleging that the child is suffi-
ciently reasonable to see the necessity of the operation, that
he would submit to it better, and bear the pain with greater
courage. Experience should have undeceived them. At this
age children know just enough to foresee, to feel, and to re-
member pain, without possessing sufficient mind to induce them
CONGENITAL HARE-LIP. 165

to bear it; they try to escape from it as much as possible, and
do all in their power to impede the operation. At the very
best, we may expect some little quiet behaviour from young
girls in whom coquetry is predominant, and who begin to like
flattery ; boys, who are insensible to this, are altogether in-
tractable. I have recently proved this by experience.

At a more advanced period, reason and courage are certainly
more developed; but should the bones be separated, their in-
creased density leaves less hope of their union. In every case
it is advantageous to operate early; the deformities are less,
and those dependent on the séparation or deviation of the
bones disappear altogether. For these reasons, I think it best
to operate at three months; life is then more certain, and the
chances of mortality less than at birth; the infant, of course,
feels the pain, but forgets it as soon as it is over, and does not
in any way impede the success of the operation.

This has always been my practice, and it has invariably
been successful. The union of the separated parts has been
effected with extraordinary rapidity.

But there is yet one other point in the operation for hare-
lip, to which I would direct attention. When there is a pro-
jecting median tubercle with two very decided lateral fissures,
one must either pare away the osseous portion which sustains
it, or endeavour, with greater or less success, to force it into
its place. Those authors who have reported cases in both
ways, have too much disregarded the deformity which resulted
from their treatment to touch on this point; at least, all have
passed it by in silence; though it is well worth a little con-
sideration.

If the fleshy tubercle project in front, attention must be
paid to the point of its insertion at the septum of the nose;
on which. frequently depends the degree of projection, as well
as the proceeding to be adopted. When this insertion is near
to the point of the nose, and we attach the tubercle to the
lateral portions of the lip, these latter draw it back; the point
of the nose follows the same direction; the ale then separate,
and the whole nose becomes flattened and sunk in, presenting
a very unpleasant appearance, more like the muzzle of an
avimal than anything else. I have more than once had occa-
sion to regret having inflicted one deformity on a child to cure
166 CONGENITAL HARE-LIP.

another that was by no means greater. What would be the
consequences if the tubercle were placed just at the end of the
nose? Now this case, which has been unnoticed by authors,
is by no means a rare one. I have seen it repeatedly, and a
short time back I was called in to operate on a hare-lip of this
sort. Being struck with the deformity which resulted from
the means hitherto used, I proposed to operate as follows :—
with a bistoury I separated the fleshy tubercle from its bony
support, and -removed the latter with cutting forceps; I then
turned horizontally backwards the fleshy part, having first
pared the edges, and made it serve for the septum, or a portion
of the septum, at the orifice of the nostrils. I then completed
the operation for the hare-lip, which was reduced to its most
simple form, in the usual way, and brought the edges together
by pins. A bandage was sufficient to keep the tubercle in
its place.

I tried this process, some time back, on an unfortunately
intractable child, in whom the difficulty of the operation was
-greatly increased. The osseous tubercle having been cut away,
and the skin carried back to form the septum of the nostrils,
I applied a support, and waited for the union to be effected.
On removing the dressings, the union appeared to be proceed-
ing satisfactorily ; but the movements of the child gave rise to
a slight discharge of blood. The assistant, with a view to
stop the hemorrhage, took hold of the tubercle with his
fingers; which was sufficient to destroy the fresh adhesions.
I operated notwithstanding for the hare-lip; the pins were
properly placed, though with great difficulty, owing to the
continual struggles of the child; at last, with great care I
succeeded in uniting the lower part of the lip; but above
there was a small space about the diameter of a pin’s head,
and the operation was not completely successful.

It is only when the labial tubercle is inserted near the
osseous nasal spine, that it is proper to preserve it as an
integral part of the lip. In such cases I cut away also a
portion of the subjacent bony tubercle. Malgaigne, in an
article published in the ‘ Gazette Médicale,’ expresses an
opinion that this method is not always without its disadvan-
tages. The most serious, he says, is the ablation of the dental
germs of two, three, or even of the four, incisors. We shall
CONGENITAL HARE-LIP. 167

see hereafter that this objection is more specious than real.
The operation, however, is not always free from danger, as the
following case will show.

Case I.— Double hare-lip. Excision of the osseous tubercle.
Hemorrhage. Death.—Karly in August, 1832, a child was
taken into the Hétel-Dieu, three months old, with a compli-
cated, congenital, double hare-lip. On the right, the fissure
extended the whole height of the lip to the roof of the
mouth and the velum palati; on the left, the fissure was
of less extent. The middle tubercle was inserted rather near
to the nasal spine, so that it was thought possible to use it
for perfecting the lip. It was separated, therefore from the
osseous tubercle, and the latter was cut away with a pair of
scissors; it contained the germs of two incisors: the re-
maining part of the operation was postponed to another day.
A small quantity of blood was lost at first, then the hemor-
rhage appeared to cease; but the efforts of suction renewed
it, and it was found necessary to use cautery. The blood
which was swallowed came away in part with the stools, and
on the day fixed for the completion of: the operation the child
was too weak, and it was deferred. But the debility only in-
creased, the median piece became gangrenous, and the child
soon died. No autopsy was made. A variety of circum-
stances, amongst which I may note great loss of blood, and
the retention of this blood in the digestive canal, may com-
promise the life of the patient; but I do not hesitate to say
that this result is very rare. Blood, when swallowed, is never
digested, and is commonly returned by vomiting; but if it re-
main in the digestive organs, it soon impairs them, becomes
a source of irritation, and gives rise to pain and diarrhea.
Purgative injections should be given to encourage its expul-
sion if necessary. A flow of blood into the mouth leads also
to a sucking effort, which becomes habitual in children, and
which may even destroy the cicatrix if formed.

In the young child upon whom I operated for this variety
of hare-lip, where the middle labial tubercle was isolated from
the lip by two lateral fissures, and inserted almost immediately
at the end of the nose, my process compietely obviated the
flattening of the nose, which was well-formed. But you have
168 CONGENITAL HARE-LIP.

seen only the result, and you are ignorant as to the extent
of the deformity, and the circumstances attending the opera-
tion. Another case which I am about to relate will confirm
the advantages of this process.

Casz II. Double congenital hare-lip. Labial tubercle in-
serled at the end of the nose. Operation; complete cure.—
Louisa Rouzon, aged 14, was admitted into the Hétel-Dieu,
early in October, 1832, affected with a very complicated double
and congenital hare-lip. The middle osseous tubercle, con-
sisting of the incisor bones, projected forward more than six
lines beyond the superior maxillary bones; it contained four
incisors, of which the two middle were very long and directed
downwards, inclining forwards at their external edges, so that
the junction of the internal edges formed an angle above; in
front of the osseous tubercle was a fleshy one, of nearly circu-
lar shape, originating immediately from the end of the nose,
from which it was only separated by an almost imperceptible
notch, and was so directed forward that it seemed to be a con-
tinuation of the nose itself. Outside this middle portion, the
two apertures of the nostrils communicated by two wide fis-
sures with the aperture of the mouth. At their posterior extre-
mity these two fissures ended in one single division, separating
in their whole length the roof of the mouth, the velum palati,
and the uvula; so that externally there was a frightful defor-
mity, and internally there was a complete communication
between the cavities of the nose and mouth. It was, in fact,
a characteristic type of complicated hare-lip, such as I have
pointed out; and for the cure of which I had suggested and
put in practice a new mode of operation. The operation on
this patient was performed on October 5th, as follows:

The patient was placed in front of the operator, with her
head thrown back and held against the breast of an assistant.
I divided with a bistoury the mucous fold which united the
cutaneous to the osseous tubercle; then, with very sharp cut-
ting pliers, I cut off from the latter so much as extended be-
yond the anterior plane of the maxillary bones. Having
finished this first stage of the operation, I pared away, with a
pointed bistoury, the lateral edges of the internal tubercle, and
afterwards its inferior edge; then, with strong scissors, I did
CONGENITAL HARE-LIP. 169

the same to the vertical edges of each lateral portion of the lip.
These incisions having been completed, the parts were brought
together in the following manner. A pin was passed about
half through the lip, about one line from the pared edge on
the left side, very near to its free edge, directed obliquely from
below upwards and from without inwards, and then obliquely
on the opposite side in a contrary direction, that is, from above
downwards, and from within outwards. This step, which is not
a new one, was intended to form a median projection to the
lip. The first pin having been made fast by a bight of thread,
the second was placed transversely, about a line and a half
higher; the third, which was longer than the others, was to
carry out a more complex object. The cutaneous tubercle,
bleeding at every part except its root and external surface, was
folded back and applied to the osseous septum of the nostrils,
so that its external face was below, in order to form a sub-
septum to the nostrils. The third pin thus comprised at
once the upper extremity of each portion of the lip, and the
free end of the folded tubercle; two cross sutures completed
the union of each angle of this flap to the labial portions. The
three needles were secured by thread twisted round them as
usual, and over them were applied strips of plaster. The
cheeks and nose were then supported, and several turns of a
roller carried around the head and face.

The patient was immediately carried to bed, and put on a
spare diet and diluent drinks. The first day or two passed .
over favorably and almost without pain. On the 8th October
slight pain came on, which soon became acute and insupport-
able. During the night between the 9th and 10th, hemorrhage
took place. Being detained at home by illness, nothing was
done in my absence; the bleeding stopped of itself, and the
pain appeared to be a little diminished, but it returned with
hemorrhage on the following night. The next morning I took
off the roller, and found nothing wrong in the two halves of
the lip; the strapping and the pins were left as they were.
But the flap of the sub-septum appeared of a blackish grey
colour; the sanies which was discharged and the fetid nau-
seous odour which exhaled from it were symptoms of approach-
ing gangrene. It was bathed with wine; a half circle was
cut in the upper strip of plaster, the edge of which rested
170 CONGENITAL HARE-LIP.

rather too much on the base of the flap; and the bandage
was re-applied. Four days after, the dressing was again taken
off; the flap had assumed a vermilion tint, and cicatrization
was going on. On the 26th it was almost complete; but it
was apparent that the sub-septum of the nostrils was very
broad, and that it would be necessary to lessen it. This was
done a few days later, by cutting away a strip from each side
with a bistoury and common forceps. Each strip did not exceed
a line at the utmost; however, the section fell across a small
artery, and gave rise to a slight hemorrhage. A plug was in-
troduced into each nostril, to keep them dilated; and, the last
incisions having healed, the operation proved quite successful.
The nose, which was previously so deformed, was quite like a
natural nose, the end was not at all flat, and in fact was rather
handsome than otherwise. The upper lip, notwithstanding
the great amount of substance it had lost, was less drawn in
than could have been expected; it was only a little pinched
up in the middle, and notwithstanding the precautions that
were taken to form a projection in the centre, it has resulted
instead in a very marked re-entering angle. The lower lip
appears a little thick and prominent. The mouth closes tole-
rably well, and the countenance altogether is tolerable.

It would be difficult to form an idea of a more hideous de-
formity from hare-lip, than that from which this girl was suf-
fering prior to the operation ; without taking into account the
discomfort in speaking, mastication and deglutition, from
these two fissures terminating behind in one complete fissure.

The object of this first part of the operation was simply to
make good the external division; we have now to combat the
separation of the maxillary bones by means of a spring support
somewhat similar in form to that used in inguinal hernia, with
a pad at each end. Should the second part of the operation
succeed, then staphyloraphy will be tried. It may be asked if
this junction is possible. I answer, yes; for it can be effected
in young people by simple muscular pressure. The apparatus
is intended to support the two maxillary bones, forcing them by
degrees into juxtaposition: it is kept in position, both before
and behind, by small straps.

On the 19th December, this young girl was in good health;
the re-entering angle of the upper lip had considerably di-
CONGENITAL HARE-LIP. 171

minished, and only offered a slight irregularity. When asked
if any improvement had taken place in the inside of her mouth,
she answered that the parts were closer together, especially
anteriorly, which she could easily ascertain with her tongue.
Now, if the parts are sensibly nearer after a trial of two
months, there is every reason to believe that a continuance of
the pressure for a few months longer will nearly, if not quite,
effect a cure.

The first time this support was used it rested on the lower
edge of the affected part, where it soon became too loose.
Applied on the cheek bones it gives pain, and children will get
rid of it. But it is beneath the cheek. bones, on that portion
of the maxillary bone which is a little behind, that the pads
should be fixed, as there is a fatty cushion in this part,
by which pain is avoided; and though the spring may not
press so directly here, it is more easily kept in place. It bears
partly on the alveolar arch, and partly on some points of
the maxillary bone. The idea of this support was first sug-
gested to me by the case of a daughter of the celebrated
manufacturer O , who was suffering from a deformity of
this nature. After several fruitless attempts, Charriére and I
succeeded in making an apparatus which was most successful.

Three months after the operation, Louisa Rouzon was again
brought to the theatre. The parts had become nearer by two
lines during this time, as incontestably proved by the measure-
ments and models taken by M. Brun. The girl could feel it
herself. The sound of the voice was still nasal, but she per-
formed the motions of suction and prehension perfectly well.
The two halves of the roof of the mouth began to touch ante-
riorly, and there was every promise that the union would be
complete. It was ordered that the pressure of the instrument
should be assisted by that of the fingers, to be repeated fre-
quently during the day. The girl was desired to come again
in six months.

This malformation has been recently explained as an arrest
of development, according to which the upper lip was formed
primarily of three distinct portions, which unite only at a more
advanced period of uterine life. This opinion gained weight
from the circumstance that the middle part of the upper maxil-
lary bones, which commonly sustains the middle labial tubercle,

 
172 CONGENITAL HARE-LIP.

has, till adult age, traces of separation from the bone to which
it adheres, for which reason it is, by some anatomists, called
the inter-maxillary or incisor bone. This was also my convic-
tion; but latterly some trust-worthy observers, who have been
specially occupied in studying the bones, have assured me that
they never met with the incisor bone, nor with the middle por-
tion of the lip separated from the fleshy or osseous lateral
portions during any period of fetal life. I must confess,
therefore, that I have now some doubts as to the view I at
first adopted from what I had myself seen. In any case, the
anatomical details given at the beginning of this subject
demand fresh inquiries.

But here physiological ideas are of little importance com-
pared with surgical means, as it was impossible to unite the
middle tubercle with the lateral portions of the lip. It may be
imagined what effect would have been produced by the upper
lip descending immediately from the end of the nose ; the lip
drawn up, leaving the teeth and the gums uncovered; the nose
drawn down, widened, flattened, and more like the muzzle of
a calf than anything else. Having rejected this course, it
became impossible to preserve the osseous tubercle entire,
because only a part of the deformity would have been reme-
died; it would have been necessary to have cut off the fleshy
tubercle, which was too considerable to admit of such a loss;
and again, what an obstacle the projection of the bones would
have presented to the union! The only reason for the pre-
servation of this osseous tubercle was the existence of the four
incisors, which were necessarily destroyed with it. But their
vicious arrangement would have made their preservation of
small utility ; the deformity would have been greater, and this
single reason could not outweigh the opposite advantages.
However, it was prudent to cut away only so much of this
tubercle as extended beyond the maxillary bones, as that which
remained, although inconsiderable, would always be of use in
partly filling up the median line of the roof of the mouth.

Case ITI.—Simple hare-lip, accompanied by separation of
the bones which form the roof of the mouth, and by a division
of the velum palati in its whole extent. Operation. Cure.
Fliny, 8 years old, entered the hospital on the 28th August,
CONGENITAL HARE-LIP. 173

with the following affection: on the left side a congenital di-
vision of the upper lip, extending from its free edge to
below the corresponding side of the nose. This division
was accompanied by a separation of the bones of the palate,
and a fissure comprising the whole extent of the velum
palati. When the child laughed, the separation of the lip
increased, and exposed several teeth. His speech was confused
and hollow, and the mucus from the nostrils passed into the
mouth through the aperture in the roof,

An attempt had already been made to correct this deformity,
but unsuccessfully ; and the patient came to the hospital for
further advice. On the morning of the 29th he was operated
on as follows: I first cut through two small freena which held
the edges of the division close to the gums; I then thrust a
bent needle, armed with thread, into the lower angle of the
edges of this division, The needle was drawn out, and the
thread served to stretch each side of the fissure, so as to admit
of their being cut as near as possible to the point of union of
the skin with the mucous membrane. This having been done
with a pair of sharp scissors, the edges were brought together
at an angle towards the sub-septum of the nose. Two needles
were passed through the edges of the division, and the wound
was united by a twisted suture. Two thick compresses were
placed on the cheeks to bring them forwards, and a bandage,
rolled at both extremities, was applied over the head, so as to
support the compresses, and keep the edges of the hare-lip
well together.

The patient was fed for four or five days with a sucking-
bottle, and he was kept from anything that might excite him
to speak or cry.

On the 3d September the needles were removed, leaving
the threads which formed the suture, and the bandage was
continued. The union appeared to be exact. On the 5th,
strips of plaster were applied to the cicatrix which was still
tender, and the bandage as before. On the 14th, the cure
was as perfect as possible; the union was exact: but the side
of the nose corresponding with the division of the lip was more
depressed, more drawn outwards than the other side. An
attempt was made to bring it to its place by means of a small
174 ACCIDENTAL HARE-LIP.

pad of lint fixed at its base by strips of plaster, which was
partially successful.

The patient remained in the hospital till the end of the
month. It was found necessary to take out a projecting
tooth, which was irritating the posterior part of the cicatrix.
As long as the bandage and the strapping were kept on, the
union appeared to be perfect ; but by degrees it was seen that
a very small and almost imperceptible triangular separation
took place at the lower part. This afterwards became less
apparent, so that the cure was as perfect as could be wished.

The title of hare-lip is not confined to the vice of conforma-
tion, such as we have been considering; but the same is
applied to all the accidental divisions of the lips caused by
malignant pustule, by wounds from fire-arms, or sharp or blunt
instruments, when they have not been united immediately
after the accidents which occasioned them. Accidental hare-
lip may occur in the lower as well as the upper lip, or in both
at the same time; and the division may take place in any
direction, whilst the congenital affection never varies.

Case 1V.—Recent and accidental hare-lip.—Thiessaut, aged
11, was brought to the hospital on the 17th of February,
1822: he had been bitten in the lower lip by a horse, with
which he was playing ; the wound was contused, and had bled
freely when it was made. Its direction was oblique from
above downwards, and from within outwards; the edges were
a moderate distance apart. I did not think it necessary to
have recourse to a suture, and recommended that the bleeding
edges should be united immediately with a strip of adhesive
plaster. The wound being brought together, a small pledget
dipped in cerate was applied to the centre, then on each side
a small piece of linen, kept in place by a strip of plaster,
the two extremities of which were near the ears, whilst the
centre pressed on the middle of the division. A sling was
then applied, the middle embracing the chin and sustaining
the lower jaw, so as to- prevent any motion, whilst it con-
tributed at the same time to keep in their places the gra-
duated compresses used to bring together the edges of the
wound.
ACCIDENTAL HARE-LIP. 175

The mother of the child was desired to watch attentively,
that he did not touch the dressing; and to feed him with
slops so that no mastication was required; also to avoid all
exciting causes to laughter or sneezing.

The chin-support was changed daily, as the saliva wetted it
and made it hard. On the sixth day the dressing was re-
moved; the union was exact, and cicatrization nearly com-
pleted; the edges were kept together by adhesive plaster for
four days more, when the cure was perfect, leaving only a
linear scar.
2 SECTION II.

ON RANULA AND ITS TREATMENT.

Iv rarely happens that those tumours called ranula originate
near the point of the tongue; they generally occur beneath
the base of its free extremity; and it is precisely owing to
their choice of this spot that the diagnosis is often obscure,
and that other tumours of quite a different character are mis-
taken for them, as I will presently explain. Tumours
resembling ranula are met with inside the mouth, and their
development may be explained in the following way.

The skin is provided with a number of follicles which secrete
a certain quantity of oily matter, which secretion, though
scanty in man, is abundant in woolly animals and _ birds,
especially aquatic birds, the delicacy and beauty of whose_
plumage is maintained by it, and preserved from being injured
by contact with water. It is still more abundant in fishes,
the whole surface of the body being lubricated by a viscid
glutinous fluid. It is the same with the mucous membranes
which line the internal surfaces of our organs. The follicles
are innumerable, and are constantly pouring out mucus to
lubricate the surfaces, Like every other tissue, they are liable
to disease, and then their secretion is sometimes suppressed,
sometimes modified in its nature or quantity; at times it be-
comes very viscid, and again the mucus may be changed into
an oily matter. The small orifices of the follicles are fre-
quently closed, and the fluid which they contain accumulates
and distends them; they become inflamed and will increase to
a considerable size. These tumours are known by their
prominence, transparency, indolence, and especially by the
glutinous serum which covers them. They are rarely single,
but very commonly grouped together in patches, adhering
to one another by this secretion. They generally occur
inside the cheeks, in front of the gums or beneath the
tongue. These tumours, then, are cysts developed in the
RANULA. 177

mucous follicles, or sero-mucous sacs formed in the excretorv
ducts of the mouth. It is requisite to be accurately informed
on these points, that it may be clearly understood what is
meant by ranula.

This name (in French, grenouillette) is derived from the
shape of the tumour, which bears some resemblance to the
back of a frog, or from its existence giving a sort of croaking
sound to the articulation, It is a swelling resulting from an
accumulation of saliva in the excretory ducts of the sub-
maxillary glands, and occasionally of the sub-lingual glands ;
the latter being much less frequent.

The excretory ducts of the sub-maxillary and sub-lingual
glands appear to be the only ducts which admit of such a
dilatation of their parietes and retention of the saliva. The
duct of the parotid gland is formed of tissues too dense and
too resisting to permit the development of such a tumour.
Therefore, it is admitted that the dilatation is peculiar to the
former, whilst fistula occurs more commonly in the latter.

However this may be, it is certain that the actual seat of
ranula has not been anatomically demonstrated; and it is
yet to be ascertained by pathological anatomy, whether it
really is localized in the excretory ducts of the sub-maxillary
salivary glands ; or whether it consists simply of a cyst formed
by a membrane similar to the serous tissues, and containing
an aqueous humour; or whether the causes are the same in
all cases, as in one now under my care, in which the mucous
follicles are the seat of the disease. It is probable, indeed,
that tumours of different’ character, belonging to each of
the three series, have been indiscriminately confounded to-
gether, and described under the title of ranula, by the many
authors, both ancient and modern, who have treated the
subject; and that affections have been considered as ranula
which bear no analogy whatever to it. Thus Celsus con-
sidered it as an abscess of a particular sort, and Ambroise
Paré, otherwise such a judicious and good observer, has made
the same mistake. Actuarius pretends to have cured it by
opening the vein, for which reason Camper said that he
considered the disease arose from dilatation of this vessel.
Fabricius d’Acquapendente placed ranula amongst encysted
tumours. John Munnicks considered that it depended on an

12
178 RANULA.

accumulation of saliva in the ducts which open under the
tongue by a principal canal, of which Wharton, who published
his work in 1656, pretended to be the: discoverer; but
Bérenger de Carpi, who wrote in 1521, had spoken of it most
clearly and precisely ; nor was it unknown, long previously, to
Galen, and other early writers.

According to some authors, ranula specially affects children,
who sometimes have it at birth, as shown by cases published in
the Commentaries of Leipzig, and in Vogel’s work. But they
probably confounded ranula, properly so called, with serous,
sub-lingual cysts, which are sometimes very large, and descend
to the sternum. Breschet, who published in the ‘ Répertoire
d’Anatomie’ a complete work on this disease, and discussed all
the questions associated with it, with that talent and ability
which characterize all his writings, opened five of these pre-
tended ranule, and ascertained on examination of the bodies
of newly born children, that they were simple serous cysts,
unconnected with the thyroid, or with tumours of the same
kind developed in the structure of this body. Camper saw
two large tumours of this sort in a very young girl; he had
also seen ranula on either side of the frenum of the tongue
in both men and women, but never in children.

The closing of the external canal of the sub-maxillary gland
may proceed from inflammation of the sub-lingual membrane,
or of the tissue itself of the tongue; thrush or ulceration near
the opening of the canal may give rise to its obliteration. In
cutting the freenum, the excretory ducts which open at the
sides of this membranous fold are sometimes involved, and
they may be obliterated by the cicatrizing of the wound.
Calcareous concretions, or small calculi formed in these ducts,
may oppose the exit of the saliva, whence may arise the accu-
mulation of this secretion, and the dilatation of the duct
whose office it is to discharge it into the mouth. It is diffi-
cult in practice to distinguish which of these causes has pro-
duced the disease, because it increases quickly, and patients
seldom apply to the surgeon till it has advanced considerably.

Although ranula usually contains ouly saliva more or less
thickened and altered, or some humour similar to saliva, a
puriform or purulent fluid has been found in the cyst; and
also, rather frequently, concretions or calculi. Hippocrates
RANULA. 179

makes mention of small stones under the tongue. In the
Ephémérides des Curieux de la Nature, in the ‘ Commentaires
de Leipzig, and in the ‘ Philosophical Transactions,’ there are
examples of these concretions of the size of a pea or a bean.
‘Blégny saw one as large as an almond. Forestus has seen
two, at least, as large as a hazel nut. J. L. Petit extracted
one shaped like an olive, and Lieutard, a surgeon at Arles,
removed one in shape and size like a pigeon’s egg. Lafaye,
in his ‘ Notes sur Dionis,’ says that a surgeon found, in a
ranula, at least eight ounces of calcareous matter. And lastly,
Louis tell us that Leclere removed about a pound of sandy
substance from a tumour of the same kind, with which a nun
was affected.

In general ranula is sufficiently defined for an attentive ob-
server to recognize the disease at once. It is a soft, whitish
tumour, regularly rounded or oblong, situated under the
tongue; fluctuating, but without pain, redness, or other in-
flammatory symptoms; yielding a little to the finger, but
quickly resuming its original form when the pressure is re-
moved, At first it is scarcely perceptible, but gradually in-
creases in size; it is usually not larger than a walnut or a
pigeon’s egg; but, in some cases, it has reached the size of a
hen’s egg.

As it developes itself, the tumour pushes the tongue back-
wards, displaces or loosens the teeth, alters the voice, impedes
the articulation, prevents suction in infants, and mastication or
deglutition in others. It depresses or pushes aside all the parts
with which it comes in contact; and at length it is apparent
externally, showing itself underneath the jaw, and at the
anterior part of the neck.

The cause and nature of the disease being once known, it
would appear easy to find a cure for it; yet we find that this
end is rarely and not easily attained. Puncture of the tumour
by the mouth is the plan usually adopted: a narrow bladed
bistoury, a lancet, or a trocar, are the instruments selected for
the operation. If the humour is limpid, and only slightly
viscid or consistent, without concretion, this sort of tapping
may procure the evacuation of the fluid in the tumour, and
give the patient temporary relief; but the opening closes soon
after the operation, the saliva accumulates again, and the
180 RANULA.

tumour reappears. J. L. Petit gives a case in which punc-
ture with a trocar was repeated ten times without curing the
disease.

Incision or puncture may be made at the prominent part of
the tumour in the mouth, or towards the anterior and upper
part of the neck. The latter has not been generally approved
of, and many practitioners have considered that an external
opening might be followed by permanent fistula. A case,
borrowed from Muys, has been cited by almost every writer,
to show the impropriety of this method of operating. Never-
theless, the case communicated by Leclerc to the Royal
Academy of Surgery, would seem to prove that there is no
reason to apprehend a salivary fistula externally. Leclerc
made a puncture beneath the chin, and enlarged the opening
with a bistoury. A quantity of fluid and sandy substance was
discharged from the aperture, and by proper dressings the cure
was effected in a short time. But this result itself affords
reason for thinking that Leclerc had to do rather with a cyst
filled with serum than with a true ranula; for the puncture
would have given only temporary relief, and the disease would
have re-appeared if its seat had been in the excretory duct of
a salivary gland.

The result, in fact, which should be aimed at, is not only
to empty the tumour, but to prevent a fresh accumulation of
fluid ; with which view it is necessary to keep the aperture
open. This end is more usually attained by actual cautery
than by any other means; but this is not infallible, as I know
from experience, and as Sabatier and other eminent surgeons
have proved. It is strange, indeed, that the opening of a dis-
tended sac, and the constant discharge of a fluid, should not
be sufficient to prevent the aperture from closing. It is,
however, an established fact ; and it would seem to prove that,
in the formation and maintenance of a fistula, there is some-
thing more needed than the mere discharge of a fluid; since a
fistula of Wharton’s duct, which would cure the ranula, could
not be produced by a simple wound, or even one involving loss
of substance, and the continual discharge of a fluid; if so, the
return of the swelling after being punctured, would prove the
existence of a serous cyst, rather than of ranula, formed by the
dilatation of the excretory ducts of a salivary gland.
RANULA. 181

Sabatier and the celebrated Louis have cured tumours of
the kind we are now considering, by cutting away some of the
parietes of the sac, and inserting in the opening tents of lint,
or pieces of bougie, or of lead wire, which were taken out every
day to admit of the discharge of the fluid accumulated in
the sac.

All that I have said about puncture, whether left to itself,
or whether kept open temporarily by some foreign body, shows
that these means are but palliative, and consequently insuffi-
cient. The same may be said of incisions, for the extent or
direction of the opening are of no importance, as it is well
known that a large wound heals in the same manner asa small
one, and very often as quickly.

Case I.—Ranula operated upon by incision.—Léon, a dyer,
aged 15, came to the Hétel-Dieu, on the 7th February, 1824,
with a tumour in his mouth. He was stout, strong, of a san-
guine temperament, with short neck, and face habitually red,
but otherwise of robust constitution. A month before he
came to the Hétel-Dieu, he was inconvenienced by feeling a
large round swelling under his tongue, in the anterior and
lower part of the mouth. He went to the hospital of La Pitié,
where a surgeon, in doubt as to the character of the disease,
ordered only emollient applications and gargles. After re-
maining there three weeks, the tumour had, according to the
patient’s account, diminished by one half. He left uncured,
and a few days afterwards came to the Hétel-Dieu.

The disease was immediately ascertained to be ranula: it
projected considerably on one side below the lower jaw; and
on the other side, beneath the tongue, it formed a double tu-
mour, larger on the right, consistent, rounded, and fluctuating
on the left.

On the 9th February, his head being supported by an assis-
tant, and his mouth opened wide, I made an incision with the
point of a bistoury, giving vent to a great quantity of greenish-
yellow, ropy fluid. The instrument by which I had intended
to keep the wound open was not applied, as it required some
alteration. I therefore ordered another, to consist of two
small spheres, joined at one point, by which the above-mentioned
inconvenience was avoided. In the course of the day a rather
182 RANULA.

large quantity of fluid continued to be discharged from the sac
of the ranula. This continued on the 10th, when a blunt’
probe was introduced into the wound, which showed a tendency
to close,

On the 11th, without any apparent cause, the patient was
seized with pain in the right side, and expectorated a little
blood. In the evening he was bled from the arm. On the
12th, the face was flushed, the breathing short and painful ;
the stitch in the side continued, with bloody Se
and a strong and frequent pulse.

He was again bled. On the 13th, the pain and oppression
continuing, twenty-five leeches were applied on the painful part.
On the 15th there was less pain, but frequent cough and con-
siderable expectoration; and he improved during the succeeding
days. A probe was introduced occasionally to prevent the
wound from closing. On the 2lst, the new instrument not
being ready, the opening was enlarged so as to admit one of
the plates of the common instrument. This was followed by
considerable swelling beneath the chin; and the instrument
could not be retained in the opening, on account of its being
too large.

Shortly afterwards this patient quitted the hospital of his
own accord; the wound being closed, without any further
filling of the salivary sac.

Since that time the patient has not been heard of, although
he was requested to show himself from time to time.

Excision of a portion of the parietes of the tumour has been
proposed and carried into effect, but in many cases this has
only postponed the period of relapse, without effecting a cure.
The loss of substance retarded the cicatrization, but it was
completed at last as in cases of simple incision. Excision
should be resorted to when the tumour is of considerable size,
and its parietes thick, firm and resisting. There is no danger
of any lesion of the nerves or important vessels ; and any slight
.effusion of blood may be easily stopped by astringents. At
the commencement of ranula, it has often been cured by cut-
ting away a portion of the sac, and cauterizing it internally.
Some time ago I was called to see a young lady, who had
suffered a short time from ranula. I cut away a portion of
the cyst with a pair of curved scissors, and touched the inte-
RANULA, 183

rior with a pencil of nitrate of silver. Active inflammation of
the sac ensued, and there has never since been any fresh accu-
mulation of fluid.

The same cannot be said of extirpation. It has been talked
of, but never practised; the fear of involving the nerves or
large blood vessels has prevented surgeons from attempting it.
If the tumour only were removed, the operation would be
sufficiently delicate and difficult, without any certainty in the
result, It would be necessary, therefore, to extirpate the gland
also; I do not know that this has ever been done; nor do I
think that it ought to be attempted.

The injection of an irritating fluid into the emptied sac
might effect a cure by inflammation and adhesion of the pa-
rietes of the cyst; but then the functions of the gland would
be destroyed; the fluid which it would. continue to secrete
would find no exit, and would gradually distend the ramifica-
tions of the excretory ducts lodged in the interstices of the
lobes which compose it; and might give rise to a swelling,
attended with acute pain, inflammation, suppuration, and ex-
ternal fistula; the inflammation might also extend to the |
tongue, the larynx and other adjoining parts. In conclusion,
if the disease is really seated in the excretory ducts of the
salivary glands, the treatment by injeetion is not reasonable,
and should not be proposed; if, on the other hand, ranula is
nothing more than an encysted tumour containing a serous or
albuminous fluid, injection may be resorted to with advantage.

The use of the catheter in the excretory ducts of the sub-
maxillary glands is difficult; and as ranula does not so much
imply the mere contraction of these ducts, as their obliteration
by foreign bodies inclosed in the tumour, or by the products of
inflammation, it appears to me that the use of small probes or
bougies must be quite unavailing.

Cautery is one of the oldest remedies. Hippocrates, in
speaking of this disease, recommends placing on the tumour a
sponge containing a warm emollient fluid; when there was
pus, he made an incision; and sometimes he waited for a
spontaneous opening,’ and then. used actual cautery. Celsus
was satisfied with opening the tumour if it was small; other-
wise he made a deeper incision, and then laying hold of the
lips of the aperture, he cut away the cyst from the surround-
184 RANULA.

ing parts, and removed it, taking great care not to injure any
of the vessels. Fabricius, who almost always followed Celsus,
only proceeded as far as incision, which I have shown to be
only a palliative. Marcus Aurelius Severinus, and Tulpius
recommend actual cautery, but, according to the latter, only
when the tumour is hard, and its parietes are very thick ; if the
contents are fluid, which may be ascertained by the touch, he
thinks a partial excision sufficient. Ambroise Paré gives the
same advice, and says that the opening should be made with
a red-hot iron.

Acids have been proposed as preferable to actual cautery,
incision, or extirpation; but here we are stopped by the fear
of not being able to limit their action, or to prevent them from
extending too far, even to the destruction of Wharton’s duct.
Camper says he has succeeded by making a wide opening in
the tumour, and then touching it with caustic ; but he acknow-
ledges that he has been obliged to repeat this several times.

It appears from the preceding observations that the remedies
for ranula, as far as they consist in discharging the fluid con-
_ tents and preventing the aperture from closing, have been
known to all who have written on the subject, but not one of
them has hit the mark. It has been seen that all these modes
of treatment are more or less defective, owing either to their
difficulty, to the fright and pain inflicted on the patient; or,
above all, because they only give temporary relief, the disease
re-appearing in the course of time. I have made use of a sure
and simple method, of which I will now give some account.

I considered that the most certain means of curing ranula
would be to keep open the aperture made in the tumour by
the introduction of some foreign body, to be retained in the
cyst; on the same principle as I have acted in cases of lachry-
mal fistula. With this view I had a small instrument made,
consisting of a hollow cylinder to admit the passage of the
saliva. This cylinder was four lines long, and about two lines
in diameter, and was terminated at each end by a small oval
plate, slightly concave on the free side, and convex where it
joined the cylinder; one of these plates was intended to be
placed inside the sac, and the other exposed, in the cavity of
the mouth. In fact, it resembles a shirt-stud. It may be
made of silver, gold, or platinum; but the latter is the best,
RANULA. 185

as it is less easily corroded by animal fluids. I used it for

the first time on a young soldier, whose case is described
below.

Case II.—Ranula. Opening of the sac. Introduction of
the instrument, Cure.—Duchateau, aged 24, a drummer of
the imperial guard, short and of bilious temperament, had a
tumour under his tongue, which had existed for three years.
It had grown slowly, without any kind of pain, but it interfered
a good deal with the motions of the tongue. He came to the
Hétel-Dieu, in October, 1817. There was a small, oblong,
semi-opaque tumour on the side of the frenum of the tongue,
occupying the position of Wharton’s duct, and appearing, in
fact, to be produced by a dilatation of this, the excretory duct
of the sub-maxillary gland. Various means had been tried,
but they were only temporarily successful. Some practitioners
had punctured the tumour to let out the fluid it contained ;
others had tried excision; and the edges of the aperture had
been cauterized; but the disease returned after a time.

I operated as follows: I made an opening in the sac witha
pair of curved scissors, from which a limpid, inodorous, viscid
and ropy fluid was discharged. Holding the little instrument
with dissecting forceps, I introduced it into the opening, leav-
ing one end exposed in the mouth. The tumour immediately
decreased, the incision cicatrized round the cylinder, and
a fortnight after the operation, the patient left the hospital
quite well. He ate, talked, and moved his tongue without
the slightest inconvenience,

Having detected some imperfections in the instrument, I
ordered some alteration to be made. The small external plate
was too broad, and its raised edge irritated the under surface
of the tongue, which was constantly in contact with it. The
edges of the plates were, therefore, bent in a contrary direc-
tion, the convexity being external; their size was diminished,
and they were made elliptical in shape. I also saw that the
opening in the cylinder was of no use, since the saliva passed
freely between the lips of the wound and the cylinder, and
further, that it was soon stopped up by particles of food; the
size of the cylinder was also reduced to three lines in length,
and about one to one and a half in thickness. The length,
186 RANULA.

however, must in all cases be regulated by the thickness of the
parietes of the cyst. In the following case the instrument
was not yet perfected, but the success was, notwithstanding,
complete.

Case III.—Ranula cured by incision.—Tellier, aged 24, en-
tered the Hétel-Dieu, in October, 1820, with a tumour, which
had existed for some years on the left side of the freenum of
the tongue ; it was ovoid in form, and its greatest diameter
extended from the front backwards, between the left lateral
portion of the tongue, and the internal surface of the lower
jaw; it was the size of a small hen’s egg, and gave rise to
difficulty in speaking, mastication, and respiration.

I raised it with the forceps, and made an incision with a
pair of curved scissors. An abundant discharge immediately
took place, of a mucous, ropy, colourless fluid, and the tumour
diminished in size. The instrument was introduced as in the
former case. The passage through the cylinder was soon
closed by particles of food. The patient was seen again eleven
days after the operation ; and then the saliva passed between the
edges of the wound and the instrument, and the latter occa-
sioned so little inconvenience that the patient was scarcely
conscious of its presence. Some months afterwards he came
to consult me for some gastric complaint ; the instrument was
in its place, and the tumour had not returned.

Many cases had been thus successfully treated, when the
following one occurred, which enabled me to try two methods
on the same person, who had two tumours of this kind, inde-
pendent of each other.

Case IV.—Double tumour. Insertion of the instrument in
one. Incision of the other—A woman named Pic, aged 48,
came to the hospital in July, 1824, having a soft tumour, as
large as a small hen’s egg, on each side of the frenum of the
tongue.. The voice was affected, as well as deglutition and
respiration. It was ascertained that these tumours did not
communicate with each other. Three months ago they had
made their appearance without any ostensible cause; and a
surgeon had opened them three times, but they closed and
formed again after discharging a viscid, transparent fluid.
RANULA. 187.

T availed myself of this opportunity to compare the plan I
had adopted with that of simple incision. I operated on the
right side, inserting the instrument; and on the left I merely:
made a wide opening. The latter tumour soon formed again;
therefore, I treated it in the same way as the first, and with.
complete success.

The following is an example of the appearance of a multi-
locular tumour during the treatment of a previously simple one ;
and of the rapid growth which such tumours sometimes make.

Casz V.—Ranula, Operation. Appearance of a multilocular
cyst. Cure.—Vilocg, a cotton-manufacturer, aged 49, had
experienced some inconvenience, for two months, under the
left half of the tongue, where he perceived a small oblong
tumour, which, since that time, had gradually increased in size.
He came to the Hétel-Dieu on the 2]st October, 1821. On
the left side of the frenum of the tongue there was an oval
tumour, with its longest diameter in the direction from back to
front, and a little from without inwards. It was 15 lines in
length, and 6 lines in breadth. The tumour was soft and fluc-
tuating ; there was no change of colour in the mucous mem-
brane; and it was without heat or pain, even on pressure. It
lifted up the left side of the tongue, and pushed it towards the
pharynx, whence arose considerable impediment in speaking,
masticating and swallowing. :

On the following day, I made an incision two lines long,
about an inch from the end of the tongue, very near the spot
where the mucous membrane of the mouth is reflected on to
the lower surface of this organ. I afterwards inserted the little
instrument obliquely into the cavity of the tumour, leaving one
of the plates outside. A clear, viscid, ropy fluid continued to
escape, and the tumour quite emptied itself.

On the third day after the operation the patient felt scarcely
any inconvenience; the instrument remained in its place, and
the fluid was discharged around it.. On the twenty-fifth day,
the instrument having escaped from the aperture over-night,
the tumour began to form anew. On squeezing it, a great
quantity of the same fluid came away. I tried to replace the
instrument, but there was not room in the cylindrical part of
it to admit of its being grasped by the thickened edges of the
188 RANULA.

aperture in the tumour, Another was made, two lines longer
in the space between the plates, which was inserted easily on
the following day.

All went on well till the 15th January, when some uneasi-
ness was experienced near the wound; and, soon after, a small
tumour made its appearance immediately behind the plate which
was exposed in the mouth. It resembled the first, and in ten
days it increased to the size of a hazel-nut. On examination,
I found that it was independent of the first, and that it was a
multilocular ranula. I made a small incision into the sac, which
discharged a rather large quantity of viscid fluid, without smell
or taste. The tumour disappeared, and with it all inconveniences.

It will be seen from these cases that, when the tumour is
very large and its parietes thick, it is better to make rather a
large opening, and even to excise a portion of it, before insert-
ing the instrument; and further, to delay this till the wound
is partly cicatrized, leaving an opening only sufficiently large
for its introduction. It will be seen by the following case, in
which an accident occurred which it is difficult to explain, that
the cicatrix is formed with great rapidity.

Case VI.—Ranula. Incision. Fruitless attempts to keep
the instrument in the wound. Syncope. Insertion of the instru-
ment.—Devaux, a gardener, aged 40, had felt, for about
ten days, a slight pain beneath the left side of the tongue,
where a small tumour soon appeared, It made such rapid
progress that, when he came to the Hétel-Dieu, it had attained
the size of a small walnut; it was situated on the left side of
the lower part of the mouth, extending towards the right as
far as the frenum of the tongue. It was larger in front
than behind, soft, fluctuating, of a violet-red colour, and semi-
transparent ; it gave no pain, but it interfered greatly with the
movements of the tongue, and altered the voice in a peculiar
manner. ‘The patient said that, when he spoke, the tumour
vibrated, and occasioned a peculiar tremor, which extended
to nearly the whole head. In other respects, he was in good
health. I operated as follows: the head being supported by
an assistant, the left side of the mouth was drawn down, and
the tongue brought out of the mouth and turned over to the
right ; in which position the tumour became more prominent.
RANULA. 189

T made an incision at the top, from which a large quantity of
transparent, ropy fluid was discharged. The canula was then
inserted ; but the wound being too wide, it came away directly.
Repeated attempts were made, but without success; and whilst
this was proceeding, the patient, from some cause or other,
fainted. He soon came to himself, but was unable to speak
for four hours. The introduction of the instrument was de-
ferred till the following day, when the wound was very nearly
closed ; it was found necessary to open it with a probe, and the
canula was inserted, and kept in by a pledget of lint, which was
retained in situ by closing the jaws.

I need not cite any more cases of successful treatment by
means of this little instrument. The other means proposed,
—such as bougies, canula, setons, &c.,—are of difficult appli-
cation, and are often unbearable ; moreover, the object of them
is to form a fistula; and experience has shown that, as soon
as the foreign body is withdrawn, the fistulous opening closes,
and the disease returns.

But it must be borne in mind, that any particular methods
of treatment or remedies are not to be regarded as exclusive;
and that they must be used only when fitted for the peculiar
disease. When inflammation attacks the excretory ducts of
the sub-lingual and sub-maxillary glands, it may also produce
ranula. In these cases, the tumour is quickly formed. and
rapidly developed; and the tension, pain and redness of the
parts will prevent this from being mistaken for the other kind,
which is produced from quite a different cause. In the cases
now under consideration, the retention of the saliva is the
effect of inflammation; and as soon as the cause is removed,
the effect will naturally subside. The inflammation must,
therefore, be subdued; and local bleeding, either with the
lancet or leeches, should take precedence of any operation.
Ranula may, in such cases, be compared to retention of urine,
arising from inflammation of the bladder or its appurtenances.
Evacuation of the fluid is only an auxiliary measure; and
recourse must be had to general and local antiphlogistic reme-
dies. The following case will prove the correctness of these
observations,

Case VII.—Ranula of an inflammatory character. Antiphlo-
190 RANULA.

gistic treatment. Cure.—Marie Engrot, aged 21, had suffered,
for six years, from a hard tumour formed by the sub-maxillary
gland beneath the lower jaw on the right side; and it had
attained the size of a hen’s egg. It was very painful when
touched; and the slightest pressure forced a jet of fluid, a mixture
of pus and saliva, into the mouth. Three weeks before, another
tumour had formed beneath the tongue, which arose. from an
accumulation of saliva in Wharton’s duct: it appeared to be
separated into two equal parts by the franum, and was hard
and resisting ; the speech was impeded in that peculiar manner
which has given the name to the disease. Respiration and
deglutition were performed with difficulty.

Having examined the patient, I considered that the tumour
was of an inflammatory nature; and my opinion was founded
on the pain, the redness, and the resistance of the dilated duct.
I therefore used the ordinary measures, applied leeches and
emollients, and had recourse to counter-irritants. These
means were successful; in four and twenty hours there was
a decided improvement ; and, on the sixteenth day, the patient
quitted the hospital. She then felt no pain; the tumour in
the mouth had disappeared, and the voice had assumed its
natural tone.

I have already stated, elsewhere, that ranula resembles
other tumours developed in the locality that is assumed to
be peculiar to it. Inflammation of other tissues, in the sub-
lingual or sub-maxillary regions, may give rise to tumours
having the external appearance of, and some analogy with,
ranula. Such are certain abscesses, the serous cysts to’ which
I have alluded, and sero-mucous cysts of the same character as
those mentioned in the first part of this article. The diagnosis
is frequently very obscure, as will be seen by the concluding
case.

Cass VIIL—Tumour resembling ranula. Puncture. Ex-
tirpation. - Cure—A sempstress, aged 69, was received into
the Hétel-Dieu, having suffered from the following affections
during the previous four months: An indolent tumour. had
appeared below, and to the left of, the point of the tongue,
which was pushed aside by degrees; at length, having got
beyond the floor of the mouth, it protruded at the upper part
RANULA. 191

and left side of the neck. Several medical men had been
consulted, and they pronounced it to be ranula. When she
entered the hospital, four months after the disease first appeared,
the tongue was raised up and pushed to the right by a tumour
as large as a pigeon’s egg: it was insensible, soft, and distinctly
fluctuating ; and, passing through the muscular floor of the
mouth, it was prolonged to the upper part of the neck. There
it swelled out anew, and formed another tumour as large as an
ordinary apple. It was insensible, like the other, and appeared
also to be fluctuating. Otherwise, the patient’s health was
good, excepting great physical and moral irritability.

The origin, form, and consistence of the tumour might easily
be deceptive as to its nature,—it might be ranula or lipoma,
To remove all doubt, I made a puncture in that part of the
tumour which raised the tongue. The bistoury was plunged
deeply, and no fluid was discharged, but some fatty flocculi
came from the lips of the wound, and showed the lypomatous
nature of the disease. It was extirpated on the 4th July ; but
this operation is apart from our present subject.

Although this case is an example of the numerous difficulties
which are encountered in the diagnosis of tumours in general,
there were some ‘peculiarities which might have led to the
detection of its true nature, independently of the exploring
puncture. The size of the tumour in the mouth was less than
is usual in old ranule, which pass down to the neck, As the
tongue offers much less resistance than the muscles between
the os hyoides and jaw, it is evident that a tumour arising
from a dilatation of Wharton’s duct would extend itself far into
the mouth, before it distended the muscles which constitute the
floor of this cavity. Another character in which this tumour
differed from ranula, was a sort of strangulation which occurred
in the middle, where the tumour passed from the mouth into
the cervical region. When ranula extends to the neck, it is
altogether more uniform in shape and rounded, like that part
under the tongue. From these differential characters, there-
fore, it might have been suspected, a priori, that this tumour
was not a ranula; which was, however, completely set at rest
by the introduction of the exploring needle.
SECTION ITI.

ON THE INTRODUCTION OF FOREIGN BODIES INTO THE
ATR-TUBES AND THE CSOPHAGUS, AND THE TREAT-
MENT OF THESE ACCIDENTS.

The introduction of a foreign body into the respiratory
passages is always a distressing occurrence; indeed, if the
patient is not relieved, he may very soon die. An operation
will not always give this relief; but under more fortunate cir-
cumstances, the foreign body presents itself at the aperture,
and is forced out by a strong expiration; sometimes it is
extracted with forceps, or it may be found afterwards between
the lips of the wound. But, in every case, the utility of an
operation is apparent, since nothing else can be done; as the
opening of the glottis, which will easily admit certain bodies,
—such as a bean, for example,—will not, in the majority of
cases, allow of their expulsion ; disease of the lungs supervenes,
which frequently leads to the death of the patient.

Cass I.—-A bean in the air-passages of a child. Tracheotomy.
Expulsion of the foreign body.—A little girl, 8 years old, stole
a bean in a shop, and swallowed it precipitately. From its
shape and lightness, this perhaps, of all bodies, finds the
most easy entrance into the aperture of the glottis, when
drawn in by the breath: such was the case with this child;
and she immediately had violent cough, and was nearly
suffocated. This accident occurred on Thursday, at 3 P.M.
M. Delens, and some others who saw her, prescribed an emetic,
which produced vomiting, but the bean was not expelled. The
night, and part of the following day, passed with alternations
of quiet and suffocation; and the child was brought to the
Hétel-Dieu on the evening of Friday.

During the night, the symptoms continued with fearful
violence. On the following morning, I ascertained their
FOREIGN BODIES IN THE TRACHEA. 193

nature: I could hear the movement of the foreign body in
the trachea (a sort of vibratory sound which is easily detected
by applying the ear above the sternum, or simply by listening
attentively to the breathing). The efforts of coughing were
violent, accompanied by nausea, and even by glairy vomiting.
The course to be pursued was plain, and the child was carried
to the theatre on Saturday morning, 13th February, 1830.

Before operating, I tried to detect the vibratogy sound, which
is a pathognomonic sign of the presence of a foreign body in
the trachea; but I could not hear it, doubtless because the
bean was then retained in one of the bronchial tubes. As it
was certain that it had not come away spontaneously, I deter-
mined to open the trachea.

I made an incision one inch in length in the median line of
the throat, a little above the upper edge of the sternum, care-
fully dividing the skin and the cellular tissue, and separating the
muscles covering the trachea. I thought I had penetrated
the air-passage, and I introduced a pair of forceps into the
lips of the aperture. The screams of the patient, which were
very piercing durmg the incisions, continued; the air did not
pass through the wound; and I was surprised that the foreign
body did not make its appearance immediately, as is usually
the case. After having in vain tried dilatation, I inserted a
bistoury to the bottom of the wound, for the purpose of enlarging
the opening ; suddenly, the air escaped with a hissing noise,
the screams ceased, and the bean was forcibly expelled through
the orifice in the trachea. It was evident that the air-passage
had not been opened during the first part of the operation, a
circumstance which should be borne in mind by operators.

The edges of the wound were carefully cleansed of the frothy
blood which covered them ; a piece of fine linen, covered with
cerate, was placed in front of the throat, which was kept in
place by compresses and several turns of a loose bandage.

The patient cried a good deal; and her voice remained even
when part of the air escaped from the opening in the trachea.
Nothing untoward occurred in connection with the operation.
There is a difficulty, however, which may present itself in
operating, and which I think it right to point out. Between
the sterno-thyroid and the sterno-hyoid muscles and the front
of the trachea, is a space filled with cellular tissue, in which

18
194 INTRODUCTION OF FOREIGN BODIES INTO

instruments may lodge, as they might do in the trachea itself.
When the elastic rings are cut through, the forceps, instead of
penetrating the trachea, may be involved in this cellular tissue,
and the operation would, consequently, be incomplete. A little
attention will suffice to prevent the operator from -being thus
misled.

The bean was five lines long, by three in width and thick-
ness. It was a little uneven, in consequence of the swelling
of the cotyledons: they have, indeed, been seen in a state of
incipient germination ; but, as this had been but a short time
in the air-passages, it had not attained any size.

In the evening, the symptoms of bronchitis were sufficiently
intense to require bleeding from the arm. The patient passed
a bad night. On Sunday, there were alternations of quiet and
dyspnoea ; respiration was carried on almost entirely by the
wound, and it was loud, in consequence of the collection of
mucus. On the evening of the same day, five leeches were
applied in front of the throat ; they bled freely, and the patient
was comfortable; the cough was less frequent; she passed a
pretty good night, and had but little fever.

On the 15th, respiration was easy; a slight whistling could
be heard at the wound; the skin was of its natural colour,
The 16th and 17th were good days, the sleep calm and quiet,
‘speech easy, and without change; very little air passed by
the wound, which might be attributed, in great measure, to
the puffiness of the edges. On the 20th, the lips of the wound
were brought together ; there was no danger from emphysema,
because the mucous membrane covered the edges of the incision,
and rendered the cellular tissue impermeable.

From this time no accident occurred. A few days after,
the parents of the girl took her home; the wound was then
reduced by two-thirds. She was brought to the Hétel- Dieu
again on the 12th March, a month after the operation, when
there was still a very. small opening, by which a stream of air
‘passed. The patient did not come again.

Several interesting considerations may be deduced from this
case, to which I will direct attention; and, in the first place,
I will say a few words as to the position in which the patient
should be placed during the operation of incision of the external
soft parts and the trachea; and afterwards, when the opening
THE AIR-TUBES AND THE G:SOPHAGUS. 195

has been made, so as to assist in the expulsion of the foreign
body.

It is evident that the best mode of making the incision of
the external soft parts and the trachea, is by holding the head
back ; but this position is unfavorable for the passage of air
from the trachea, and still more so for the expulsion of the
foreign body. Indeed, we have seen in the above case, that
the incision first made in the trachea did not give vent either
to air or to the foreign body. This was probably owing to the
small extent of the incision ; but it certainly, in part, proceeded
from holding the head back.’ When the head is thrown back,
the edges of the wound are kept together ; when bent forward,
on the contrary, the edges separate more easily, and allow the
air and the foreign body to be expelled, especially when this
is done by a spontaneous effort. Thus, I may lay it down as
a useful precept, derived from this and other cases of operation
for tracheotomy, to hold back the head for the incision of the
soft parts and the trachea; but to bend it forward, to adinit of
the passage of the air and the spontaneous expulsion of the
foreign body.

As regards the diagnosis of foreign bodies in the trachea,
there is one sign which I think it will be well to add as cha-
racteristic, namely, the sensation of the body striking against
the walls of the canal, which may be detected by the hand or
the ear. This is not equally distinct in all cases, nor at all
periods of its continuance in the trachea. Indeed it may be
adherent, and therefore, not being moved by the air, it cannot
strike against the sides of this tube; or it may be enveloped
in thick mucus, and the shock be much weaker than when it
is free.

The mode of dressing also deserves attention. The edges
of the wound were not brought together at once, for fear of
emphysema, as during the first few days the permeable cellular
tissue readily admits of the ingress of air; but after this, it is
altered by inflammation and becomes compact, when this is
no longer to be apprehended ; and the healing may be hastened
by bringing the edges of the wound together. This should
be always followed as the most prudent and rational course.

[' a. e., If in this instance the trachea was opened at all at this time, which does
not appear to have been the case.—T.]
196 INTRODUCTION OF FOREIGN BODIES INTO

Casz II.—Bean in the air passages ; tracheotomy ; cure.—
A boy, six years old, was amusing himself on the 18th May,
1822, by throwing beans into the air and catching them in
his mouth, when one of them passed the epiglottis into the
air passages ; he was instantly seized with cough and a sense
of suffocation, in which state he remained for an hour. He
then became quiet and took some food, but the symptoms soon
returned. The cough was suffocating, vomiting frequent, and
anxiety extreme. A medical man was called in, and he thought
(why, it does not appear) that the foreign body was in the
esophagus, which he probed repeatedly, and administered
emetics ; but these means were, as might be foreseen, unsuc-
cessful. The patient was choking continually, had rattling in
the throat, and complained of very acute pain in the trachea,
which probably induced the doctor to apply leeches on the
throat.

On the fifth day the symptoms became so alarming, that
the parents of the child considered it necessary to seek further
assistance ; and he was brought to the Hétel-Dieu, on the 23rd
May. The following were the: symptoms: great dejection,
proceeding partly from his sufferings and partly from the
fatigue of the journey from the country; voice gone, face
puffed, eyes projecting and injected, nose and lips bluish, re-
spiration very quick, and accompanied by a loud rattling sound
in the trachea, which extended also considerably into the
bronchial ramifications. During inspiration there was a noise
at the bottom of the larynx, as of a body rubbing or striking
against it, similar to that of a valve flapping backwards and
forwards against the edges of the opening it is intended to
close; a peculiar sort of sound that could proceed only from
the shock of a foreign body coming in contact suddenly with
the edges of the glottis when moved by the current of air.
During respiration a convulsive cough came on, at unequal
intervals, which took away the patient’s breath and threatened
him with suffocation. Asphyxia was imminent, and it was
necessary to adopt some immediate step to afford relief. Tra-
cheotomy appeared to be the only chance of saving the patient ;
and although the case was serious, I did not hesitate, and pro-
ceeded with the operation as follows :

The child lay on his back with his head a little thrown back;
THE AIR-TUBES AND THE GiSOPHAGUS, 197

I made an incision extending from the inferior portion of the
cricoid cartilage to the upper part of the sternum, dividing the
skin and the subcutaneous cellular tissue. An extensive ecchy-
mosis, proceeding from the bites of several leeches, rather in-
creased the difficulty of the operation ; another deeper incision,
however, layed bare the trachea. As very little venous blood
came from the edges of the wound, I hastened on with the
operation; I grasped the trachea between the thumb and
middle finger of my left hand, and introduced the fore finger
into the wound as far as the trachea; this served as a guide
to the bistoury, with which I made a puncture in the trachea,
and slightly increased the opening downwards; the air escaped
accompanied with blood and mucus. After giving the patient
a little rest, I enlarged the opening with a blunt-pointed bis-
toury, to the extent of an inch or an inch and a quarter; a
larger volume of air passed out, with mucus and blood. I in-
troduced into the lips of the wound the blades of a pair of
forceps, to keep them apart and admit of the passage of the
foreign body, which showed itself twice at the aperture ; I tried
to seize it with the forceps, and succeeded once, but only a
small fragment came away, and the rest was expelled by a
strong expiratory effort. It was a bean, as the child had said,
and had increased considerably in size. The patient felt almost
immediate relief. A great quantity of thick mucus came away,
mixed with blood which had passed into the air passages during
the operation. The patient was carried to bed. Though the
wound did not bleed, it was not thought advisable to unite the
edges at once, for fear of emphysema in the cellular tissue.
The wound was dressed simply with linen covered with cerate,
on which some lint and a compress were applied ; barley-water
&c., to drink.

On the 24th, the livid tint of the nose, lips, and cheeks was
replaced by considerable redness. There was fever during the
day; a good deal of mucus passed from the opening; the
cough was frequent, but during the night the patient had some
sleep; there was mucous rattle through a great extent of the
anterior and superior region of the lungs; the pulse, which
was very weak before the operation, had acquired strength, and
was rather hard and frequent; skin, hot and dry; respiration
quick. Leeches were applied to the lower part of the neck ;
198 INTRODUCTION OF FOREIGN BODIES INTO

the same dressing as before; the edges of the wound were left
separate. Barley-water, &c., for drink.

The succeeding night and following day pretty good; the
leeches appear to have quieted the irritation of the bronchial
tubes and the trachea; the face was less flushed ; respiration
still frequent, but rather less difficult. Pus and a great quan-
tity of mucus coming from the wound; mucous rattle; consti-
pation for three days; fever rather high. The edges of the
wound were brought together with strapping and graduated
compresses. A mild mercurial dose was administered ; barley
water, &c.

On the 26th, there was much cough and increased fever
during the day. The patient was greatly agitated ; the bandage
applied to keep together the edges of the wound had been de-
ranged by the violent fits of coughing; he did not, however,
pass a bad night, and had some sleep. Respiration continued
difficult and quick, pulse frequent, skin hot and rather moist.
It was feared that a troublesome form of inflammation might
occur in the air passages, or else phlegmon in the cellular
tissue of the neck, about the wound. Some ipecacuanha was
ordered, and six leeches were applied to the front of the
trachea.

-On the 27th, there was sensible amendment. The leeches
had been of great service; he had not taken the ipecacuanha.
Cough less frequent; respiration still rather quick, but less
difficult ; febrile action moderate ; a quantity of pus coming
away from the edges of the wound, the dressing on which kept
its place. The child was weak and pale, and asked for food.
A few spoonfuls of broth and a little boiled meat were
allowed.

On the 28th, the improvement continued; cough much less
frequent ; fever had almost left him; respiration but little
embarrassed ; voice natural. Though the lips of wound yielded
a quantity of pus, they were nearly united ; no mucus passed ;
appetite good. Milk and barley-water, and broth.

The 29th, no more fever. The edges of the wound granu-
lating ; but air still passed; little cough; a slight mucous rat-
tle; good appetite.

Up to the 4th June nothing particular occurred. The
child was quite convalescent ; the wound, which was nearly
THE AIR-TUBES AND THE CESOPHAGUS. 199

cicatrized, still discharged a little pus; but neither air nor
mucus. The cough had nearly ceased, and the voice was in
its normal state; the digestive functions were performed
healthily. The pain, loss of blood, and spare diet, had consider-
ably weakened the little patient, who much wished to go home,
and was sent accordingly.

It often happens that the foreign body, whatever it may be,
is not expelled immediately after the operation, although cough-
ing, sneezing, nausea, and other provocative means are resorted
to. In such cases the lips of the wound should be kept apart
by means of a small silver tube, or lead or silver wire. It is
always indispensable to apply some dressing to the wound, but
lint or other light substance should not be used; as such
bodies have been known to insinuate themselves into the
trachea, giving rise to very serious mischief.

I performed an operation, about eighteen years ago, at the
Hoétel-Dieu, in a very similar case to the last. The bean did
not come away on opening the trachea, nor on the next day;
on the third day it was found by the assistant on the dressing.
The cure was completed in a short time.

When the bodies introduced into the larynx and trachea are
very light, round and easily moveable, the difficulties are in-
creased, as they obey the impulses of the air more readily, and
move about in the air passages with less obstruction. Such
bodies as are fixed, either in the ventricles of the larynx, in
the aperture of the glottis, or towards the bifurcation of the
bronchial tubes, produce a constant pain and a permanent dif-
ficulty of breathing, rather than those sudden fits of suffocation
which I have had occasion to notice. Indeed, it may occur,
under certain circumstances, that the mucous membrane be-
comes reconciled to their presence, aud that the patient feels
no inconvenience until they move to another part.

Case IIl.—A half-franc piece in the trachea. Intermittent
fits of suffocation. Subsequent death from phthisis.—A young
man, whilst amusing himself by throwing up a half-franc piece
and catching it in his mouth, let it slip into the air passages.
After the first effects of the accident had subsided, irregular
fits of coughing and suffocation succeeded, during which the
foreign body appeared to pass from one extremity of the trachea
200 INTRODUCTION OF FOREIGN BODIES INTO

to the other. During the intervals of quiet, the position of
the piece could not be ascertained, and the patient felt very
little difficulty in breathing. He much wished for the opera-
tion, but there would have been little propriety in performing
it when the foreign body was fixed in a position that could not
be ascertained.

For five years the piece was moveable, and at intervals caused
great discomfort ; but afterwards it became fixed in a bronchial
tube, and occasioned but, little inconvenience.

The patient was attacked by symptoms of phthisis in India,
whither he had gone on business, and he died ten years after
the accident. The piece was found in the middle of a tuber-
cular cavity. The patient was then 36 years of age, and was
originally of a robust constitution.

From this case we learn that a very hard, small, foreign body
may not be expelled after it has been received into the glottis,
although it might be of a form which would render such ex-
pulsion easy ; and, indeed, this most commonly happens. Some-
times, however, the body is expelled forcibly, as I once saw
in the case.of a lawyer’s wife. This lady, having allowed the
pip of an orange to pass into the windpipe, had frequent spas-
modic symptoms. ‘The most characteristic feature was a sound
like the whistling of air through a brass tube. After trying
various means, the pip was expelled. The case reported above
shows that the retention of a foreign body may give rise to such
serious consequences, that everything should be tried to pre-
vent them.

Suffocation is not always the effect of the introduction of
foreign bodies into the air passages; but it may arise from
abnormal growths, polypus, &c.

Case 1V.—JIntermittent fits of suffocation. Death. Autopsy.
Polypus causing stoppage of the glottis.—An elderly man was
admitted into the Hétel-Dieu, with disease of the urinary
passages. He experienced from time to time fits of suffocation,
which were attributed to asthma, or spasm of the glottis. The
soundness of the respiratory functions during the intervals
between these fits, lulled any suspicion of disease in these parts,
and consequently nothing was done. The patient died quite
suddenly in one of these spasmodic attacks.
THE AIR-TUBES AND THE CESOPHAGUS. 201

On opening the body it was found that the glottis was
completely closed by a growth consisting of cellular and vas-
cular tissue covered by mucous membrane. It was a true
polypus, which had its origin in one of the folds which extend
from the sides of the epiglottis to the arytenoid cartilages. It
was more than 18 lines long, and was bifurcated at its free
extremity. This polypus was suspended at the lower extremity
of the cavity of the pharynx, and whilst in this situation it
produced no inconvenience ; but when, by a change of position,
it rose above the aperture of the glottis, it more or less closed
this opening, and its presence thus gave rise to the above
mentioned symptoms. The patient died from a sudden and
complete stoppage of this nature.

This is a rare and highly interesting case, and affords another
proof of the utility of careful examination in analogous in-
stances. The symptoms of suffocation, which occur suddenly
without appreciable lesion of the lungs, should be examined by
the finger, the eye, and the ear. Doubtless the existence of
this polypus might have been ascertained during life, and it
might have been easily extirpated ; it is a lesson for the future,
and it will not, I trust, be lost.

M. Louis has shown me a pedunculated polypus which was
developed at the bottom of the bladder, and which gave rise
to intermittent retention of urine. It had caused considerable
hypertrophy of the coats of the bladder, and well demonstrated
the mechanical cause of certain forms of hypertrophy of the
heart. .

Sometimes death will take place before it is possible to
operate. Ten years ago I was called in to see a patient who
was seized with symptoms of suffocation whilst eating. When
I arrived, accompanied by M. Marx, the patient was dead.
On opening the body we found all the sinuses of the brain
gorged with blood. All the organs were healthy; but the
upper part of the air passages was plugged by a piece of meat
of the size of a walnut.

The operation of tracheotomy is not performed solely to assist
in the expulsion or extraction of foreign bodies; it is appli-
cable also in cases of stoppage of the glottis by the development
of a false membrane, or the swelling of its mucous membrane.
Thus, for example, we have seen it succeed in croup, and quite
202 INTRODUCTION OF FOREIGN BODIES INTO

recently it was most successful in a case of angina with oedema,
of which I will narrate the details.

Casz V.—Acute laryngitis become chronic. Cidema followed
by asphyxia. Tracheotomy. Cure.—On the 24th October,
1832, Mad. B—, a governess, aged 34, was brought to the
Hétel-Dieu, in a state of suffocation, which threatened fatal
consequences every moment. She had been attacked five
months previously with inflammation of the throat, and severe
bronchitis, For a length of time she had experienced pain
and heat along the anterior part of the neck; the voice had
become hoarse, and for several days there was entire loss of
speech. Quiet, bleeding, the application of leeches, and emol-
lient and soothing drinks, allayed the greater part of these
symptoms. Soon after this amendment took place, she re-
sumed her usual occupation, and went to church to sing with
her pupils. This tired her very much, and the symptoms soon
returned, with less severity but greater tenacity.

The patient had frequent cough, and constant pain and heat
in the larynx; the voice was altered, respiration difficult, some-
times at night whistling, and of a convulsive character. She
was better at times, but at length was compelled to come to
the hospital. The posterior wall of the pharynx was red,
slightly painful, and a little swollen; the larynx and all the
surrounding parts were the seat of peculiar uneasiness. Respi-
ration was difficult ; inspiration was accompanied by whistling
sound; voice hoarse and weak ; the patient complained of very
distressing pain behind the lower part of the sternum. During
sleep, which was of short duration, respiration became more
difficult, and the laryngeal whistling more perceptible.

On the 25th, 26th, and 27th, the treatment was simple,
consisting of mild drinks to promote expectoration, foot-baths,
sinapisms, poultices round the neck, and soothing gargles.
The disease continued increasing, and the uneasiness about the
larynx became greater; the patient fancied she had a foreign
body in her throat, which prevented her from breathing; the
cough came on by fits of some duration; the laryngeal
whistling became louder; the voice was very hoarse, very
weak, and interrupted; there was prostration, drowsiness dur-
ing the day, sleeplessness, aud great disquietude at night; the
THE ATR-TUBES AND THE CG&SOPHAGUS. 203

countenance was expressive of anxiety; the pulse had sutficient
power, without being frequent, but was irregular during the
fits of coughing. At this period M. Husson touched the upper
aperture of the larynx, and fancied he detected a swelling ; he,
as well as Recamier and Broussais, thought that the disease
was angina with oedema.

On the 29th, 30th, and 31st October, seven grains of ipeca-
cuanha were administered three times each day; there were
several evacuations both from the stomach and bowels; the
vomiting was accompanied by rather serious symptoms, such
as convulsions, afflux of blood to the brain, and frequent cough,
threatening suffocation. On the 30th, the last dose was not
given. .

These means were as unsuccessful as those previously tried.
The disease still increased. Recourse was had to marsh-mallow
emulsions, sinapisms to the legs, leeches to the vulva. The
catamenia were scanty.

On the 2d November the dyspnoea had increased; she
was bled largely from the arm, and sinapisms were applied to
the thighs; a purgative injection was prescribed.

On the 3rd, the same; thirty leeches were applied to the
lower part and sides of the neck; in the evening the patient
was rather better. On the 4th, the night had been distress-
ingly restless; in the morning the respiration was very
irregular and spasmodic; the air could scarcely be heard
entering the chest; inspiration was so difficult that it produced
a sound like the lowing of a cow; the patient was obliged to
sit upright. Copious bleeding from the arm ; sinapisms to the
thighs.

On the 5th, state the same. I was consulted; I examined
the patient, touched the superior opening of the larynx, de-
tected a considerable obstruction, and was satisfied of the pre-
sence of inflammatory edema. Another bleeding. Sinapisms
to the legs and arms.

On the 6th and 7th, the repeated fits of suffocation betokened
that death was imminent, unless recourse was had to energetic
measures. Hzmatosis was already partly suspended, and im-
perfect oxygenation of the blood gave to the complexion a
leaden hue; there was distressing dyspnoea. During the
cough, the face remained pale or became red. The patient
204 INTRODUCTION OF FOREIGN BODIES INTO

was in a state of agony impossible to describe; her features
were distorted; she was alarmed and thought she was dying.
She was again bled from the arm, without any amendment.
At three o’clock tracheotomy was considered indispensable, and
I operated as follows.

The patient being recumbent, with the head bent back, I
made an incision an inch and a half long, in the median line
of the neck, in front of the trachea, beginning at the lower
edge of the cricoid cartilage. Having reached the trachea
without dividing any artery that required a ligature, and made
a puncture between two of the cartilaginous rings, I made an
incision an inch long from below upwards, with a blunt-pointed
bistoury ; I then made two small transverse incisions in the
trachea, giving a crucial form to the wound; the aperture
immediately allowed the escape of air and mucus from the
trachea and the bronchial tubes; and the patient felt instant
relief.

The respiration and the pulse became more regular by
degrees; the pallor and the drowsiness diminished, and the
patient had several hours’ sleep during the night. On the
following morning she said she was rather better; the air
passing through the wound gave out a metallic sound.

On the 9th, it was observed that the aperture had a ten-
dency to contract, and was partly effaced by the mucus and
pus which dried aiid hardened round its edges. An elastic
gum tube, seven lines in diameter, was introduced ; this was
taken out and cleaned occasionally. As the slightest effort
of coughing displaced this tube, an ivory one was substituted,
which was again replaced by a small instrument like a pair of
dissecting forceps, the two ends of which, when separated, kept
the lips of the wound apart.

On the 12th, a gentle purgative was administered ; also some
broth with sulphate of soda. On the i4th, I introduced a
seton at the nape of the neck. On the 16th, on closing the
wound for a moment, it was observed that the speech was less
hoarse, respiration easier, and the whistling noise less intense.

On the 20th, I enlarged the opening, dividing a fibro-carti-
lage. The exhibition of calomel was continued till the patient
left the hospital, on the 5th December. She was then in a
satisfactory state, though not quite well. The wound was
THE AIR-TUBES AND THE CESOPHAGUS. 205

nearly healed, and the affection of the larynx had almost dis-
appeared.

On the 20th January, the patient wrote from the country
to say that the aperture was quite closed, that the cough
occurred only at long intervals, and that the hoarseness had’
very greatly diminished.

On the 3lst March she came to the Hétel-Dieu ; she was
quite cured, and in perfect health.

I will make no remarks on this interesting operation.
Those who remember having seen the patient can alone appre-
ciate the benefit she derived when many had entirely given
her up.

It must not, however, be supposed that the opening of the
air passages is.a resource to be relied on, when the parts are the
seat of any serious disease. It may be asserted that success
in such cases is the exception. Further, surgeons have ac-
knowledged long ago that the operation of tracheotomy, which
presents so little danger, and is attended so seldom by acci-
dents when performed on healthy parts in which foreign bodies
have been introduced, is almost always fatal when performed
on diseased organs. I am quite of this way of thinking, and
as I have performed this operation very frequently, my opinion
is the result of experience.

I do not wish, however, that the question should be decided
on my authority alone, for, after all, facts are the most power-
ful authorities.

1 This operation has been known from the most remote
times, for it is said to have been invented by Asclepiades ; it
was afterwards described by Paulus Zigineta and Avicena, who
placed little confidence in it; for Paulus himself, whilst praising
it, says it is seldom successful. Louis, who has most recom-
mended it amongst the moderns, scarcely ever performed it
except for the extraction of foreign bodies. Maunoir, of
Geneva, who was one of the first to recommend it in cases of
croup, has not derived much advantage from it; and Pelleton,
who had practised it a great many times at the Hétel-Dieu,
and has published his observations, was successful only in

1 [It should be remarked that the following observations are from the pen of one

of the editors, M. Marx ; but, as they are introduced here, it is to be presumed that
they are based on the opinions of M. Dupuytren.—T.]
206 INTRODUCTION OF FOREIGN BODIES INTO

cases of foreign bodies, and he regarded it as always ineffica-
cious and dangerous in cases of croup.

It is worthy of remark that the most skilful and experienced
men agree in acknowledging that there is but little chance of
success in the cases I have pointed out. It must, therefore,
appear very extraordinary that this operation should have been
latterly proposed in cases of croup, as a remedy frequently
efficacious, and likely to become much more so if performed at
an early stage of the disease. In support of this assertion
numerous cases of cure have been cited, operated upon under
the most unfavorable circumstances, of which one in four
was successful. It has been deduced from these facts, sup-
ported by the cases in which the operation has been performed
early, that if the operation were performed at the beginning,
half the number of cases would be cured.

But here, setting apart the first results of one out of four
cured, it is of importance to notice the last assertion, for if
taken seriously by practitioners, it might have the worst
results; as other therapeutic means would be neglected, and
recourse would be had to the operation, which, in our opinion,
can have but a fatal result in cases of confirmed croup.

All practitioners agree as to the difficulty of a positive diag-
nosis of croup at the commencement of the attack; and when
the nature of the disease is placed heyond doubt, it is almost
necessarily fatal; thus, neither the sound of the voice, which
is said to be the most certain indication, nor even the false
membrane which is expectorated, are indubitable evidence;
for the hoarse croupal voice occurs in many cases of angina so
common to children; and the false membrane occurs in various
diseases of the air passages, which are not so serious as true
croup. Now, the uncertainty of these signs will not prevent
the able practitioner from employing such active medicinal
means as may be adapted to combat the disease which he
suspects, as well as the symptoms which he observes ; whereas
he might be stopped altogether, were he influenced by the
propriety of having recourse to so serious an operation as
tracheotomy. Should he go on, would he not be taxed with
imprudence and unskilfulness if the patient should die? for he
would have performed an operation which nothing could justify ;
and if the patient recovered, might he not reasonably be told
THE AIR-TUBES AND THE CESOPHAGUS. 207

that there was no proof that the operation had cured the croup,
since the symptoms observed might have been those of another
affection? And this dilemma will be so much the stronger
against the doctrine here opposed, inasmuch as the author who
maintains it declares that the less the patient has been bled so
much the more favorable are the chances of the operation ;
which is tantamount to disapproving of one of the most suc-
cessful agents in the cases of angina referred to.

But in regard to croup, as well as to edema of the glottis,
it should be known that constriction of the aperture of the
larynx is not the principal disease. In cedema of the glottis,
the ulceration of the larynx, the disease of the cartilages, and
the causes of the cedema itself, are, in truth, the most serious
incidents ; also in cases of croup, it is the inflammation of the
whole mucous membrane of the air passages, and that plastic
secretion which is observed in the ultimate ramifications of the
bronchial tubes, as well as in the larynx and the trachea, which
constitute the elements of the disease. Now, will it suffice, in
this case, to open the trachea, to clean out its interior, and to
apply small quantities of caustic in solution, to modify this
morbid state, and arrest the deposit of the false membrane ?
Here experience again supplies an answer. This method,
which appears to have been so successful with its author, has
not been equally fortunate in the hands of other practitioners.

Cases of croup, or, to speak more properly, of croup-like
affections, are snfficiently frequent, and consequently the oppor-
tunities of practising tracheotomy sufficiently numerous, to
admit of a due appreciation of the utility of this measure.
Here are the results which these operations show, according
even to the confessions of those who performed them:

 

 

 

Operations, Cured. Dead.
Amussat Sh SDs 6 0 6
Beaudelocque ... . 15 0 15
Blandin . . 1... 5 0 5
Bretonneau ‘ses 18 4 14
Gerdy . 6 4 2
Guersent . 6 0 4
Roux 4 0 60
Trousseau . 80 20 6
Velpeau 6 0
466 | (28 118

 

 

 

 
208 INTRODUCTION OF FOREIGN BODIES INTO

Thus, admitting that all those operated upon had true croup,
we have 28 recoveries against 118 deaths. But there is one
great objection to any proceeding which has a chance of suc-
cess only in the hands of its author, namely, that after he is
gone, it is almost necessarily abandoned. Therefore, we do
not the less persist in regarding tracheotomy in croupal affec-
tions as a desperate resource, and almost always followed by
death.

The real cause of the ill success of this operation in cases of
morbid lesions of the air passages, is certainly owing to tra-
cheotomy not reaching at all the cause of the disease; for
inflammation continues its course, and albuminous deposits
continue to form in the small ramifications of the bronchial
tubes; these assertions are proved by post-mortem examina-
tions. Now, in opening the trachea, the risk of the operation
is added to those of the disease, the effects of traumatic in-
flammation to those of existing inflammation ; the fatal chances
of the latter are aggravated; and most practitioners have con-
fessed that the operation in such cases generally hastens the
death of the patients.

In oedema of the glottis the operation seems to hold out
better chances of success, and we have seen, in fact, that it
does succeed. There is only one obstacle, and that is below
the opening made in the trachea; if the air enters freely into
the lungs, recovery ought to follow the operation; yet this is
by no means the case, and most commonly the patients die ;
but this is because the affection is not a simple one, and because
the lungs are almost always seriously diseased. This distinc-
tion is very important, since the probable success of the opera-
tion depends upon the lesion being local. The diagnosis of
cases in which tracheotomy is expedient, is sometimes attended
with great difficulty.

In the month of June, 1839, a woman was received into the
Hétel-Dieu, with all the symptoms of imminent asphyxia. The
obstacle appeared evidently to exist in the glottis. After using
all the remedies prescribed in such cases, tracheotomy was
resorted to. The percussion of the chest gave a normal sound ;
respiration was feeble, accompanied by. a slight rattle. The
woman having died on the following day, the autopsy was made
with great care. The glottis was of the ordinary size; the
THE AIR-TUBES AND THE CESOPHAGUS. 209

submucous cellular tissue was not infiltrated by serum, nor
swollen; there was merely a slight injection. The trachea
and bronchial tubes showed no trace of disease. It was impos-
sible to assign any otlier cause for her death than a functional
disturbance of the part.

When the disease is beyond the resources of art, tracheotomy
may be performed with the view of prolonging the life of the
patient ; as happened in the following case.

Cass VI—Cancerous tumour of the neck. Tracheotomy.
Death A—,, aged 18, of weak constitution, had been the
subject for some time of a large hard tumour on the right side
of the neck, below the angle of the jaw; it extended inter-
nally as much as externally, interfering with respiration and
deglutition, and giving rise to shooting pains. She came to
the Hoétel-Dieu six months previously. The nature of the
pain, the peculiar appearance of the tumour, and the deterio-
ration which had commenced in the health of this young girl,
led me to believe that the disease was of a cancerous nature ;
its situation and its depth made it dangerous, perhaps impos-
sible, to extirpate it. Some palliatives were administered, and
she left the hospital. About two months afterwards she came
again, in a much worse state; the tumour was twice as large;
a sort of dull fluctuation or softening was felt at the upper
part; the tumour was, as on the former occasion but more
certainly, pronounced to be cancerous and incurable. The
patient had become much thinner, her complexion was much
changed, deglutition and respiration were more difficult. She
continued getting worse from day to day, and at last death
from suffocation appeared at times imminent. I recommended
that tracheotomy should be performed, if a more serious attack
should occur. The patient, I observed, may die from suffoca-
tion at any moment in extreme agony; whilst by cutting into
the trachea, she will breathe freely, may have a month longer
to live, and will perhaps die in a less painful manner. On the
following day a frightful fit of suffocation came on, and the
operation was at once performed by the house-surgeon. The
lower part of the thyroid (?) membrane, and two or three rings
of the trachea were cut through, and an elastic gum tube was
introduced into the wound ; respiration was restored, and the

14
210 INTRODUCTION OF FOREIGN BODIES INTO

patient was relieved instantly. She passed the month, as I
had foretold, with tolerable quiet. By means of the cesophagus
tube, some drink and liquid food were administered. For one
or two days she seemed to improve; but she soon relapsed ;
the cough became more violent, and during these fits of
coughing she threw up a large quantity of fetid sero-purulent
matter, which, judging from the condition of the right side of
the chest, I thought proceeded from a vomica existing in the
upper portion of the right lung, near the bronchial tubes.
The patient died at the expiration of a month. The night
before her death, a sort of whitish-yellow exudation,—an unor-
ganized false membrane—coated,without firmly adhering to, the
tongue and all the internal surface of the cheeks and mouth.

The same exudation had been observed a few days before in
another patient, who died from diffused phlegmon of the arm.

At the autopsy, extreme emaciation was apparent. The
tumour, when cut, presented a cerebriform appearance, and
there exuded from it a whitish, milky fiuid, which could be
taken up on the blade of the scalpel, a characteristic sign of
carcinomatous degeneration. The chest being opened, the
left lung appeared slightly gorged with blood; there were
some old cellular adhesions on this side; the right lung was
in a state of grey hepatization; a large collection of purulent
matter had existed at its lower edge, against the diaphragm ;
there was none there now, but it was from this part that the dis-
charge proceeded, which I thought came from the upper part ;
some portions of the lungs, which were less inflamed and less
gorged, floated in water, the rest fell to the bottom of the
vessel; on this side there were some patches of recent and
unorganized false membrane.

Instead of entering the air passages, foreign bodies may be-
come fixed in the cesophagus; in which case there are three
modes of proceeding—extracting them by incision, or by the
mouth, or by forcing them into the stomach.

Case VIL.—A _five.franc piece fixed in the Esophagus. Ex-
traction. Reflections on the passage of foreign bodies through
the various parts of the digestive canal—A young man laid a
wager with some friends that he would swallow a five-franc
piece. He intended to pretend to swallow it, and merely to
THE AIR-TUBES AND THE CG:SOPHAGUS, 21)

conceal it in his mouth, but in endeavouring to do this, he ac-
tually did swallow it. It was stopped at once at the upper
part of the oesophagus, and gave rise to serious disturbance,
such as acute pain, attempts at vomiting, and extreme diffi-
culty, amounting almost to impossibility, in swallowing solid
or liquid food. He came to the Hétel-Dieu on the same
evening, 12th May, 1830, and was attended by M. Sanson.
Some attempts were made to extract the piece with a pair of
long forceps, but they were unsuccessful, and tended rather to
push it farther down.

On the following day, the symptoms were aggravated rather
than otherwise ; the desire to vomit was constant, and the strain-
ing very painful, With Hunter’s forceps I felt the piece at
the level of the upper extremity of the sternum. Every
endeavour to lay hold of it was, however, unavailing; and I
then had recourse to another instrument which I have used
with success in similar cases. It consists of a long strip of
whalebone, very flexible, with a small silver extremity articu-
lated in such a way as to admit of slight lateral movement.
This appendage is six lines wide, and about the same length,
conical in form, with the point downwards, and capable of
passing easily between the parietes of the pharynx or of the
cesophagus and the foreign body; its two sides increase in
width at the upper end, and are hollowed and well adapted
to lay hold of the object to be extracted. This instrument
was passed into the cesophagus below the piece, and lifted it up
into the pharynx and back part of the mouth, whence it
was easily taken with a pair of common forceps. The
only consequences to the patient were a certain amount of
irritation of the cesophagus, caused by the presence of the
foreign body ; but these symptoms soon gave way to antiphlo-
gistic treatment.

Bodies of such a size are not easily passed through the con-
tracted parts of the alimentary canal and finally evacuated.
It happens, however, sometimes ; but under other circumstances
they are arrested at some contracted part and give rise to se-
rious lesions, finally destroying the patient.

I will narrate two cases of M. Larrey, which are worthy of
notice.

A soldier, for a wager, swallowed a five-franc piece. It
212 INTRODUCTION OF FOREIGN BODIES INTO

stuck for a few moments in the esophagus, and caused great
pain, but at last went down into the stomach. Its presence
produced no ill effects, and it was evacuated per anum, twenty-
one days afterwards.

Another soldier did the same thing. The piece fixed itself
almost immediately above the cardiac orifice of the stomach ;
and the man was obliged to seek assistance in the military
hospital. Larrey tried to extract it, but did not succeed.
The piece kept its place, but it was so fixed as not to prevent
food from passing into the stomach. The symptoms diminished
gradually, but the pain and annoyance at the spot where it was
fixed never ceased entirely. The patient, however, left the hos-
pital and returned to his duty; but six months afterwards he
came in again, and died of fever. At the autopsy the five-
franc piece was found placed obliquely two inches above the
cardiac orifice of the stomach; and at this spot there was ex-
tensive ulceration, accompanied by considerable congestion and
scirrhous hardening.

The different termination of these three cases is a point of
considerable interest. In one, the body was extracted; in the
second, it was spontaneously expelled ; whereas, in the third, it
gave rise to organic lesions which contributed to the death of
the patient.

In a case reported by M. Pigné, the only instrument used
was the hand. A man, eating potatoes greedily, was seized
with symptoms indicating that one had stuck in his throat.

A distinguished surgeon easily discovered that it was fixed in
the. upper part of the esophagus. Having failed in extracting
it after many attempts, the patient was sent to me; and I soon
effected the object by crushing the potato with my fingers
applied to the throat externally.

For a length of time there was no established practice for
the extraction of foreign bodies from the cesophagus: I have
given some attention to the subject, and the following is the
result of my experience.

I considered that the sound might be employed for the
cesophagus in the same way as it is used for the urethra. This
is always necessary when the foreign body is not within reach,
for, if its position be not exactly ascertained, it is impossible
to bring to bear ‘other proper means for its extraction. The
THE AIR-TUBES AND THE CESOPHAGUS. 2138

instrument I use may be called an cesophageal sound, and con-
sists of a flexible rod of silver, capable of overcoming some re-
sistance, and about eighteen or twenty inches in length, with a
ring or handle of some sort at one end, and a small spherical ball
at the other. It is well to have several such instruments of
different sizes, with balls varying also in diameter.

* With such an instrument you can neither hurt nor irritate
the cesophagus, and when it once touches the foreign body, you
can easily ascertain its depth, its density, the degree of tenacity
with which it is held, and the direction in which it is placed.
The ball will also enable you to judge as to the size of the ob-
ject and the space between it and the parietes of the passage.
Further, this instrament may be used also in other cases, such
as detecting the seat and extent of contractions which some-
times affect the cesophagus, and interfere with its functions.

Case VIII.—Penny piece (gros sou) in the pharyne.—
Gauthier, aged 22, having on the 6th November, 1820, passed
the evening in drinking with some companions, and having
two penny pieces left, layed a wager that he would eat them.
He carried this into effect at once, and swallowed one, which
stuck in the pharynx, and produced retching. He tried in
vain to lay hold of it with his fingers; he took an emetic,
which acted powerfully, but without the desired effect, and he
then came to the Hétel-Dieu. The next morning I examined
him, and extracted the body. I first used the sound which I
have described above, and having introduced it into the pha-
rynx to the depth of eight inches, I felt some resistance, and
ou calling the attention of the assistants, they all distinctly
heard the silver ball strike against. the piece of money as I
moved the sound rapidly but lightly to and fro. The foreign
body was placed across the pharynx, and arrested at the point
where this muscular canal contracts and is continued under the
name of cesophagus. I then used a pair of long forceps,
slightly curved to suit the passage, and having introduced
them into the pharynx, I soon laid hold of the penny, and
was on the point of extracting it, when it escaped, in conse-
quence of the patient’s struggles. The next attempt was
more fortunate, and the piece was soon brought forth. On
214 FOREIGN BODIES IN THE CESOPHAGUS.
the succeeding day the patient was well enough to quit the
hospital, having no symptoms of irritation.

Other instruments are also used for the extraction of foreign
bodies from the cesophagus, which I will enumerate but not
describe, every surgeon having altered them according to his
own ideas. I will not speak of the sharp-pointed hook, which
is more adapted to pierce the cesophagus, than to bring up 2
foreign body. Stedman has successfully used this instrument,
but with a blunt end instead of a point. This and similar hooks
must necessarily be carried below the object to be extracted ;
and the same observations are applicable to the hook of Petit,
&c. In ‘some of the old surgical collections there is an instru-
ment made like a parasol, which was passed beneath the object,
then opened and withdrawn. Finally it has been proposed to
use what are called cesophageal forceps, similar to those of
Hunter, but longer and slightly curved. The two elastic arms
of which they consist are inclosed in a silver or India-rubber
tube. This is undoubtedly the most appropriate instrument,
but it has these faults: it does not take firm hold of the body ;
it sometimes nips the sides of the oesophagus, and exposes them
to laceration by the sharp projections which some foreign bodies
present.

Should it be thought expedient to force the foreign body into
the stomach, the best instrument, and the most easily procurable,
is a long slip of whalebone, tolerably strong and flexible, with
a piece of sponge well fastened to one of the ends.
SECTION IV.

ON THE TREATMENT OF GOITRE BY THE SETON.

Persons of a lymphatic habit, characterised by a soft and
white skin, rounded form, and quiet habits, are more subject
than others to goitre. It affects women more frequently than
men, children than adults. In its healthy state, the thyroid
gland, which is the seat of this complaint, weighs one to two
ounces; in a morbid condition it may reach to one or two
pounds. It is endemic in the valleys of Savoy and the Valais,
where some of us may have seen it, and is often accompanied by
cretinism, and spares neither sex nor age. Travellers, stopping
at the wretched villages, are surrounded in a moment by persons
with goftre, and cretins, whose inarticulate cries are almost
wild and frightful. Such is the influence of climate, that an
adult going into a country subject to goitre would be exposed
to the disease.

Various causes have been pointed out as determining goitre.
Fodéré, in the curious details which he gives in regard to places
where this affection prevails, insists, perhaps too exclusively, on
the humidity of the atmosphere and on temperature: he says
that the inhabitants of these parts are almost always in a vapour
bath. No doubt a hot and humid temperature, during a great
part of the year, may have a decided action on our organs; but
goitre also affects persons who are differently circumstanced.

Case I.—Large goitre. Seton, Recovery—A woman of
adult age came to the Hétel Dieu with goitre, which she had
had for twelve or fifteen years. It was very large, and involved
both sides of the thyroid gland. A seton was passed through
each lobe, and, after continued suppuration during several
months, the patient was completely cured. The cicatrices only
of the setons were observable on the skin covering the thyroid
gland. As to the goitre, it had almost entirely disappeared.
There still existed a nucleus as large as a small walnut, hard
and insensible, but it remained stationary for many years.
216 THE TREATMENT OF GOITRE

I will enter into some details on the manner of performing
this operation, and give my opinion as to this mode of treatment,
and some other therapeutic agents which have been much
boasted of as antidotes.

Amongst the medicinal means used in this disease, iodine has
above all others been resorted to most indiscriminately ; and it
would appear that no goitre ought to withstand its employ-
ment.

In many cases, however, it fails; and a very little reflection
would have enabled its advocates to anticipate such a result.
Goitre depends on different causes ; sometimes it is a simple
hypertrophy of the thyroid gland ; at other times it is a scirrhous
degeneration ; and, again, it may be formed by cysts variously
filled. Iodine cannot possibly act on such different affections ;
in fact, as I have already said, it does not succeed better, in many
cases, than the powder of Sancy, burnt sponge, mercurial frictions,
camphor liniments, ammoniacal or anodyne plasters, and a num-
ber of other pharmaceutical remedies which have been so much
vaunted. It is but fair, however, to add, that iodine has
effected some cures.

The therapeutics of goitre, therefore, present nothing but
obscurity and uncertainty, notwithstanding the pompous asser-
tions of so many authors and quacks, who pretend that they
are constantly discovering new specifics, and narrate case after
case of success.

To arrive at any useful result, it would be necessary to
undertake a series of observations, and to begin by well
establishing the nature of the disease, distinguishing those
cases which are similar in outward appearance, but very
different in their nature.

In the absence of such a work, it behoves every practitioner
to point out such therapeutic agents as he has found successful.
I will confine my remarks to the seton, which I prefer, and
which I have used with advantage. Professor Quadri, of
Naples, has lately boasted of this as a novelty; in which,
however, he is mistaken, as I put it in practice some years
ago on a patient, and with success. ;

Some time after the employment of the seton, the goitre
begins to diminish, and in a few months it is entirely dispersed ;
this process, indeed, sometimes continues after the seton has
BY THE SETON. 217

been withdrawn, and the wounds are healed up. It is difficult
to say how the seton acts, whether by inflammation of the
tissue of the thyroid gland, or by the suppurative action; but,
however this may be, it is effectual.

When the seton is passed through the thyroid gland, there
is always considerable loss of venous blood, which escapes with
fearful impetuosity, but soon subsides. It is similar to the
bleeding which takes place in the extirpation of polypus from
the nasal fosse; sometimes occasioning syncope, which, but
for dashing cold water to the face, might prove fatal. This
hemorrhage, which arises from the large venous plexus situated
in front of the thyroid gland, is stopped by desiring the patient
to breathe freely, so that the venous circulation may not be
impeded, by the use of cold lotions, or by gentle pressure. The
seton ought usually to remain some months to produce the
desired effect; but this must, of course, depend on the pro-
gressive improvement that takes place. One precaution must
not be lost sight of, namely, to bear in mind distinctly the
situation of the thyroid arteries.

I cannot say of the seton, as has been maintained in regard
to iodine and other specifics, that it will always cure goitre.
Scirrhus, for example, which at times occurs in the thyroid
gland, can never be advantageously treated by such means;
but hypertrophy, cysts, and hydatids, in which iodine prepara-
tions and other pretended remedies so often fail, are forms of
the disease which readily yield to it. I will cite one case in
which the seton was unsuccessful, which will show that though
the best means are tried, they are not infallible.

Case II.—Large goitre, ineffectually treated by a seton,
and by the use of iodine internally and externally.—Josephine
Charles, aged 26, unmarried, a sock-maker, short, of sanguine
habit and good constitution, was an inhabitant of the village
of St. Maurice, in the department of La Meuse, situated at
the extreme end of a valley containing springs and stagnant
water. Of 360 inhabitants of the village, 50 had goitre; and,
from time immemorial, the people of the valley had been
subject to this disease; but there were no cretins, The
mother of our patient died eleven years ago, having a large
goitre, from which she was suffering before the birth of
218 THE TREATMENT OF GOITRE

Josephine. She was the youngest of a family of eight, none
of whom were affected with the disease, neither was her father,
At 18; years of age, the catamenia appeared for the first time.
At 14, she was exerting her strength to carry a heavy load of
wood on her head and shoulders, and a week after, she perceived
an enlargement of the anterior and middle part of the neck.
For a year this swelling went on increasing, chiefly on the
right side. The tumour was well-defined ; and, notwithstanding
the application of leeches, it continued to enlarge.

At length, at the end of twelve years, the patient came to
the Hétel-Dieu. Her neck was very large, projecting forward
in the median line, and more on the right side than on the
left. The skin was of natural colour, showing anteriorly
several large veins beneath it. The enlargement and
protuberance of the neck arose from the development of a
trilobed tumour, occupying the anterior and lateral regions of
the neck. It could be defined by the finger on every side;
and it was ascertained that it extended downwards in front of
the clavicle and sternum, projecting three inches in front of
the chest. lLaterally it was contained within a line drawn
perpendicularly from the mastoid process to the clavicle,
especially on the right side; above, and in the middle, it did
not rise very high, not covering the larynx ; but at the sides
it extended to the horizontal ramus of the lower jaw. It
occupied a considerable space, being divided into three lobes; the
middle one below the larynx was of the size of a small apple,
and those on the sides the size of pears; that on the right side
being the largest.

These three tumours were not independent of each other,
but they formed one; the skin was not adherent ; they were
circumscribed, hard, and resisting, but less so than scirrhus ;
no fluctuation or pulsation could be detected, and pressure did
not give pain. The two lateral tumours were crossed and
covered by the sterno-mastoid muscles; they were well-defined
by the finger when the patient tried to bend her head forward
against an opposing force. The carotid arteries were thrown
very much outwards, and their pulsation could be detected
external to the sterno-mastoid muscles. In swallowing, the
tumour rose a little, but this motion was scarcely perceptible,
During any great effort, the veins of the neck swelled, and the
BY THE SETON 219

tumour increased in size; the same happened at the catamenial
period, which came on twice in a month, and lasted three or
four days each time. There was very little inconvenience in
respiration, deglutition, or digestion; the general state of
health was good, the sleep regular, and the tumours gave no
pain.

On the 15th of February, I passed a seton-needle through the
right tumour, carrying it from within outwards, and transversely
from one side of the tumour to the other; thus passing beneath
the sterno-mastoid muscles, and avoiding the large veins and the
carotid artery; a portion of thread was left in; very little
blood was lost. The wounds were simply dressed in the
evening, when pain came on in the neck and shoulder, with
headache ; the pulse was greatly accelerated, skin hot, excessive
thirst. These symptoms were relieved by bleeding, but they
returned on the following day, and were subdued by spare
diet, emollient drinks, and foot-baths; very little swelling
took place in the neck; suppuration began on the seventh
day; the seton was dressed daily; it suppurated extensively
for four months or more, but there was no diminution in the
size of the goitre. On the 5th of June, iodine was administered
internally, in combination with iodide of potassium. A few
days afterwards, the iodine ointment was rubbed on the goitre.
No success attended this treatment, though it was carefully
followed for many months; the patient became much thinner,
and left the hospital on the 6th of August, without any improve-
ment as regards the goitre.

Thus, as I have said, it would be wrong to say that the
seton is efficacious in all cases; this remedy succeeds only in
certain varieties of the disease. It may be conceived, how-
ever, that suppuration is an excellent means for dispersing
tumours. Sometimes it excites violent inflammation, which is
almost always diverted by antiphlogistic remedies ; but should
it happen otherwise, the seton must be withdrawn for a time.
Another accident which may attend the use of the seton is
arterial hemorrhage, which, however, stops of itself immediately
the seton is withdrawn. It may be replaced a few days
afterwards; and this simple precaution suffices to stop the
hemorrhage, and to prevent its recurrence.
SECTION V.

ON PERMANENT CONTRACTION OF THE FINGERS,
AND ITS CAUSES.

TuE cause of contraction of the fingers, and especially of the
ring finger, was almost unknown until the present time.. It
is not a matter of surprise that it should have been regarded as
incurable, when we consider the numberless causes to which it
was attributed, the endless remedies that were tried, and the
theories that were framed as to its origin. The authors who
have treated of the subject, have done so in a very incomplete
manner. M. Boyer, in his ‘ Traité des maladies chirurgicales,’
describes it under the name of Crispatura tendinum, but he
says very little about it. Astley Cooper, in his work “On
Dislocations and Fractures of the Joints,” says, that a finger
or a-toe may be drawn by degrees from its. normal position by
the contraction of the flexor tendon and its sheath; and that,
in consequence of this distortion, the first and second phalanges
of the toes project upwards against the shoe, so as to prevent
the patient from walking. He adds, that he has frequently
seen such contractions in young women, and attributes them
to the habit of wearing tight shoes. He recommends ampu-
tation of the distorted toe in such cases.

Probably, if search were made, something more might be
found in books; but my life has been so entirely passed in
practice, that I have not had time to go through the various
works; and I shall be glad to learn that they who have
preceded me, and have written on this subject, have discovered
the cause and the means of cure.

These contractions have at different times been supposed to
proceed from rheumatism, gout, external violence, fracture, or
from the infection of some poisonous matter in the system.
We shall soon see what little foundation there is for these
assumed causes.

Most of those who are thus affected, have been in the habit

a
PERMANENT CONTRACTION OF THE FINGERS. 221

of using force with the palm of the hand, and of handling hard
bodies, such as a hammer, an oar, or a plough. Thus the
wine-dealer and the coachman, whose cases I shall cite, were
in the habit, the one of boring his casks with a gimlet, or
piling up his casks; and the other of continually using his
whip on the backs of his horses. I could also give, as an
example, the case of a clerk, who used to stamp his letters
with a seal, the handle of which pressed forcibly against the
palm of his hand. It is found also in masons, who lay hold
of stones with the ends of their fingers, also in gardeners, &c.
It, however, generally attacks those who are compelled to use
the palm of the hand.

The affection usually commences in the ring-finger, whence
it extends to the others, especially to the little finger, and
increases by almost insensible degrees. The patient at first
feels a little stiffness in the palm of the hand, and a difficulty
in extending the fingers, which soon become a quarter, a third,
or half bent. The flexure is sometimes carried much farther,
and the ungual extremities of the fingers are bent into the
palm of the hand. From the very beginning a cord is felt on
the palmar surface of the fingers and hand, which is drawn
tighter when an effort is made to straighten the fingers, and
disappears entirely when they are quite bent. It is of roundish
form, and its most salient part is at the articulation of the
finger with the corresponding metacarpal bone, where it forms
a sort of bridge. Its extremities are lost insensibly at the
second phalanx of the finger, and about the middle of the palm
of the hand, or perhaps short of this point.

The skin covering the finger is thrown into arched
folds, the concavity of which is below, and the convexity
above. This condition is for a time limited to the finger
primarily affected; but at a later period the other fingers are,
though in a less degree, involved in the deformity.

Notwithstanding all these appearances of deep-seated mischief,
the joints of the affected fingers show no trace of anchylosis,
and, without excepting even the first phalanx, they may be
easily bent; but, beyond a certain point, they cannot be
straightened with any amount of effort; and I have seen one
hundred to one hundred and fifty pounds weight suspended by
the hook which the finger forms, without changing its position
222 PERMANENT CONTRACTION

a line. It would seem as if the finger were prevented from
being straightened by an inflexible barrier placed along its
dorsal aspect ; but there is really no other obstacle than the
cord on the palmar surface of the fingers and hand, the bold
prominence of which is proportioned to the efforts made to
straighten the finger. The affection begins, proceeds, and
reaches its climax without any pain. Even the efforts I have
mentioned cause scarcely any; and it would seem to consist
in some mechanical obstacle, in tissues having very few of
the properties which render other parts sensible to external
violence.

But how are these inconveniences to be accounted for?
The ring-finger is incapable of extension, and the others will
not admit of it completely ; the patient, consequently, cannot
lay hold of large objects; if he presses anything tightly, he
experiences a sharp pain; the act of grasping is obstructed,
and causes 2 painful sensation. When at rest there is no pain ;
and none is felt till he endeavours to straighten his fingers too
suddenly.

I have seen thirty or forty such cases, and could cite
numberless opinions on the cause of contraction of the ring-
finger. Some have regarded it as due to a thickened or horny
texture of the skin, not considering it as arising from any
specific cause; others have thought that it depends on
spasmodic affection of the muscles; but this explanation is
purely hypothetical, for all the movements, excepting that of
extension, are executed with perfect freedom. Many have
considered that the contraction is connected with a disease
of the flexor tendons, and I was of this opinion for a length of
time. But I was anxious to ascertain the nature of the dis-
ease; whether it was the result of inflammation, or of abnormal
adhesion of the cellular tissue, or a chronic affection of these
parts. By repeated dissections I found that none of the sup-
posed alterations existed. Some have ascribed it to a disease
of the thecse of the tendons; others to some peculiarity in the
articular extremities of the phalanges and the lateral ligaments.
Tf the articulation be examined, it will be seen that the surfaces
are very extended, and that they are united in such a manner
as to render the motion of flexion much easier than that of
extension. The lateral ligaments on both sides of the joint
OF THE FINGERS. 223

present a peculiarity which is worth noticing. They are nearer
to the anterior than to the posterior surface, the result of
which is that the fingers have a greater tendency to bend than
to straighten. But, admitting that this hypothesis is of some
value, it cannot be applicable to men in the prime of life;
besides, it will not stand against facts. Lastly, there are some
who fancy that the contraction is owing to a disease of the
articulating surfaces, which may deprive them of their polish,
and lead to wear or anchylosis of the joints.

I will not dilate any further on these various opinions, and
I have merely alluded to them because they are connected
with the history of the disease. The important point is that
an obstacle exists, and we should endeavour to discover the
true cause. A very few years ago, it was thought that con-
traction of the ring-finger arose from an alteration in the
flexor tendons; and, on looking at the projection at the anterior
part of the finger, this opinion seemed plausible.

Such was the state of the question, when a man suffering
from the affection died. I had watched him for some time,

and I availed myself of the opportunity to seek further infor-
mation.

Caszr I.—Permanent contraction of the fingers. Death.
Dissection—An old man, who had suffered for a length of
time from contraction of the fingers, having died, I determined
on having a careful anatomical examination of the parts; as
soon as I obtained possession of the arm, I had a drawing
made of it, and then proceeded to the dissection. Having
removed the skin from the palm of the hand and from the
palmar surface of the fingers, the folds and wrinkles which it
presented previously entirely disappeared; so that it was evi-
dent that this appearance, which it assumed during the affection,
did not appertain to the skin itself, but was imparted to it
secondarily. Continuing the dissection, I laid bare the
palmar fascia, and observed with surprise that it was
in a state of tension, contracted and diminished in length ;
from its lower part something like cords proceeded to the sides
of the affected finger. On endeavouring to extend the fingers,
I clearly perceived that the fascia became still more tense ;
here was a ray of light, and I suspected that this tissue had
224 PERMANENT CONTRACTION

something to do with the disease. But it remained to discover
the affected point; I cut through the prolongations which it
gave off to the sides of the fingers, and the contraction ceased
instantly ; the fingers became nearly straight, and a very slight
effort extended the phalanges completely. The tendons re-
mained entire, and the thece were not opened; all that had
been done was the removal of the skin, and the section of the
prolongations of the fascia which proceeded to the base of the
phalanges, With the view of leaving nothing in doubt, and
resolving all objections, I laid bare the tendons; they were
of the natural size, and were as supple as usual, the surfaces
being smooth. I then proceeded further; the articulations
were in their normal state, the bones were neither enlarged
nor uneven, nor did they show the least sign of alteration
either externally or internally ; I could perceive no change in
the inclination of the articulating surfaces, no alteration in the
external ligaments, no anchylosis, neither had the synovial
sheaths, the cartilages, nor the synovia experienced any change.
It was, therefore, natural to conclude, that the origin of the
affection was in’ the extreme tension of the palmar fascia, and
that the contraction itself resulted from injury of the fascia by
the forcible and continued action of some hard body against
the palm of the hand. It only remained, therefore, to apply
this new theory to cases as they might occur.

The various opinions which have been given to the world as
to the cause of this affection, have necessarily involved great
uncertainty of treatment. Many practitioners have considered
it incurable. Dr. Bennati, on consulting Astley Cooper about
an Italian pianoforte player named Ferrari, who suffered from
the deformity, was told by this celebrated English surgeon
that it is incurable; from which it is clear that the nature
of the disease was not then known to him. Others, whilst
admitting the possibility of curing it, have lauded various
methods, which have generally proved ineffectual. Having
had many such cases under my care, I have at different times
tried poultices and various emollient applications, leeches, and
friction with ointments, especially mercurial; I have also tried
alkaline and sulphurous douches, &c., at every temperature,
but without success. I then attempted permanent extension,
with the aid of an instrument made by Lacroix; but this led
OF THE FINGERS. 225

to no improvement, on the contrary, it gave rise to severe pain
in the palm of the hand, after continuing it for some time, and
it was abandoned. Some surgeons proposed section of the
flexor tendons, which operation was performed twice. The
first time the tendon was cut through the middle, which gave
rise to inflammation and contraction along the sheath; the
patient’s life was endangered and the finger continued con-
tracted. In the other case the section was made much lower;
no accident followed, but the finger remained almost as much
bent as before. Some time after these operations, which were
performed by very good surgeons, I was consulted in a similar
case.

Cass II.—Contraction of the ring and little fingers, com-
pletely cured by simple division of the palmar fascia.—In
1811, L—-—, a wholesale wine-dealer, having received a great
many casks of wine from the south, was assisting his workmen
in stowing them away and piling them up on each other.
Whilst trying to lift up one of the casks, which are usually
very large, by putting his left hand below the projecting edge
formed by the extremity of the staves, he felt a cracking sen-
sation and a slight pain inside the palm of the hand. For
some time the part was sensitive and stiff, but by degrees these
symptoms subsided, and he thought no more of them.

He had almost forgotten the occurrence, when he perceived
that the ring finger had a tendency to contract towards the
palm, and was incapable of extension like the others. Not
feeling any pain, he took no notice of this slight deformity ;
but by degrees it grew worse, and the contraction became
greater every year. At the beginning of 1831, the ring and
little fingers were quite bent and rested on the palm of the
hand ; the second phalanx was bent upon the first, and the ex-
tremity of the third was applied to the middle of the ulnar
side of the palm. The little finger was much bent, and con-
stantly directed towards the palm of the hand. The skin was
puckered and dragged towards the base of the two contracted
fingers.

The patient, annoyed by the increase of the distortion, and
wishing to get rid of it, consulted several medical men, who
all thought that the seat of the disease was in the flexor tendons

15
226 PERMANENT CONTRACTION

of the affected fingers, and that the only remedy was a section
of these parts. Some advocated the cutting of both tendons,
and others of one only. M. Mailly thought likewise, that the
affection arose probably from contraction of the flexor tendons,
but he advised the patient to seek my opinion. Immediately
I saw the hand, I was satisfied that the affection did not arise
from contraction of the flexor tendons, but solely from that of
the palmar fascia, and that by dividing this structure the fingers
would be set at perfect liberty. The operation was appointed
for the 12th June, when I proceeded in the following manner,
aided by Drs. Mailly and Marx.

The patient’s hand being firmly fixed, I began by making.
a transverse incision, six lines in extent, opposite the meta-
carpo-phalangeal articulation of the ring finger; the bistoury
first divided the skin, and afterwards the palmar fascia with a
cracking noise which was distinctly heard. When the incision
was completed, the ring finger was immediately liberated, and
could be extended almost as easily as in a natural state. Wish-
ing to spare the patient the pain of another incision, I endea-
voured to extend the section of the fascia, by slipping the bis-
toury transversely and deeply beneath the skin towards the
ulnar edge of the hand, so as to disengage the little finger, but
I did not succeed. I determined, in consequence, on making
a fresh transverse incision opposite the articulation of the first
and second phalanges of the little finger, and thus detached
its extremity from the palm of the hand; but the remainder
of the finger continued as before. Another incision then di-
vided the skin and the fascia opposite the corresponding meta-
carpo-phalangeal articulation, which disengaged the finger in
a slight degree, but the effect was incomplete. At last I made
a third transverse incision opposite the middle of the first pha-
lanx, and the finger was immediately set free ; showing clearly
that this last incision had included the point of insertion of
the digital process of the fascia. Very little blood was lost.
The wounds were dressed with dry lint, and the two fingers
were kept extended by an appropriate instrument fixed on the
back of the hand.

During the day and the night there was little or no pain,
merely a slight inconvenience from keeping the fingers in a
state of extension. On the following morning the back of the
OF THE FINGERS. 227

hand. was rather oedematous, owing to the pressure of the in-
strument, which was clumsily made. On the 14th, a new in-
strument was applied, made by Lacroix, consisting of a semi-
cylindrical piece of pasteboard, with four metallic branches
which could be lengthened or shortened at pleasure, each
liaving a sort of thimble at the end to receive the extremities
of the fingers. At first the patient appeared relieved, but in
the evening the pain returned with increased violence, and
the hand became swollen all over. I did not remove the in-
strument, but ordered the hand to be constantly bathed with
Goulard wash, by which means the pain and swelling dimi-
nished and were bearable.

On the 15th, the lint was removed, but suppuration had
scarcely commenced ; the hand was still swollen, with pain and
tension of the extended fingers. The instrument was, however,
kept on as before, and the lotion was continued. On the 16th,
the swelling had subsided and there was only stiffness of the
fingers; suppuration was well established. 17th, the symptoms
still diminished, and the fingers were extended a few degrees
more without pain. On the succeeding days the swelling and
tension disappeared altogether, and the wounds were approach-
ing towards cicatrization, though slowly, in consequence of their
lips being kept apart intentionally by the forced extension of
the hand. The wounds were healed by the 2d of July, closing
in the following order: Ist, that which corresponded with the
articulation of the first and second phalanges of the ring finger ;
2d, that which was opposite the middle part of the first pha-
lanx of the same; 3d, that which was connected with the
metacarpo-phalangeal articulation of the little finger ; 4th, that
which was first made, and which corresponded with the meta-
carpo-phalangeal articulation of the ring finger. The patient
continued to wear the instrument for more than a month, so
as to prevent the approximation of the cut edges of the fascia,
as they healed. When the instrument was removed, he was
able to bend his fingers, and only felt a little stiffness from
their having been kept so long in one position.

On the 2d of August, the patient wore the instrument only
at night, and the joints already showed great suppleness,
proving that the use of the flexor tendons was perfect, and that
the fingers would return to their natural state in a short time.
228 PERMANENT CONTRACTION

The facts of the above case leave no doubt as to the cause
of the affection, and fully confirm my opinion.

The following short description of the palmar fascia will
show how it acts in producing these effects. The superficial
portion of the fascia is derived partly from the insertion of the
palmaris longus tendon, and is partly a prolongation of the
anterior annular ligament of the carpus. At its commencement
it is very strong, and then thins off gradually towards its lower
edge, dividing into four parts, which are severally directed to-
wards the heads of the last four metacarpal bones. Here, each of
these processes bifurcates to admit of the passage of the flexor
tendons, and either subdivision keeps along the sides of the
phalanges, and not in front, as many anatomists have described.
It is these prolongations which are more stretched than the
fascia, and which require to be divided. When the skin and
the fascia are dissected, there is some difficulty in separating
them, owing to the cellular tissue and some fibrous prolonga-
tions which arise from the fascia. These adhesions account
for the puckering and movements of the skin. In cutting
through these fibrous prolongations, it might be apprehended
that the nerves and vessels would be involved; but, when the
fascia is in a state of tension, it forms a sort of protecting
arch across them, so that it may be cut without any danger.
The use of the palmar fascia is to support the tendons of the
flexor muscles, to preserve the palmar arch, and generally to pro-
tect the various parts of the hand. In roosting birds it is very
largely developed, and is remarkably elastic. Such are the
functions usually attributed to the palmar fascia, but it has
others, whereby it tends to keep the fingers semiflexed, which
is their natural position in a state of repose ; and this function,
when exaggerated by disease, produces contraction of the fingers,

This contraction, especially of the ring finger, is therefore
an affection, of which the cause is now ascertained, as well as
the method of treatment.

Case IIl.—Contraction of the fingers. Operation A man
named Demartan, a coachman, aged about 40, came to the
hospital early in December. For some years past he had per-
ceived his fingers incline towards the palm of the hand, espe-
cially the ring finger. When he came to be examined, the
OF THE FINGERS. 229

fingers were not more than an inch and a half from the palm,
the skin of which was in creases with their concavity towards
the fingers. In extending the phalanges, a sort of cord was
seen, stretching from the finger to the palm of the hand;
and both hands were similarly affected. The diagnosis was
clear. When the patient moved his fingers, the tension of the
fascia was manifest.

Having put on the stretch this shortened portion of the
fascia, I made two semicircular incisions with a curved bis-
toury; one at the base of the ring finger, so as cut through
the two lateral prolongations of the fascia belonging to this
finger; the other an inch and a quarter below the first, in
the palm of the hand, in order to make a second section of this
digital prolongation, and to separate its base from the palmar
portion of the fascia. As soon as these incisions were com-
pleted, the ring finger almost immediately assumed its natural
position. Very little blood was lost. The patient being weak,
the operation on the other hand was postponed. The dress-
ings were the same as those used in the preceding case. On
the 10th January, the patient was quite well; the wounds
had healed, and the fingers were perfectly straight and ex-
tended.

These cases prove incontestably that contraction of the
fingers arises from a shortening of the palmar fascia, and more
especially of the prolongations which it gives off at the base of
the fingers; as also that the affection may be cured by a sec-
tion across these prolongations and that part of the fascia from
which they proceed.

Three cases are not sufficient to establish a maxim, but they
will scarcely fail to attract the attention of practitioners, and
by these means do good survice to science and humanity, in
the multiplication of observations on the causes, symptoms,
effects and treatment of this affection, and principally with
reference to the operation which I have proposed for its cure.
I wish for such observations with all my heart, whether for or
against my theory; for I desire above all to be useful in the
cause to which I have devoted myself. But it must be well
understood that cases which may have some analogy are not
always the same; and that the best remedies may fail by their
wrong application ; such, for example, as the use of my opera-
230 PERMANENT CONTRACTION

tion in contractions of the fingers arising from rheumatism,
gout, or paronychia, &c.

I repeat that this affection may proceed from many different
causes, and that the same remedy is not applicable to all; for
it is evident that if contraction of the palmar fascia were not
distinguished from abnormal changes in the tendons, a serious
error might be committed.

To enable the reader to establish a differential diagnosis of
the various diseases which might be improperly attributed to
this affection of the palmar fascia, I will give some account of
several cases in which permanent flexion of the fingers occurred
from other causes. The first is that of an old porter, aged 74,
who has been for some years a street sweeper. Five or six years
ago the palm of his hand was injured by a piece of wood, and
two years ago he observed that the middle and ring fingers of
his right hand began to contract, since which time the con-
traction has made rapid progress. He referred it to cold from
which he suffered during a severe winter. Now the fingers
are about one quarter bent, and it is impossible to straighten
them by any exertion or force. Two hard projecting cords
proceed from the palm of the hand to the base of the con-
tracted fingers. When an effort is made to straighten them,
' these cords become more salient, and the tendon of the pal-
maris longus muscle is seen to move, and to become extended
all along the lower part of the fore-arm. I have selected this
case of true contraction, so that the existence of its character-
istic sign may enable you to distinguish between this and other
similar affections.

In other cases, one or more fingers may be bent towards
the hand without any contraction of the fascia. This disposition
of the parts may then result from alteration of the phalanges,
as you will observe in the two following cases.

Casr IV.—Alteration of the phalanges. Contraction —A
hoy, about 14 years of age, lately came to the hospital with a
white swelling in the ankle-joint, On examining him, it was
found that the little finger of his left hand was contracted,
and had been so from childhood. The finger was curved in a
half-circle; the first phalanx was immovable on the second,
and the second on the third; but the articulation of the first
OF THE FINGERS. 231

phalanx with the fifth metacarpal bone was perfectly free. It
could be ‘bent backwards, as in its natural state, When these
motions were attempted, no cord was seen in the palm of the
hand towards the base of the finger; therefore, in this case,
there was an affection of the phalanges, and not of the palmar
fascia.

The other case presented exactly the same symptoms; and
thus, in both, the absence of the cord, the free motion in every
direction of the metacarpo-phalangeal joint, the immobility of
the second phalanx on the first, and of the third on the second,
are distinguishing marks of the disease, which was anchylosis of
these articulations.

A cicatrix resulting from a wound may be mistaken for the
cord ; but it is superficial, and, besides, the cause was apparent.

Casz V.—In this case, the last two fingers were constantly
bent towards the palm of the hand; they could, however, be
readily extended, and there was no cord; all the articulations
were perfectly free. The patient had received a sabre-cut on
the back of the hand, which had divided the extensor tendons
of the two fingers: the divided ends not having reunited, the
flexors having no antagonists, kept the fingers constantly
applied to the palm of the hand. In this case, therefore,
there was no contraction, but a passive flexion of the fingers,
in consequence of the section of the extensor tendons.

Casr VI.—Contraction of the ring-finger by the destruction
of its extensor. Useless section of the flexvor—P. Ballon,
aged 42, received a gun-shot wound near the fourth metacarpal
bone of the right hand, which injured the back of. the hand
superficially, completely divided the flexor-tendon of the ring-
finger, and ever afterwards prevented its extension. Some time
after the wound was healed, the finger was firmly fixed to the
palm of the hand; and three years subsequently the patient
was desirous of getting rid of the finger, which was always in
his way, whether he was using his hand open or shut.

On his entering the hospital, the palmar surface of the bent
finger nearly touched the palm of the hand; the paint of
principal flexion was at the articulation of the first and second
phalanges, this joint appearing to be, almost soldered. The
232 PERMANENT CONTRACTION

skin on the palmar surface of the finger was contracted, and
kept the finger firm against any force used to straighten it.
At the same time, a sharp pain and a dragging sensation were
felt at the upper and anterior part of the fore-arm, in the
mass of the flexor muscles.

The patient was desirous of having the finger amputated,
and it was about being done, when some one proposed to
divide the flexor tendons; and this idea was adopted, without
reflecting that, even supposing the finger could be straightened,
which was extremely doubtful, the contraction of the skin, the
action of the lateral ligaments, and the inclination of the
articular surfaces, which always favour flexion, would conjointly
prevent the finger from being otherwise than useless,

A section of the flexor tendons was made, by plunging a
bistoury through the integuments near the body of the first:
phalanx, directing the cutting edge of the instrument towards
the tendons. The finger was then straightened, but not
without an effort; and, in doing this, the skin of the palm of
the hand was torn, and a noise was heard, arising from breaking
through the false anchylosis of the joint. The finger was kept
extended by means of a splint, but this was soon abandoned
in consequence of inflammatory symptoms. It was then
fastened to the adjoining finger; but, so far from this
succeeding, the relatively greater strength of the flexors
caused the sound finger to carry with it the diseased one
into a state of flexion. The patient left the hospital after
some time, with his finger rather less bent, and with a little
more power of motion.

A contused wound, again, may produce similar results;
which happened in the following case.

Casz VII.—Contused wound, giving rise to contraction of
the finger-—This person was affected with contraction of the
little finger, which was curved like an arch; all the other
articulations were free, as well as that uniting the first phalanx
with the fifth metacarpal; there was no cord in the palm of
the hand; the flexor and extensor tendons of the finger were
sound. The contraction in this case arose from a disease of
the skin, which was destroyed throughout the whole extent of
the palm of the hand, in consequence of a contused wound
OF THE FINGERS. 233

occasioned by the wheel of a carriage. The healing of this
wound took place by bringing together the edges, instead of by
the production of new skin; whence resulted a cicatrix, which
prevented the straightening of the little finger.

Burns in the palm of the hand often produce the same
effect, when not properly treated; that is, when the edges of
the wound are kept in contact, instead of being separated, so
as to admit of the generation of new skin to replace that which
had been lost. Adhesions thus take place, which are obstacles
to free motion, and produce contractions; but in this case
there was no cord to be felt or seen in the palm of the hand.

Case VIII.—Contraction of the middle finger occasioned by
a burn. Incision. Recovery.—A little girl, aged 4, named
Granjot, came to me on 19th August, 1833. Her right middle
finger was half bent; she was able to flex it entirely, but not
to straighten it; for it was held by a strong rigid band along
the middle of the finger, from its second phalanx to the upper
third of the palm of the hand. It was narrow and very sharp
at the finger, increasing in width towards the palm of the
hand, where it felt like a very hard cord. The skin was
much raised by it, especially about the joints. The metacarpo-
phalangeal articulation resembled an arch, and the band in
question was the cord of the arc. In the course of the latter
were cicatrices of burns.

From these signs it was easy to recognize a contraction of
the palmar fascia; and, in fact, it was ascertained that at six-
teen months old the child had been burnt by placing her hand
on a hot saucepan. In consequence of improper treatment,
the finger became more and more contracted as the wound
healed.

I proposed an operation that would restore the finger to its
natural state. Five incisions were made successively along the
course of the band, at the articulations of the finger, and at
the folds in the palm; they were made obliquely, so that the
wounds should gape less, through the whole thickness of the fold,
and the finger could he immediately extended without violence
being used.

To keep the finger in an extended position, a splint of
suitable form was fixed on the dorsal surface of the fore-arm and
234 PERMANENT CONTRACTION

finger, lined with wool; this was fastened to the fore-arm by
a bandage, and a pad of lint was placed behind the metacarpo-
phalangeal articulation. The end of the finger, held by two
or three turns of a narrow bandage, was fixed to the splint,
which was proportionately narrow at this extremity, and the
finger was thus bent backwards. The wounds were covered
with lint, on which was placed a small concave pasteboard
Splint, so as to fit the convex position into which the finger
was forced. The whole was supported by a roller.

The wounds did not suppurate perceptibly, but their edges
were encrusted with a sero-fibrinous exudation.

The wounds closed after two weeks of the same dressing
daily, and the finger remained straight without any support.
A week afterwards the cicatrices were complete, though still
rather tender; and the child could bend and straighten the
finger with tolerable ease.

Contractions are frequently acquired in certain occupations ;
arising from deformity of the articular surfaces of the pha-
langes. Thus, women who are employed in knitting, keep
the little finger curved and separated from the others for a
length of time, which frequently leads to contraction of this
finger, arising from deformity of the articulations of the first
and second phalanges. This is not so common now as it used
to be, but it is said to occur frequently in Germany, where the
women walk about with their knitting.

Caszr [X.—Deformity of the articulations, Contraction of
the four fingers.—A strong young girl, a lace-maker, was lately
sent to me, having the four fingers of both hands contracted
towards the palm. They were bent in about a quarter of a
circle ; but the metacarpo-phalangeal articulations were quite
free. They could be freely bent backwards, and when so
moved there was no cord or projection of any sort. This was
not the case at the junction of the second with the first pha-
langes, which could not be straightened, owing to. some insu-
perable obstacle arising from a deformity of the articular
surfaces of the extremities of the first and second phalanges,
which was no doubt produced by the nature of her occupation.

The next is a case quite distinct from an affection of the
palmar fascia, The patient was a tailor, and we are aware that,
OF THE FINGERS. 235

when at work, they hold the little finger bent and apart from
the others to catch the thread. The patient could not extend
the ring-finger, and he felt great pain in attempting to do so;
but there was nothing to indicate any lesion in the palm of the
hand. The mischief was in the articulation of the second with
the third phalanx, where there existed a serous tumour of the
kind called accidental synovial cysts; the nature of this affec-
tion is easily ascertained ; therefore it is impossible to confound
this form of contraction of the finger with that produced by
other causes.

Contractions of the fingers arising from injury of the flexor
tendons might, at first sight, be mistaken for true fascial con-
tractions ; but in the latter the projecting cord formed by the
fascia is much more superficial, and does not yield to any
extending force which can be employed.

Casz X.—Injury of one of the flexor tendons. Contraction.
— This is a case of contraction of the middle finger, which was
bent in a half-circle. Along the whole length of the finger
there was a cutaneous cicatrix, beneath which was felt a hard,
round, resisting cord; which wasthetendon. The patient had
had a whitlow, and the surgeon had cut deeply into the middle
finger, laying open the sheath of the tendon in its whole length,
whence resulted the contraction of the finger.

Another case is that of a young man about 20, a law-student,
having the four fingers of both hands contracted, though the
thumb was quite free. The fingers were half bent, and no
force could straighten them. Four hard, projecting cords
existed in the paltn of the hand, from the middle to the base
of the fingers.

This young man attributed the affection to the negligence
of his nurse, in not having opened the hands and straightened
the fingers. This absurd idea shows, at least, that it was of
long standing, and might possibly have been congenital. The
palmar aponeurosis might have been too short for the office it had
to fulfil, and thus have given rise to contraction of the fingers.

Injury to a joint is, again, ‘another of the numerous causes
of contraction.

Casz X1.—Contraction occasioned by injury of a joint. —This
236 PERMANENT CONTRACTION

case presented permanent flexion of the right fore-finger, which,
from the articulation of the third with the second phalanx, was
strongly inclined towards the palm of the hand. There was no
motion whatever in this joint, anchylosis being completely
established. The patient had received a blow, from a sharp
instrument, on the back of the finger, which penetrated into
the joint; inflammation and suppuration ensued, and anchy-
losis was the consequence. The other joints were quite free.

I will cite one more case. An engraver, in May, 183],
received a pistol-shot, which penetrated the upper and inner
part of the fore-arm, the ball passing through the flesh without
touching the bones. The ulnar nerve was divided, and this
was immediately followed by paralysis of the inner part of
the fore-arm, and of the last two fingers of the hand, to which
this nerve is distributed. Having been called in immediately,
I enlarged the wounds to prevent any sort of strangulation,
and placed a simple dressing on. No accident occurred, and
in a month he was quite well. But the paralysis remained,
and was accompanied by contraction of the last two fingers
towards the palm of the hand, on which they rested. The
articulations of the fingers and phalanges were quite free; but,
on attempting to extend them, there was great resistance; the
patient felt great pain and considerable tension at the cica-
trix. The flexor muscles had suffered considerable loss of sub-
stance, and were shortened, thus determining a permanent and
marked flexure of the last two fingers. The same effects were
seen in a patient who came to the Hétel-Dieu, in January,
1832. The wheel of a heavily-laden cart had passed over
the anterior surface of the fore-arm, and lacerated the flexor
muscles ; which occasioned permanent flexion of the fingers.

The lesion under consideration may arise from a bridle on
the back of the hand.

Cast XII.—Contraction of the left middle-finger by a bridle
on the back of the hand, Operation. Recovery.—Josephine
Lecor, a healthy child, 4 years old, had been affected, for two
years, with contraction of the left middle-finger, which so
greatly interfered with the motions of the hand, that the
parents of the child brought her to the hospital on the 7th of
July, 1833. There was permanent flexion of the four fingers,
OF THE FINGERS. 237

which prevented their entire extension,—not very perceptible
in the fore, ring, and little fingers, but considerable’ in the
middle one; the latter was bent forwards, almost at a right
angle from the articulation of the first with the second
phalanx, and backwards, at the articulation of the first
phalanx with the third metacarpal bone, almost forming the
letter Z; the first phalanx representing the middle portion of
the letter.

This angular distortion was so decided, that it required an
effort to bring every part of the finger to rest on a horizontal
plane. The hand also appeared to have an inclination backwards
from the radio-carpal articulation, towards the dorsal surface of
the fore-arm. The cause appeared to be at the back of the hand,
where there was a hard, rigid bridle, stretched like the cord of
an arc, and formed by the skin, which appeared to cover some
resisting body; this had arisen from the opening of a small
abscess at the back of the hand. The first effect had evidently
been to drag and force the hand, to an unnatural extent,
towards the dorsal surface of the fore-arm, involving the
extension of the phalanges on the metacarpal bones; whence
it happened that the hand was not in an uniform plane, but
convex anteriorly ; and the flexor tendons, being obliged to
pass over this return pulley (represented by the projection of
the upper surface of the carpal bones), had been dragged and
stretched. .

This dragging of the flexors, which are inserted into the
last phalanges, had determined the flexion of the latter only,
because the hand and the first phalanges were subjected to a
greater antagonistic force,—namely, that of the accidental
bridle, in addition to the force of the extensors, the vicious
contraction of which had become, from habit, permanent.

The only means by which the hand could be restored to its
natural state was, to cut the bridle which had produced and
kept up the deformity. On the 9th of July, the operation was
performed as follows. An incision, about an inch in length,
was made through the skin, parallel to the bridle ; its dense,
fibrous tissue, thus laid bare, was cut across; the ligamentous
adhesions to the corresponding extensor tendon were carefully
divided; and there remained only a simple wound, which was

* brought together by strapping. But this alone would, in all
238 PERMANENT CONTRACTION

probability, have been useless; the vicious habit which the
parts had acquired would soon have brought things to their
previous state; new abnormal adhesions would have been soon
formed ; and all the benefits of the operation would have been
lost. To avoid this, a graduated compress, and above it a thin
plate, extending from the inferior third of the fore-arm to the
end of the fingers, were so placed as to keep the fingers in a
permanent and uniform state of extension.

This simple apparatus was supported by several turns of a
roller, the pressure of which on the back of the hand was
lessened by a long, graduated compress over the. soft lint
which covered the wound. At a later period, the straight
splint was changed for a curved one; and this was applied in
front, so as to retain the hand in a proper position with
reference to the fore-arm, to keep apart the divided ends of
the ligamentous band, and oppose insensibly the vicious force
which tended to bring back the parts to their abnormal
condition. Nothing happened to interfere with the success
of the operation, which was so satisfactory, that the patient
left the hospital seventeen days after the operation, having the
full and free use of the hand.

Thus, amongst the cases cited with a view to point out the
characteristic differences between the various kinds of con-
tractions of the fingers, we find them arising from the following
causes: from true shortening of the palmar fascia; from
deformity of the articular surfaces of the phalanges; from
section of the extensor tendons; from destruction of the
fibrous sheath of the tendons; and, lastly, from disease or loss
of substance of the flexor muscles of the fingers.

I was desirous of procuring a preparation which should
prove the seat of the affection to be such as I have
represented; and chance has thrown in my way the arm,
fore-arm, and hand of a person who suffered to a great extent
from contraction of the fingers. I have carefully dissected the
parts, which present the following appearances. The palmaris
longus tendon, and the palmar fascia, have been isolated from
the subjacent parts. If the flexor muscles had had any part
in the ‘production of the affection, it is clear that, by pulling
them, the contraction would be perceptibly increased, which
was not the case; for, whether I pulled at the superficial or °
ON THE FINGERS. 239

deep layer, the cord in front of the last two fingers remained
nearly unaltered. If, on the other hand, I extended the
phalanges towards the back of the hand, the cord became very
apparent, but the flexor tendons followed this movement in a
very trifling degree. Further, if the flexors had any influence
in this affection, the section of their tendons above the wrist
would do away with the contraction of the fingers ; but it had
no such effect. The section of these tendons in the palm of
the hand had no better result. But if the tendons had no
influence on the contraction of the fingers, it was far otherwise
with the palmar fascia; for the slightest traction of the latter
increased the curvature of the fingers towards the palm of the
hand ; if the fingers were extended, the cord became rigid and
stretched, and was formed entirely by the fascia; the latter
was isolated from all the other parts, so that it was easy to see
that it presented the only obstacle to the straightening of the
last two fingers. If any doubt still remained as to the cause
of the affection, one more experiment would make it vanish ;
—I mean the section of the aponeurotic expansions. Imme-
diately this was done the flexion ceased, and the fingers
assumed nearly their natural position.

The affection I have described is not confined to the hand,
but also attacks the sole of the foot. I know a family of three
persons, in whom it exists in a very marked manner. The
two sisters (twins), aged 36, are affected precisely in the same
manner, in the second toe of the right foot. The angular
position of the toe is striking; the first and second phalanges
are flexed at an acute angle, and the last phalanx is slightly
extended. On examining the bottom of the foot, the cord
acting on the two phalanges is visible. These women walk
on the extremity of the toe, which is broad and long, in
consequence of the inclination of the last phalanx. There is
nothing to remark as to the nail. The cord is superficial,
increasing on tension and diminishing on flexion, and separable
from the tendons. The articulation§ are perfectly free; there
has never been any pain or inconvenience in walking.

Their brother, aged 43, also suffers from contraction of the
plantar fascia, affecting the third toe of both feet; and the
angle formed by the phalanges is more acute. The cord can
be clearly traced, forming a kind of bridge. Originally, he

~
240 PERMANENT CONTRACTION OF THE TOES.

walked on the points of the toes, and he escaped the conscrip-
tion in consequence ; but of late years the position is slightly
altered, and he treads on a broader surface. These three
persons are able to take long walks without fatigue, but there
is something rather awkward in their gait. The deformity
was congenital.

Sometimes these contractions of the toes have made it
necessary to resort to amputation; but this operation often
gives rise to serious consequences.

Case XIII.—Contraction of the second toe. Amputation.
Recovery.—On the 15th of April, 1833, a tanner, named Cotte,
aged 39, came to the Hétel-Dieu. For twenty-four years, the
second toe of his left foot had been contracted in such a way,
that the last two phalanges were bent almost at right angles
on the first. He said that, whilst running barefoot, at 12 years
of age, he stumbled against a stone, and split the nail of the
toe in question; that the pain was sharp at the moment, but
not sufficient to stop his running. From that time he had
observed the toe gradually becoming contracted. At first, he
was able, with some trouble, to bring it into its natural
position ; but he was afterwards unable to straighten it, and it
became so troublesome to him, that he was anxious to get rid
of it; for which purpose he came to the Hoétel-Dieu, and the
operation was performed on the 22d of April.

Until lately, it was usual, in such cases, to divide the
tendons and the aponeurosis of the toe, or else to amputate
it at its junction with the metacarpal bones. Such operations
often led to the most serious consequences, and sometimes were
even fatal. Having observed that only the last two phalanges
were generally much curved, and that the first was so placed
as not to press against either the sole or the upper-leather of
the shoe, I so far modified the operation as to take off only
the last two phalanges ; by which means the end was obtained
with less risk. The renf&¥ining phalanx ranged very well with
the others ; and the wound having healed favorably, the patient
returned to his usual occupations in a few days.
SECTION VI.

ON THE GROWTH OF THE TOE-NAIL INTO THE FLESH.

I have often been struck with the frequent occurrence of
distortion of the nail of the great toe, and with its reproduc-
tion, notwithstanding all the means adopted to prevent it.
Convinced that it was necessary to study the causes which
gave rise to it, that it might be successfully treated, I examined
every patient having this deformity, and soon discovered that
there were two distinct varieties which require very different
handling.

Before I say more, I will enter into a few anatomical par-
ticulars, which appear to me indispensable. And first we
must understand what is meant by the word nail ; whether it
is the horny epidermic production which, under the form of
hard, oblong plates, covers the dorsal extremity of the fingers
and toes, independently of the soft parts to which they adhere ;
or whether we are, according to some anatomists, to consider
the subjacent modified dermis as forming part of the nail pro-
perly so called; in a word, whether we are speaking of the
secreted organ only, or of the secreting apparatus joined with
it. This distinction is essential; for in the first case we
cannot talk of diseases of the nail, as the nail cannot be
diseased, a state of disease implying a state of organization ; in
the second case, the expression would be perfectly correct. To
prevent all misconception, I will give you my reasons for
adopting the first opinion. It appears to me that two objects
so different should not be confounded, and that the matrix of
the nail is no more the nail, than the bulb of the hair is the
hair itself. This being established, let us examine the nail in
all its bearings. Every one must know that it consists
of three parts: Ist, the root or posterior part; 2d, the
body or middle part; 3d, the free extremity or anterior
part ; and two surfaces, internal and external; the mention of
these divisions is sufficient, but what is of more importance 18

16
242 GROWTH OF THE TOE-NAIL

to know the relation which the nail bears to the surrounding
skin.

Supposing the skin to be stretched, and the lower part of
the nail to be pushed backwards so as to be fixed in the skin,
it is evident that the latter would be folded back on itself, and
would present a concave, thin, semilunar edge; and the nail
at the upper part and the sides would be comprised within the
two folds of this envelope; whilst its internal surface would
adhere to the skin, and its exterior be free. From this it
appears that the connexion of the nail is only with the epi-
dermis, which follows the folds and sinuosities of the true skin
which it covers. Properly speaking, therefore, the nail is but
a portion of the epidermis, thicker than the rest, and capable
of being detached from the skin beneath.

If the nail and its subjacent dermis be examined, it will be
observed that they have no connection with each other, but
that the dermis, softer and more vascular than in other parts,
is furnished at its upper part with longitudinal fibres, which
are in relation with the longitudinal fibres of the thickened
epidermis; so that, in accordance with the ingenious idea of
Meckel, the fibres of the dermis may be compared to the
tactile papille, and the lower and internal surface of the nail
to the mucous plexus of Malpighi. In regard to the hard,
horny portion, there is nothing remarkable to observe, except
its entirely inorganic nature, and its complete resemblance to
the epidermis, of which it forms a part.

Considering that portion of the skin into which the nail is
fixed to be the producing organ, I have called it the matrix of
the nail. I have directed the attention of practitioners to the
inflammation of this part; and having carefully distinguished
between this and the disease known as in-growing nail, I have
proposed the best means for curing both.

T have observed above that the nail itself cannot be diseased,
the morbid condition being only due to the surrounding skin ;
but as it generally happens that any affection of the nail arises
from disease of the skin, people have stumbled at this, and
have mistaken the effect for the cause. It is a matter of
astonishment that so little attention has been paid by authors
to the history of these diseases ; though the horrid pain
which they inflict, and the difficulty in curing them, should
INTO THE FLESH. 243

have made them a subject of peculiar attention and re-
search.

The morbid affections of the skin surrounding the nails are
always of an inflammatory character; but the inflammation
may vary in its nature and its results according to the variety
of the morbid causes. Thus, the cause is sometimes organic,
at other times it is inorganic.

In the first case, it may happen that the external cause has
acted directly and specially on the nail, and that the latter,
from some physical change, either in its substance, form, or
direction, may have effected a change in the skin to which it
adheres: it would then seem to be a disease of the nail; but
this does not signify, for as long as the skin is not involved,
there cannot exist any disease ; for this only commences with
the affection of the skin, at which period pain and other cha-
racteristic signs of inflammation are developed.

In the second case, also, the disease sometimes seems to
begin by an affection of the nail; but it is clear then that the
nail is involved only in consequence of some modification or
vicious secretion of the skin; thus the skin is first affected, the
nail follows, and then the surrounding integument. But if it
be true (and it seems incontestable), that in all these different
cases there exists but one disease, namely, inflammation of the
skin connected with the nail, the sigus cf the disease, as well
as its treatment, must be very different according to the parti-
cular seat and intensity of the inflammation. Clinical obser-
vations have here been of the greatest use, and have established
a well-marked distinction between the various affections of the
skin and the nails ; depending on their seat either at the ex-
tremities or sides of the toes, or at the posterior fold from
which the nail takes its origin; or on the question whether
the disease proceeds from the action of the affected nail on the
surrounding flesh, or whether it has commenced by inflamma-
tion of the matrix. We will now consider cases of the first
kind.

The nail may, as I have already said, be altered in its form,
substance, or direction, and the affection may depend on an
external cause acting specially upon it, or on some derange-
ment in the functions of the secreting integument; and this
derangement may be due to organic or inorganic causes.
244 GROWTH OF THE TOE-NAIL

Whenever the nail is affected, it always happens, as a conse-
quence of its conformation, that it is distorted, and that it
forces itself into the flesh ; this disease is known by various
names, but I prefer calling it the in-growing nail, a disease
with which authors have confounded other morbid affections of
the skin and nails.

This disease never occurs in the hands, and: is usually con-
fined to the great toe; but sometimes, though rarely, the
other toes are affected. If the conformation of the nail be
borne in mind, its flattened body, the direction of the angles,
and its situation in the skin which surrounds and covers it, it
may readily be conceived that a tight or ill-made shoe will
force the angles into the skin ; and this will be done the more
easily, as the skin itself is pushed outwards and upwards, so as
partly to cover the nail. This irritation is increased by walk-
ing, and very painful inflammation is the consequence. Such
is the ordinary cause of in-growing nail on the inner edge of
the great toe.

It has been imagined that the custom of cutting the nail
round has contributed to the production of this affection. M.
Brachet, of Lyons, attributes it to the pressure of the flesh, whilst
standing or walking, against the angles of the nail, which irritate
and penetrate into it. M. Patissier, considering that the lower
orders, who usually wear large shoes, and do not cut their nails
either round or square, are more peculiarly subject to this
disease, thinks it arises from their neglect to cut their nails at
all; the nails, having thus attained a great length, hend over
and inwards, and becoming strong, solid and resisting, they
proceed in the same direction without opposition. And he
adds that the fact of the inner edge being more frequently
affected than the outer, may be due to the habit of leaning
more on one side of the foot in walking; and that the fact of
the great toe being most frequently affected is due to the much
freer movement of that toe during exercise. It may arise also
from the too great convexity or thickness of the nail, which,
instead of yielding to pressure and becoming flat, exercises a
resisting force, and inserts its angles into the surrounding
tissues. All these causes may combine at the same time, and
it is seldom that any one exists alone.

‘1 [* Incarnation de l’Ongle,’ will scarcely admit of being literally Anglicised.—T.]
INTO THE FLESH. 245

It generally begins at the point where the anterior joins the
lateral edge. This appears to arise from the fleshy cushion
interfering with the scissors in cutting the nails, so that the
person stops without finishing off the angle. This allows the
nail to go on growing, and it soon forms a sharp point, which
pierces and injures the skin, exciting ulceration, which soon
extends along the whole side of the nail. On removing nails,
this sharp point is generally found to have been the exciting
cause. Having pointed out the causes productive of the first
variety of the disease, let us now proceed to consider its
progress.

The pain is very great as soon as the nail has injured the
flesh, and it is a severe task to walk or even to stand. A
serous, or sero-purulent oozing takes place at the affected part,
and if the patient tries to walk, the whole foot becomes swollen.
The pain continues to increase, the oozing is more abundant ;
the sanious pus which is discharged is the more fetid, as it
mingles with the perspiration of the feet. The patient, racked
with pain, tries to raise up the nail, and to cut it back, from
which he sometimes derives a temporary relief; but, far from
effecting a cure, this proceeding may increase the difficulty of
the ultimate treatment. If left to itself, the ulcer will some-
times degenerate into a cancerous sore, or become the seat of
large fungoid excrescences; and at times the inflammation
extends to the periosteum, giving rise to caries and necrosis of
one or more of the phalanges. This affection is occasionally
mistaken for other diseases.

Case I.—Nail growing into the flesh. Division of the nail.
Avulsion. Recovery —The Marquis of C— had been suffering
for more than eight years from pain in his great toe, and had
consulted several medical men, who all told him it was a gouty
affection. Having exhausted all the known specifics for this
disease, without any effect, and being unable to walk, he con-
sulted me; I discovered at once that it arose from the nail
growing into the flesh, and that the removal of the exciting
cause would effect a cure. The patient could scarcely be
brought to believe that he had not the gout, having heen for
eight years under this persuasion ; but at length he consented
to have the operation performed. The nail was divided in two,
246 GROWTH OF THE TOE-NAIL

by a cut of a pair of scissors, and each portion was torn away
with the dissecting forceps. A simple dressing was applied, and
in a few days the patient had quite recovered, and got rid of
his gout and all the remedies he had been in the habit of
using.

When left to itself, it is incurable; on the contrary, it
generally gets worse. Besides the intolerable pain, it may
give rise to complications which prudence and experience should
induce one to endeavour to prevent.

Several methods of treatment have been at various times
proposed. That of Albucasis and Paulus Aigineta’ has been
cited by authors; it consists in raising the nail with a probe,
cutting away the fungous growths, and burning away the rest
with caustic. They also allude to the treatment of Aquapen-
dente and of Fabricius, who used a spatula to lift up the nail,
placing a small roll of dry lint between the nail and the fleshy
part of the toe, so as to press down the flesh from the nail,
and to admit of the free edge of the latter extricating itself,
and being afterwards cut away.

Of all the means adopted, that of Desault is best known.
He proposed to keep the nail separated from the flesh, so that
both cause and effect might cease to exist, and he adopted a
modification of Fabricius’s process. Desault suggested the
introduction of a small plate of tin beneath the edge of the
in-growing nail, about an inch and a half long, and three or
four lines broad, so that the flesh might be pressed down below
its ordinary level, and the nail be raised. The pulp of the toe
was covered with a cushion of lint and cerate, and this dressing
was kept on by a small bandage. The dressing was renewed
every third day, and at the same time the foot was bathed with
some emollient decoction. The flesh by degrees became more
depressed, and admitted of the nail growing over it; the
dressing then became Jess painful, and when the edge of the
nail was quite clear of the flesh, the cure was considered
effectual. In Desault’s Journal de Chirurgie, the case of a
young girl is cited, who was cured in a month by this method.
Since Desault’s time it has been proposed to substitute a plate
of lead instead of tin; but this cannot be done, at least in the
early stage of treatment, as the lead does not offer sufficient

' See Vol. LI, p. 414 of the Society’s ‘ Translation.’ (T.)
INTO THE FLESH. 247

resistance, but bends and is not easily introduced beneath the
nail; at best it can be used only towards the end of the treat-
ment. However this may be, Desault’s process is far from
proving so effectual as it was once thought to be. Not to
mention the excessive pain which the early part of the process
inflicts, and which is repeated at each dressing, it is very often
found necessary to keep the patient under treatment for two,
three, or even more than six months; at times it fails alto-
gether, and in any case it operates seriously by extreme pres-
sure on the already irritated tissues. It is the method, however,
generally adopted by practitioners.

M. Guilmot, attributing the distortion to the pressure of
the shoe on the inner angle of the upper edge of the nail, has
proposed to pare away this angle, from the middle of the free
edge to the same point of the inner edge, and to cut the rest
of the nail very short. He observes that, in some cases, it is
necessary only to cut the nail as close as possible in the
direction pointed out. If the nail should adhere very closely
to the pulp of the toe, the foot should first be well soaked in
a bath, the nail should be gently raised up with a spatula, and
cut away as far as may be necessary. This must be repeated
frequently ; and it is recommended to wear a rather long shoe,
fitting tight over the metatarsus, to prevent the great toe being
driven to the end. By such means M. Guilmot cured himself
of an ingrowing nail which had given him pain for a space of
fifteen years; and he has cited other successful cases; but,
notwithstanding, this proceeding must be generally considered
rather as palliative than curative.

M. Brachet has also tried a new mode of treatment, and
has been successful in fifteen cases. It consists in cutting
away all the flesh which overgrows the nail; and he gives the
following account of the operation: ‘“ I make two stages of the
operation ; at first, the patient’s foot being held by an assistant
on my knee, I take hold of the end of the toe with my left
hand, and plunge a bistoury vertically outside the turn of the
nail, between it and the outgrowing flesh, across from the
dorsal to the plantar surface ; then bringing the bistoury back-
wards and outwards, I form a flap, free posteriorly, but fixed
anteriorly by its base. At the second part of the operation,
I lay hold of this flap with the forceps, and turning forward
248 ‘GROWTH OF THE 'TOE-NAIL

the cutting edge of the bistoury, I carry it all along the edge
of the nail, and remove at one cut the whole of the flesh
beyond it. There remains only a small wound, from which
there is little loss of blood; the inflammation is trifling;
healthy suppuration goes on for a few days, and a firm cica-
trization takes place, which admits of walking to any extent
without any fear of a relapse.”

M. Sommé, a surgeon at Antwerp, has proposed to cut off
that portion of the nail which has grown into the flesh, and
then to fill the cavity with powdered alum, so as to dry up the
ae of the ulcer, and to prevent the further growth of the
nail.

M. Blaquiére’s practice is as follows: he begins by thinning
a half or a third of the nail on the affected side, and then
makes an incision from the base towards the free edge, and
tears off all the part which has grown into the flesh; he then
dresses the wound with lint steeped in tincture of myrrh and
aloes, until it is covered by a firm, thick, and almost insensible
cicatrix, upon which he directs the new growth of the nail by
slipping beneath its edge a pledget of lint, which keeps it
separate from the flesh, and prevents its growing in again.
M. Blaquiére has succeeded thus in curing some of the worst
cases.

Astley Cooper recommends thinning the nail as much as
possible with a bistoury, and introducing a small roll of lint
beneath the part disengaged from the flesh; when active in-
flammation, however, prevents the introduction of the lint, he
tears off the nail with forceps.

I have here given an account of various processes, all having
in view the same object, namely, to disengage the nail from
the flesh, and to give it a new direction; some removing a
portion of the nail, others part of the flesh; but it is evident
that these means can only be palliative, and are often altoge-
ther unsuccessful.

If the flesh growing laterally beyond the nail be destroyed,
it is partially reproduced, and if ever so little should remain,
it will spread in walking and form a ridge against the nail,
which, growing still in the same direction, will find its way
into the flesh. For, it must be observed that M. Brachet,
who recommends this process, maintains it only under the idea
INTO THE FLESH. 249

that the injury is occasioned by the pressure of the pulp of
the toe on the side of the nail, whence he deduces the neces-
sity of removing the overlapping part. But it appears to me
that M. Brachet is wrong, as every one is subject to this pres-
sure, and yet very few receive any injury; we constantly see
people who turn their toes in, and who would consequently
exercise this pressure with increased force; but are they more
subject than others to in-growing nail? Not at all. The
cause of the mischief is in the conformation of the nail, and
the direction which it takes in consequence; it is the nail that
must be attacked, otherwise it will always be lying in wait for
an opportunity to do mischief. If, instead of cutting off the
surplus flesh, a portion of the nail be removed, all may go on
well for a time; but if it be allowed to grow as before, it will
again assume a distorted direction. It is true that the growth
and direction may be watched, but all the care that can be
given will very rarely succeed. Desault’s process of inserting
a small plate of tin, at first sight seems good ; but on reflection
it must be admitted that the object will not thereby be perma-
nently attained. What is to become of the lateral growth of
the nail which has been forced beyond the flesh ? It will always
have a tendency to bend in upon itself, and whether it be cut
level with the flesh, or be permitted to overgrow it on the side,
it will frequently happen that it will again make its way into
the flesh. It may perhaps be asked, how is it then that these
methods have been successful? Whenever the determining
cause is the pure effect of accident, and not of the structure of
the nail, the success of these means will depend on the early
treatment or otherwise of the case. For example, suppose a
well-formed nail to be injured by a tight shoe, or some external
violence, if Desault’s process be tried a few days after the flesh
has been pierced, it is pretty certain that the inflammation
will not have proceeded to such a length as to be much aug-
mented by the artificial pressure; and the nail being turned
aside, there is no reason why the disease should return. But,
I repeat, whenever the cause of the injury is in the nail itself,
all these means will most commonly be useless.

Being struck by these disadvantages, and having in view
the cause of the mischief, I came to a decision a long time
ago, that it was preferable to remove the nail altogether. This
250 GROWTH OF THE TOE-NAIL.

operation had already been frequently performed by manv
surgeons, but not very skilfully. They laid hold of the an-
terior edge of the nail with a pair of forceps, which were kept
together by a ring, to ensure a firmer hold, and by a strong
pull the nail was torn away. But, independently of the ex-
treme pain which such a barbarous process inflicted on the
patient, it happened not unfrequently that either the forceps
slipped from their hold, or the portion held by the forceps was
broken off, leaving the rest, so that the patient was horribly
tortured in vain.

This is the way I proceed: when the inflammation of the
part has been subdued by the application of emollients for
some days, and when I think it a favorable time for the ope-
ration, I pass the point of a pair of straight, strong, sharp
scissors under the middle of the free edge of the nail, and slip
it quickly up to the root, dividing the nail at one cut into two
equal parts; then laying hold of the affected side with a pair
of dissecting forceps, I tear it off, turning it back upon itself
from within outwards; and I do the same with the other side
should it be necessary. When the fungous flesh near the
wound is too much raised, I cauterize it, and thus ensure a
cure as far as possible. After the operation, the skin beneath
the nail dries up, the ulceration decreases and cicatrizes in four
and twenty or eight and forty hours; so that in five or six days
the patient will be able to walk as usual. The nail seldom
grows again in old people, but it sometimes does in young
ones.

At first sight, it might be thought that this operation is
very painful; but the patients rarely cry out. When the nail
has been entirely removed, there is no return of the disease, but
it may re-appear if any portion remain behind.

Casz II.—Nail growing into the flesh. Extirpation of the
external half. R. S., aged 16, of robust habit, entered the
Hétel-Dieu, on the 18th June, 1821. For six months he had
worn shoes thicker and tighter than usual, and his feet were
so squeezed that he limped in walking ; the outer angle of the
right great toe-nail was bent inwards, and driven into the flesh,
which swelled up and covered it. Redness and pain came on,
and the lameness increased. The soft part being jammed by
INTO THE FLESH. 251

the outer toes, and compressed in every way by the shoes, be-
came hard, callous and whitish, with a fissure in which the nail
was fixed. Although suffering much the patient continued his
usual occupations, until a small suppurating wound, at times
also discharging blood, made its appearance, when he came to
the Hétel-Dieu.

On the 3rd of July, after a few days’ rest, some baths, and
emollient applications, I operated upon him. I divided the
nail in the middle, from the free extremity to the root, with a
pair of strong straight scissors; I then laid hold of the outer
half, and, turning it back, tore it off with dissecting forceps ;
I also pared off the callosity, which covered it, with a pair of
scissors. There was but little bleeding. The wound was
dressed with cerate, lint, a compress, and a bandage.

On the 4th, 5th, and 6th, he went on well, with the same
dressing, and a spare diet. On the 7th, the wound was healed,
and the patient left the hospital cured, and walked well; but
he was cautioned to wear larger shoes, and to wrap the toe in a
piece of linen with ointment.

Casg I1I.—Ezxtirpation of the nail growing into the flesh.
Cautery to fungous growths. About the end of February, 1812,
Jacob, a blacksmith, aged 45, whilst at work, let fall a bar of
iron on his left foot; the great toe was much bruised, and the
extravasated blood turned the nail black. Having neglected it,
a collection of pus formed beneath the nail, loosened it, and,
after finding vent, it left the toe in an ulcerated state, which
was kept up by the nail being forced into the flesh.

The patient, tired out by pain and by the persistence of the
disease, applied to a quack, who first tried to cut the nail, but
failing, he endeavoured to tear it-off. He was equally unfor-
tunate in this, for the nail broke instead of coming away; the
wound was laid bare, and the patient dressed it himself with a
blackish ointment, which the man gave him, but of the name
and nature of which he was ignorant. As he continued to
suffer, and saw that his toe got worse instead of better, he came
to the Hétel-Dieu on the 24th December, 1812. At this time
the toe was swollen, and was very painful when put to the
ground. The new nail had forced itself into the flesh, Before
operating, poultices were applied for some days. I then
252 GROWTH OF THE TOE NAIL

divided the nail into two parts lengthwise, and, laying hold of
them successively with the dissecting forceps, I tore them away,
turning back the one outwards, and the other inwards. When
the scab fell off, it was discovered that some portions remained,
which I removed with a bistoury, as well as the skin which
formed their matrix. By doing this I prevented all chance of
any relapse, having deprived the nail of its reproducing organ.
Since then the wound was dressed with lint, sometimes dry,
sometimes dipped in a stimulating lotion, according to its
state, and the patient left the hospital in less than a month with
only a small point of ulceration, which healed in two or three
days afterwards.

Casz IV.—Osseous tumour existing for several months on the
upper part of the last phalanx of the right great toe, raising up
the nail. LExtirpation of the tumour and of the nail_—Louisa
Duvillard, aged 15, of good constitution, experienced acute
pain in her great toe, in May, 1821, which was aggravated by
walking ; on examining it, she found there was a small ex-
crescence beneath the nail. A medical man, who was con-
sulted, prescribed several topical applications, but without
effect. During this time the patient walked with difficulty,
and in great pain.

She came to the Hoétel-Dieu on the lst of July, 1822. A
small, hard, resisting tumour, about the size of a large pea, and
very painful on pressure, existed under the nail of the right
great toe ; the nail was lifted up, and the free extremity separated
from the upper surface of the third phalanx. I detected the
osseous nature of the tumour, and determined on removing it.
The patient had a bath, and after a few days’ rest I operated as
follows, on the 6th of July. I circumscribed the base of the
tumour by an incision with a strong straight bistoury, and
removed it entirely without touching the nail. But little
blood followed. A very thin cushion of lint was inserted
between the nail and the flesh, and a poultice applied round
the great toe. On the 10th, the lint was taken out; suppu-
ration had commenced. ‘The dressing was renewed daily, and
on the sixteenth day after the operation the patient was able
to walk without the slightest pain. On the Ist of August, the
nail was still separated from the soft parts, and had not resumed
INTO THE FLESH. 2538

its natural position ; however, the cicatrization of the Little
wound was complete, and there was neither protuberance nor
hardness, The patient walked well, and felt no pain, and she
left the hospital on the 4th August.

In April, 1823, she came again to the hospital, with the
nail of the right great toe growing into the flesh. She said
that about three months after she quitted the hospital the
cicatrix became soft; a little blood was discharged after a
longer walk than usual, and from that moment the whole of
the skin surrounding the nail had become the seat of inflam-
mation, which was kept up by the lateral edges of the nail
being forced into the flesh, I had no doubt as to the pro-
priety of removing the nail, and soon circumscribed the affected
part by an incision ; the operation was speedily over, notwith-
standing the screams and resistance of the patient. Suppura-
tion was established in a few days; some cellular and vascular
excrescences were destroyed by nitrate of silver, and the patient
finally quitted the hospital on the seventeenth day after the
operation, quite cured.

Such is my mode of proceeding in simple cases of in-growing
nail; but I must observe that it is by no means of such fre-
quent occurrence as may be generally believed ; and although
it would appear, by surgical books, that cases are met with daily
to which the above operation is applicable, every hospital sur-
geon must know how rare it is to see the affection so limited
or so little advanced, as to be cured by the simple removal of
the nail.

I wish now to direct attention to another stage of the
disease which requires quite a different treatment. In 1814,
Mr. Wardrop' published an account of a sort of whitlow
which he named Onychia maligna, and which is nothing more
than ulceration of the matrix of the nail. But Wardrop,
in pointing out this disease which I had alluded to several
years previously, has confounded together several varieties of
this affection; and, in consequence of this confusion, he has
proposed the same treatment and the same rules for cases
altogether unlike. I have not arrived at the same conclusions ;
I have distinguished this affection from that which originated
from in-growing nail, They are quite different, and conse-

1 « Med.-Chir. Trans.,’ vol. v, p. 129.
254 GROWTH OF THE TOE-NAIL

quently the treatment should differ. If the first of these
propositions should be established, the second will follow as a
matter of course.

In stating that the nail itself could not be considered as
liable to any disease, I admitted that it might be more or less
altered in its structure, form, or direction, and that it might, in
consequence of such alteration, injure the adjoining skin. I
have, therefore, classed together those affections which arise
from alteration of the nail; and have made a separate class of
those in which the mischief originates in the surrounding inte-
gument. Itis with the latter that we have now to do.

They may arise, like the former, from an external or me-
chanical cause, or from a peculiar morbid action. Thus, the
surrounding skin may be irritated by contusions, pressure,
punctures, lacerations, and lesions of all sorts, and inflamma-
tion may follow sooner or later; and the same has been
observed in men who work in alkali manufactories, and espe-
cially amongst soap-boilers. In cases where there is no external
cause, it is a much more difficult subject. These cases may
frequently be due to the action of syphilitic virus, and, occur-
ring at the matrix of the nail, they have been then named
onglade.' Almost all the authors who have written on venereal
diseases, have omitted to speak of this affection. Hunter,
Swédiaur, Astruc, Benjamin Bell, Cullerier, and Lagneau, have
not alluded to it; neither is it mentioned in the ‘ Nouveau
Dictionnaire de Médecine,’ in Samuel Cooper’s Dictionary, nor
in the ‘Dictionnaire abrégé des sciences médicales.’ Wardrop has
confounded it with the common inflammation of the matrix of
the nail; and Boyer has not pointed out these ulcers when
treating of venereal ulcers generally. Boyveau-Laffecteur has
afforded them a line and a half; the ‘ Dictionnaire des sciences
médicales’, half a page ; and Jourdan, in his ‘ Traité des maladies
vénériennes,’ has said a few words about them. Whatever may
be the cause, whether a syphilitic virus exist or not, and whether
the onglade be due to its presence, it is nevertheless certain that
this disease shows itself in a very peculiar form: 1st, it affects
the nails of the feet and hands indiscriminately ; 2nd, it
attacks several at once; 3rd, it sometimes shows itself in small

‘ [The French term has been retained, in the absence of any corresponding
English word.—T.]
INTO THE FLESH. 255

‘ulcers at the intervals between the fingers, whence it spreads
to the circumference of the nail; 4th, the nail is detached
spontaneously from the integument; 5th, it resists all anti-
syphilitic remedies ; (I have tried more than thirty times, and
I have never found that mercury, though administered judi-
ciously internally and externally, and sometimes for a long
period, produced any satisfactory result; on the contrary, I
have seen it make the wound blacker in colour and more fetid
in smell: Mr. Wardrop says, however, that he has given mer-
cury with success ;) 6th, the cure is effected by simple dressing,
as soon as the nail has fallen off. In regard to the greyish
colour of the bottom of the ulcer, and the form which is said
to be peculiar to venereal sores, a person must look with a
partial eye to detect these characteristics in the ulcers round
the nail; and, setting aside all the peculiarities which I have
enumerated, the most experienced surgeon would find diffi-
culty in distinguishing it from common inflammation of the
matrix of the nail. M. Lelut, in his excellent work on
Onglade, is also of opinion that the affection is not of a syphi-
litie nature. Moreover, it is not a common disease, since
there have been only four patients with it during the past year
in the venereal hospital of Paris.

Cast V.—Onglade.—Caroline N—, a woman of the town,
aged 22, was affected, on the 17th of March, 1826, with an in-
dolent discharge which had continued for a month; mucous
pustules were also developed on the labia and parts near the
genitals; there were also some reddish superficial sores at the
lower extremity of the right nympha. Mercurial fumigation
was ordered.

30th June. There were red spots at the margin of the
anus, and superficial mucous pustules. The genitals were
healthy, excepting slight ulceration about the commissures.
Same treatment continued. On the 15th of August, these
symptoms had disappeared.

On the 21st of September, the patient had several sores at the
matrix of the nails of the two fore-fingers, and another near
the nail of the right great toe. The ulceration commenced
near the root of the nails, and formed a sort of ridge round
them; soon afterwards the root detached itself, and the body
256 GROWTH OF THE TOE-NAIL

alone of the nail adhered to the skin; suppuration became
abundant, and the patient suffered acute pain, especially in
the foot, which prevented her from walking.

On the 16th of October, the nails of the great toe and right
fore-finger were removed; the first came off easily, but the
other adhered firmly to the skin by its body only. The pain
was now limited to the finger on which the nail still remained.
It may be a question whether the nails would grow again regu-
larly. The wounds looked rather badly, having a fungoid aspect,
and suppurating copiously. They were bathed at first with
diluted chlorate of soda, and afterwards dressed with opium
cerate.

Case VI,.—Onglade-——V—, aged 38 to 40, of good con-
stitution, and usually living in the country, had several ulcer-
ations, which she was told were syphilitic, at the root of the
nails of the two great toes, of the third left toe, and of the
index and ring-fingers of the left hand. When I first saw her,
the nail of the right great toe was off, and the ulcerous sore,
simply dressed with cerate for some time, was going on well.
The nail of the ring-finger was also detached, and the wound
was almost healed by means of simple dressing. The nail of
the third left toe was nearly detached, and this gave but little
pain; but the principal point was the nail of the left great
-toe. The disease had existed only a short time at the base of
the nail, and was. accompanied by all the symptoms of the
most acute inflammation. The. patient said that she had never
had any other symptom of syphilis, and several medical men
who saw her told me the same. The inflammation had origi-
nated without any known cause; the different fingers and toes
had been attacked successively at short intervals; and when
the nails came off, which they did spontaneously, the wounds
soon got better and healed. lLeeches were applied round the
left great toe, which bled freely, and the pain was diminished.
Antisyphilitic treatment was tried, but as the mischief was
sensibly aggravated, it was discontinued. I am now trying
antiphlogistic means, and I shall remove the nail as soon as it
is practicable ; and there is every reason to believe that it will
heal as quickly as the others.

The two cases I have just cited are in many respects incom-
INTO THE FLESH. 257

plete ; but I have thought it right to bring them forward, as
some of the facts which they comprise may tend to clear up
the disputed question in regard to the affection now under
discussion.

In the first case it is difficult to affirm that there was
syphilis. At first there was a discharge which did appear to
be of a venereal character; mercury was employed, and the
discharge continued, though less abundantly ; a slight improve-
ment, due, perhaps, to rest, regimen and refreshing drinks,
rather than to the medical treatment. Six weeks later there
were new symptoms, which were probably venereal, but I do
not think they were a continuation of the first. After a second
treatment there were no other symptoms, and a month after-
wards the first sign of disease of the nail made its appearance.
The question is an obscure one, but the very. obscurity of
the causes induced me to cite the case.

In the second case there was no reason to suspect syphilitic
infection. The nail disease appeared as an isolated fact, un-
connected with any local or general derangement of the system.
The administration of mercury produced no good result; and,
which is more remarkable, the fingers and toes healed spon-
taneously as soon as the nails came off. The two cases men-
tioned by Lelut in his work also prove the inetlicacy of mercury
in this affection.

It would seem as if the disease, which I have designated as
onglade, had no other object than the release of the nail;
when once. off, all goes on well, and a simple cerate dressing is
sufficient to ensure recovery. It is very different from those
incurable ulcerations of the skin forming the matrix of the nail.

I have occasionally seen alteration of the matrix of the nail
in persons affected with impetiginous eruptions. A case of
this sort occurred recently at the Hétel-Dieu, which I cured
by the use of sulphurous lotions. In regard to the other cases
of inflammation not due to any mechanical injury, we do not
know generally whence they originate ; and instead of seeking
to explain them, the simpler course is to admit that they are
due to some constitutional peculiarity.

I thought I could easily distinguish the affection which
commences with in-growing nail, from that which originates in
the skin, by the following peculiarity: when the disease is

17
258 GROWTH OF THE TOE-NAIL

produced by the nail, the fungous growths to which the in-
flammation has given rise are in front and on the sides of the
nail; but when it is an affection of the skin, they are always
at the base of the nail. In general this is a characteristic
distinction ; but after all, what are these fungous growths but
a consequence of inflammation of the skin? And since it is
clear that the inflammation, from either cause, may extend to
all the surrounding skin, any distinction that can be made
must depend, chiefly, on the condition presented in a more or
less advanced state of the disease. The cases, however, in
which the two varieties combine are rare, and it may be affirmed
that the line I have drawn is really founded on general obser-
vation and experience.

However this may be, the disease gives rise to very similar
results. The skin is stretched, of a violet-red colour, and
painful ; the nail is shortened and reduced in width ; sometimes,
indeed, it has wholly disappeared, and, instead of a nail, there
are only some traces of a horny substance; the nail, too, is
frequently found concealed beneath the fungous flesh; its
colour is grey or black, and in certain cases it does not adhere
as in its normal state: the wound generally discharges a sa-
nious or bloody pus, with a very fetid smell. When the patient
walks or even stands, the fungous growths begin bleeding;
no sort of shoe can be borne, and the least friction is exces-
sively painful; it is almost impossible to remain in the same
room with patients affected by this disease, to such a degree is
the air and clothing about them tainted by the combination
of the ichorous pus oozing from the ulcer, and. the copious
perspiration from their feet.

These symptoms occur in nearly every case; sometimes,
however, the affected spot is immediately beneath the nail,
when small swellings occur which raise up the nail, and occa-
sion greater pain in consequence of the pressure. These
tumours may be of various kinds, either fibrous, cartilaginous,
osseous, or vascular; and as a proof that their development is
due to the alteration of the skin which covers the nail, I may
add that, if the operation be limited to the removal of the
tumours, without cutting back the skin from which they
originated, the latter usually becomes diseased, and must be
extirpated sooner or later.
INTO THE FLESH. 259

It may be imagined, from what I have said, that the treat-
ment I have adopted so successfully in cases of in-growing nail,
is not applicable to the other variety, in which the skin is
diseased, and towards which the remedies should be directed.
If nothing more be done than removing the nail, the seat of
the evil will still remain, and it has been proved by numerous
observations that this affection is not to be so cured. If
caustic be applied after the removal of the nail, the skin only
is destroyed which is immediately subjacent, leaving that
which invests the root extending very often to a great depth.

These considerations have induced me to remove, not only
the ulcerated parts but, the whole of the fold of skin whence
the nail originates and derives its nourishment.

In performing this operation, I make the patient sit on a
bed ora chair, and, holding the diseased toe with the left hand,
I make a deep, semicircular incision with a straight bistoury,
three lines beyond the fold of skin which supports the nail at
its root. This incision is in a direction parallel to the fold,
which it entirely cireumscribes; then, the toe being held by
an assistant, I draw forward the flap with dissecting forceps,
and detach with the knife all the skin that is connected with
the nail, and contributed to its production: if any traces of
horny substance remain, I extirpate these also, so that no part
of the diseased tissues is left. All the white and fibrous parts
at the bottom, or the sides of the wound, should be carefully
removed ; for these are the rudiments of reproduction of the
nail, which would keep up the disease.

This operation is always attended with very severe pain, but
it does not last long. The toe should be immediately covered
with a piece of lint spread with cerate, and a thin pad of
lint completes the dressing. The leg should rest on a pillow,
and be half bent on the thigh.

The patient usually feels some pain for several hours after
the operation ; but this soon passes off, and in three or four
days the first dressing may be removed; the wound is then
almost always covered with healthy pus. Simple dressing is
continued; the surface of the wound is soon covered with
vascular grauulations, which must be kept back from time
to time with nitrate of silver. Should any small horny fibres
be reproduced, they should be torn away, and the portion
260 GROWTH OF THE TOE-NAIL

of skin which gave them birth should be cut away; and the
part will generally heal by the fifteenth or eighteenth day,
when the patient may resume his usual avocations.

If the cicatrix be examined some time after the operation, it
will be found to consist of a smooth thick skin, without any
nail, but having sometimes a horny consistence. In cases
attributed to syphilitic taint, I have followed up the operation
with the knife by cauterizing the parts with a strip of lint dipped
in nitrate of mercury, which most effectually prevents any re-
lapse, as the diseased organs are destroyed.

In proposing this as the quickest and the surest mode of
treatment, I do not mean to say that an operation is always
indispensable. I would recommend the trial of other means,
avoiding so painful an operation, such as antiphlogistics of all
sorts, baths, rest, leeches, poultices; or else the treatment
adapted to syphilis, such as calomel powder, mercurial oint-
ment, &c. In private practice I have sometimes successfully
used an application of lint steeped in strong red wine and
liquid acetate of lead, in the proportions of one pint of the
former and one ounce of the latter.

Casz VII.—Removal of the matrix of the nail—On the
8d of May, 1814, a man was admitted to the Hétel Dieu, named
J. Charit, who had just left the Hospital of La Pitié. For six
months he had observed a peculiarity in the two great toes,
different from the others; he was compelled to go to the
hospital in consequence of the pain he had suffered so long,
of the impossibility of walking for a quarter of an hour without
resting, the continual discharge of a blackish fetid pus with
which the nails of both great toes were continually bathed.
For some days the feet were cleansed, and simple dressings
were applied ; at length he was operated upon ; and, according
to his account, they cut through the middle part of each nail
with scissors from the front to the root; then both portions
were taken off with dissecting forceps: the operation was very
painful ; inflammation was kept down, and the patient was pro-
mised a speedy recovery. The fungous ulcerations, however,
continued, the suppuration was still blackish and fetid, and
with it some softened fragments of horny matter came
INTO THE FLESH. 261

away; the pain became gradually more intense, and at last he
quitted the hospital.

On his admission into the Hotel Dieu, the portion of skin,
which in a healthy state underlies the nail, presented an
ulcerated, fungous, blackish, fetid surface; at intervals there
were some uneven pencils of fringed horny fibres, adhering to
the skin at one end and free at the other. At the junction of
the lateral edges with the upper surface there was some of the
nail in the flesh, a portion showing itself of a prismatic shape.
The fold of the skin, which serves as the base for the root of
the nail, and which constitutes its matrix, was in a disorganized
state.

When I saw him in the morning I pronounced it to be an
organic affection of the matrices of the nails, and proposed my
mode of treatment to him.

He was carried to the theatre and laid on a bed. I took
hold of one of the toes, and with a straight bistoury I made a
deep, semicircular incision, parallel to the fold of skin which
supports the base of the nail; with the same instrument I cut
deeply into and wholly removed the fungous and horny growths
of which I have spoken, as well as the triangular piece; and I
also carefully removed those portions of the flesh from which
appeared to originate some irregular, uneven, greyish excres-
cences, the product of a vicious secretion of the corneous
substance which constitutes the nail. The operation was per-
formed on both toes, and was borne with firmness by the
patient. The toes were simply dressed in the way described
above.

The patient suffered great pain for a few hours after the
operation, but was afterwards very quiet. In five days, the
first dressing was removed, when suppuration had begun; a
similar dressing was applied. Some cellular and vascular
excrescences were kept down with nitrate of silver. As the
left toe gave some pain, I examined it carefully, and, perceiving
some thin horny fibres in the angle where the upper surface
joins the lateral edges, I removed the part, after having
circumscribed with the bistoury that point of the skin from
which it originated. The pain soon ceased altogether, and
he could walk about the wards of the hospital without incon-
venience. On the eighteenth day after the operation
262 GROWTH OF THE TOE-NAIL

cicatrization was complete, aud he was in a condition to
quit the hospital.

Cast VIII.—In-growing nail of the left foot. Avulsion,
Affection of the matrix of the nail of the right foot. Removal
of the skin.—Letourneur, aged 18, of strong constitution, was
admitted to the Hétel-Dieu towards the end of July, 1826.

At the external edge of the left great toe, the nail was
growing into the flesh. There was nothing peculiar in this
affection: the skin all round the nail was red and swollen,
but not ulcerated, except at the point of insertion; the
extremity of the toe was slightly swollen, and the pain was
rather sharp, but bearable. The patient complained more of
the pain which the right toe gave him; this was not the same
affection: the skin round the nail was ulcerated throughout ;
fungous growths rose at the base, and the nail itself was
blackened and separated into several strips of irregular shape ;
in fact, all the symptoms of in-growing nail were clearly
developed.

I was much struck with the singular conjunction of the two
varieties of the disease in the same person; and I remember
another similar case which occurred to me in the course of my
practice. A different treatment was necessary for each toe.
The nail of the left one was divided with scissors into two equal
parts, and these were torn away, care being taken to eradicate
every part that remained. Then, with a bistoury, I took off
all the skin which gave origin to the nail of the right toe. There
was but little blood lost. The patient, who had suffered much,
was then carried to bed, and the wounds were properly dressed.
The wound left by the removal of the nail of the left toe was
completely cicatrized in six days, but the other was not cured
in less than eleven days. On the fourteenth day after the ope-
ration, the patient quitted the hospital quite well. On the 18th
of October he came again to the hospital, to ask for a certificate ;
and the toes were examined, and appeared in a very satisfactory
state. The cicatrix was well formed and smooth, and the skin
in some parts had something approaching to a horny con-
sistence ; but the nail had not reappeared on either toe, and
the patient walked without the least inconvenience.
INTO THE FLESH. 263

Case IX.—Crushed nail. Ulceration. Repeated operations.
Recovery.—Hippolyte, a sawyer, received a blow on the great
toe, in November, 1825, by a piece of wood falling on it. The
nail presented an ecchymosed condition, and was, as it were,
flattened; the flesh round it became inflamed, and ulceration
took place at the inner side. The toe was leeched and poulticed,
and the patient kept his bed for twenty-eight days, when he
went to work again still suffering. The soft parts became
much swollen, and discharged a little blood during the day,
when he was tired with walking, and at night the bleeding
was more copious. For two months he tried all sorts of
ointments. After this, he went into a hospital, where the nail
was taken off by passing a bistoury between it and the skin,
but without touching the root. The surrounding soft parts
were not excised, but they were brought together by a small
bandage, which caused considerable pressure on the toe. The
wound was cicatrized in ten days, except at a single point.
There was no trace of a nail, and the small ulcer was cauterized
daily with nitrate of silver. Forty-two days after he entered
the hospital, the patient quitted it, but without being com-
pletely cured; he was advised not to walk, but of this he took
no heed. Hight days after, the mischief reappeared in a worse
form than before. At the two posterior angles of the cicatrix,
there were two fragments of a horny substance which seemed
disposed to unite, and which irritated the cicatrix very con-
siderably. Fungous growths then began to appear round the
root of the nail, and the ulcer on the inner side was large enough
to admit the end of the finger. The patient came to the
Hotel-Dieu on the 26th of February. I removed the nail and the
surrounding flesh, as I have already described. The wound cica-
trized ; but there still remained a small ulcer at the inner edge, as
after the first operation, A month afterwards, a small frag-
ment of nail appeared at the bottom of the ulcer, which I
removed, forming a flap above it. The wound was dressed
with cerate; it bled for a few days, because the patient chose
to get up, but afterwards it went on well, and no further
portion of nail made its appearance. The part soon healed,
and the patient was radically cured of a disease which had
continued for six months, and had not yielded to any of the
means previously tried.
264 GROWTH OF THE TOE-NAIL

Case X.—Nail growing into the flesh. Relapses. Various
modes of treatment.—Another patient was admitted into the
Hétel-Dieu, in 1825, whose case is very interesting, in conse-
quence of the frequent relapses, notwithstanding the various
modes of treatment that were resorted to.

Lalande, a baker, had his great toe crushed by a rough
stone, in July, by which the flesh, towards the anterior and
inner angle of the nail, was much bruised and lacerated. The
nail was divided in halves, and a good deal of blood was dis-
charged from the wound ; for the first fortnight the toe was
swollen, and so painful that the patient had no sleep. These
symptoms became worse when he deviated a little from strict
regimen. He went to a hospital a fortnight afterwards. The
surgeon availed himself of the accidental lesion of the nail to
remove the two parts, simply by turning them back on them-
selves; and the toe was bound round. Four days after, it
was observed that a reproduction of the nail, at the edges, had
commenced; and a new nail was soon developed, which,
growing over the wound, prevented the formation of the cicatrix.
A month had scarcely elapsed when it was found necessary
again to have recourse to avulsion; and it was performed, as
on the first occasion, without destroying the root. The nail
came again; and after remaining two months and a half in the
hospital, the patient quitted it, contrary to the advice of the
surgeon.

Though he was not cured, he resumed his usual occupations,
and continued them for four months and a half in constant
pain; and, as the mischief was increasing, he came to the
Hotel-Dieu on the 18th of March. The nail was then separated
into numerous fragments, and the surrounding soft parts were
so swollen and fungiform, that they covered nearly the whole
nail. I cut into them deeply; but the patient was so restless
during the operation, that I could not remove the whole of
the flesh at the edges. Hence, there sprang up two small
portions of nail at the posterior angles of the wound; the
latter quickly cicatrized throughout. The small fragments
were moveable, and easily torn away; but, fearing a repetition
of the reproductive process, I destroyed their matrices by two
longitudinal incisions. On the 13th of May, Lalande left the
Hotel-Dieu quite cured.
INTO THE FLESH. 265

The reproduction of the in-growing nail has been very ably
described in the work of M. Jardon. He observes, that
tightness of the shoe increases the transverse curve of the .
nail to such an extent, that the extremities of the curve or
lateral edges become almost perpendicular. When the nail
assumes this vicious form it is in vain to remove it, as the
matrix itself, by which the nail is moulded, is distorted, and
the nail must necessarily take the same direction.

With reference to the cases just cited, it will be seen
that they tend to confirm what I had previously advanced.
Therefore, I will confine myself to a recapitulation of the
principles I have established, in such a form as may be readily
understood.

1. The term “nail” should be applied only to the hard
horny substance, and not, as several anatomists have done, to
the portion of skin which adheres to and produces it.

2. The nail being only an inorganic production, there
cannot be any disease of the nails; but the disease is always
in the skin which surrounds them.

3. The nail may, however, be primarily altered by some
external force brought to bear upon it, whereby its substance,
form, or direction is physically changed; but so long as the
distortion of the nail produces no irritation of the skin, there
is no disease.

4. Inflammation of the skin of the nails may result from an
organic or an inorganic cause.

5. The disease differs in its characters according to the part
it attacks, or according as its origin may be primarily an
alteration of the nail or otherwise: the treatment varies in
these cases.

6. In general, when the nail is affected, the distortion which
results causes it to press on the flesh, and this constitutes in-
growing nail.

7. The affection of the nail which causes it to grow into
the flesh, may be primary and dependent on some external
cause, or consecutive to some modification of the skin which
produces it.

8. Avulsion of the nail is the only certain mode of treat-
ment for in-growing nail; and this is unsuccessful when the
affection of the nail is consequent on disease of the skin.
66 GROWTH OF TOE-NAIL INTO THE FLESH.

9. The disease, characterised by primary inflammation of
the matrix of the nail, is altogether distinct in its symptoms,
its results, and above all in the treatment it requires, from
that which is due to the antecedent alteration of the horny
substance.

10. The affection of the skin around the nails, called syphi-
litic, and named by authors Onglade, is but a variety of what I
have described ; it is essentially the same disease with some dif-
ferent characters, and it may receive the same treatment, seeing
that anti-venereal remedies are inefficacious.

11. The removal with the bistoury of the whole of the
diseased skin should be preferred to every other therapeutic
measure; it is both quicker and more certain.

12. In all cases, however, other means ought not to be
neglected; as by antiphlogistic, discutient, antiseptic, or
cathartic remedies the patient may be spared a most painful
operation,
SECTION VII.

TRAUMATIC EMPHYSEMA.—EMPHYSEMA ARISING FROM
-FRACTURE OF THE RIBS, AND FROM LACERATION OF
THE LUNGS AND THE PLEURA.

As a consequence of fractures of the ribs, especially where
the fractured extremities are pushed inwards and lacerate the
lungs and the pleura, it sometimes happens that air is dif-
fused into the neighbouring parts, and infiltrated into the
cellular tissue, distending the cells, and giving rise to the
affection named Traumatic Emphysema. As respiration is
continually going on, the quantity of air taken in at each inspi-
ration increases this result, so that emphysema may extend
over the whole body. Its formation is the more rapid, since,
in this sort of emphysema, there is usually no wound in the
parietes of the chest. In regard to the exciting causes, frac-
tures of the ribs offer essential differences to be considered,
because the accidents resulting from them are very various, and
are sometimes fatal.

At times some external violence acts upon the sternum,
which is pressed towards the vertebral column, and the curva-
ture of the ribs is pushed beyond the natural elasticity of these
bones ; at other times the chest is compressed transversely,
and the tendency of the ribs is to straighten, the pressure
acting in each instance on the very point of fracture. In the
first case, namely, that in which fracture arises from an indi-
rect cause, the fragments are forced outwards, and the resulting
accidents are, in general, unimportant; but this is not the
case in other fractures. We have not only to anticipate injury
to the intercostal artery, but also the lesion of much more
important organs. ‘The principal accidents arising from frac-
tured ribs are—lIst, laceration of the pleura; 2d, injury of the
intercostal artery; and 3d, of the lungs, and consequently
emphysema.
268 TRAUMATIC EMPHYSEMA.

But there are other primary complications which are much
more serious, which are not alluded to by authors, and which
occasion immediate death. The large vessels, the pericardium,
the heart itself, may be extensively injured, of which Cases 3
and 4 offer remarkable examples.

By chance two individuals lately came to the Hétel-Dieu,
suffering in avery different degree from traumatic emphysema.
Fortunately, we have here two analogous cases, which, from
the nature, the diversity, or the violence of the producing
causes, necessarily put on varied forms and characters.

Case I.—Fracture of the ribs by a wheel passing over the
chest. Emphysema.—A. water-carrier, aged 68, was struck on
the 8th December, 1832, by the pole of a wood-dealer’s cart,
and thrown down in a position nearly transverse to the wheel,
which passed over the anterior and left side of his chest.
Though the cart was empty, the weight of the wheel was suffi-
cient to produce the following effects. The man had cough,
great oppression, and frequent, hard pulse. On an attentive
examination of the right side of the thorax I did not detect any
lesion: but on the left side there was great pain towards the
precordial region, which was very sensitive to the touch. On
applying the hand, a manifest sensation of crepitation was per-
ceptible, similar to that occasioned by the rubbing together
of the broken ends of fractured ribs during the respiratory
movements of the thorax. This condition was also perceptible
to the ear, which likewise detected a sound analogous to that
which would arise from the fall of drops of water in rapid suc-
cession. There was also a considerable swelling on the same
side, without the least appearance of inflammation or discolo-
ration of the skin. The swelling yielded to the hand, by
which it could be shifted from place to place ; and this was not
all, for on pressing it in this way,a decided crepitation was
felt, such as occurs when the cellular ti§sue of animals is
inflated for the purpose of skinning them. These were unmis-
takeable signs of fracture of the ribs and of emphysema in this
region ; that is to say, an infiltration of air into the subcutaneous
cellular tissue. The life of the patient, nevertheless, did not
appear to be in danger; the emphysema was inconsiderable ;
hitherto it was confined to the left side of the chest, and there
_TRAUMATIC EMPHYSEMA. 269

was nothing to show that it had invaded the internal organs;
and experience has proved that, when this phenomenon is cir-
cumscribed in extent, and the infiltration of air does not exceed
a few cubic inches, the absorption is accomplished easily in a
short time. Jt is, on the other hand, very serious when the
air has filled not only the whole extent of the cutaneous cellular
tissue, but also that of the internal organs of the thorax, and
even of the abdomen; when there is not only infiltration, but
even extravasation of air into the great cavities of the serous
membranes. This was the case with another patient, of whom
I shall shortly speak. In regard to the one now before us, it is
necessary to take account of the lesions which directly gave rise
to the development of emphysema. I have already stated
what signs indicated fracture of the ribs; and it happened
no doubt that the fragments, pressing upon the pulmonary
organs, lacerated the pleura, and, perhaps, penetrated the air-
vesicles to a greater or less extent; whence arose an organic
lesion of the lungs, and the irruption of air towards the thoracic
parietes. In this case the small quantity of air which escaped
from its natural channels, would lead to the belief that the
laceration was not extensive.

I will now explain the mechanical nature of this infiltration.
When, in consequence of old attacks of pleurisy or pleuro-
pneumonia, organic adhesions are formed between the two
pleure, establishing a continuity of tissue between the parietal
and costal layers and the surface of the chest, it is easy to
understand how emphysema occurs j—the air passing directly
from the interior of the lungs into the newly organized cellular
tissue, and thence into the subcutaneous cellular tissue. When
there are no adhesions, the inspired air escapes partly by the
aperture made at the surface of the lung, and spreads at first
into the surrounding tissues, and into the pleural cavity.
Thence it is forced every way, both by the alternating move-
ments of expansion and contraction in breathing, and by its
natural elasticity; and infiltrates gradually into the cellular
tissue and into all the internal and external organs ; so that,
if the quantity of extravasated air is considerable, it occupies
not only the walls of the thorax and of the abdomen, the upper
and lower extremities, the scrotum, the neck and the head,
but also the pleure, the two mediastina, the pericardium itself,
270 TRAUMATIC EMPHYSEMA.

and even the cellular tissue which unites the various organic
elements which compose the lungs.

The patient in question was at first bled on the day he
entered the hospital; this was repeated on the following
morning. Compresses, saturated in a solution of acetate of
lead in water, were applied to the affected side, and the trunk
was enveloped in a bandage. In making use of the latter, I
sought to suspend the respiratory action of the external muscles,
and to compel the patient to breathe only by the diaphragm ;
with the view of favouring the union of the fractured ribs, as
well as of opposing, as much as possible, the causes of emphy-
sema. I can prove by examples the possibility of breathing
solely by the aid of this internal muscle. Indeed, such must
be the case when all the external muscles are paralysed, in
consequence of a lesion of the upper part of the spinal cord.

Cast II.—Fracture of the ribs by a kick. Emphysema.
Death, Autopsy.—A man, older than the last, and of much
stronger constitution, was felled to the ground in a quarrel;
and his adversary, not content with this, kicked him repeatedly
on the chest, principally with his heel. Several ribs were
fractured, the fragments of which were forcibly pressed inwards,
seriously wounding the lungs: extensive emphysema followed,
which soon spread to the shoulder, then to all the anterior and
posterior regions of the thorax, to the neck, in which the
swelling was considerable even the day after the accident, and
finally to the abdominal region and scrotum. The man was
. otherwise suffering from long-standing asthma, dependent on
disease of the heart,—-a most unfavorable complication in the
case.

So extensive an emphysema is always, in itself, a very serious
affection : the infiltration progresses frightfully ; the atmospheric
air, as I have already shown, rapidly invades the cellular tissue
of the internal organs, and the patients are soon deprived of
the power of respiration. I have seen many die in great agony
from suffocation produced by the above causes. It may, there-
fore, be imagined what is likely to happen when the respiratory
functions are impaired by severe asthma, in addition to emphy-
sema such as occurred in this instance. Patients in such cases
soon die; and I quite despaired of this old man’s life. You will
TRAUMATIC EMPHYSEMA. 271

have observed his deep anxiety, his impotent efforts to articulate
even a few words in answer to questions: at every inspiration
a fresh column of air escaped through the opening of the lung
and aggravated the mischief; not only was there superficial
infiltration, but also extravasation of air into the great cavities ;
the expectoration was tinged with blood, showing severe injury
of the lung; the pulse was small, contracted, and irregular.
Under such circumstances, every effort of art was futile. What
could be done? Could we adopt the same means as were used
in the last case? they would only have hastened his death ;
for it may be conceived that a body-bandage would have in-
creased the agony to the last degree. Incisions of the skin
have been recommended, so as to admit of the escape of the
infiltrated air; and, although I have not the slightest confidence
in this measure, I have tried it on different parts of the body,
principally on the surface of the chest, rather in conformity
with received opinion than in the hope of any good result.
They did no good, and it would be needless to say why. In
the treatment of limited emphysema, circumscribed in extent,
in which there is well-grounded hope of successfully combating
the causes which gave rise to and supported it, and in which,
consequently, the organic lesions are not beyond the resources
of art, it may be imagined that incisions made on the spot
might prevent a more extended infiltration of air, by pro-
viding it with a superficial exit; but in cases analogous to
that I am now relating, the insufficiency of this resource is too
clear to require further demonstration.

The anticipations in the present case were but too correet:
the patient died a few hours afterwards, and the autopsy con-
firmed the previous diagnosis. Externally there was general
tumefaction, without discoloration of the skin, soft, unequal,
easily impressible, and capable of being displaced readily by the
hand, and accompanied by that peculiar crepitation which marks
emphysema. Internally, the great quantity of air in the ante-
rior and posterior mediastina was extraordinary ; and its pre-
sence was likewise detected throughout the whole extent of the
interlobular tissue of the lungs. Three ribs were broken on
the right side, and the corresponding surface of the lung pre
sented an extensive and deep laceration.

In the first case a speedy improvement was manifested. In
272 TRAUMATIC EMPHYSEMA.

six days the patient felt no uneasiness on the side affected ;
the effort of coughing gave no pain; the expectoration bore no
trace of blood ; the infiltration had almost entirely disappeared ;
the pulse was good, the respiration was very little obstructed,
and the appetite returned; the patient rallied speedily, and
was soon afterwards discharged quite cured. ,

It has been seen in these two cases that emphysema bore
an important part; it was the most prominent feature, and was
carried to such an extent, especially in the latter, that it became
of itself a serious disease, independently of the grave lesions
which gave rise to it. In other cases, it appears only as a
secondary symptom, not easily to be recognized. It is neces-
sary, however, to ascertain its existence, not only with a view
of arresting its progress, but also to avail ourselves of it in the
diagnosis of other complications.

Case II1.—Fracture of ribs. Wound of the heart by a
Sragment of rib. Instant death.—Aubin, a carman, aged 23,
of strong constitution, being at the time rather intoxicated,
was caught between the nave of the wheel of his own cart,
and that of another coming in an opposite direction. He
immediately lost all consciousness, and when brought to the
Hotel-Dieu, he showed no signs of life.

Autopsy.—tThere were slight ecchymoses on each side of the
chest, showing that this cavity had been transversely compressed.
On removing the integuments covering the ribs, it was found
that the eighth and ninth were fractured at the union of the
posterior two thirds with the anterior third. There was a
depression at the seat of the fracture. There was nothing
remarkable in the right pleura, the left was filled with a large
quantity of black blood, liquid and mixed with enormous clots.
The diaphragm was pushed downwards ; the lungs were driven
upwards aud inwards. On getting rid of the extravasated
blood, the source of it was sought for. The arch of the aorta,
and the thoracic portion of this vessel, were not touched.

The pericardium presented a slight bluish tint, and con-
tained a little black coagulated blood. On its left side was
an aperture two inches long, directed from above downwards,
and from left to right. The heart was large and firm ; on its
posterior surface there was a transverse wound, one inch and a
TRAUMATIC EMPHYSEMA. 278

half long, penetrating the cavity of the two ventricles, the edges
of which were slightly ecchymosed, as if a transverse incision
had been made after death with a blunt instrument, for the
purpose of examining the cavities of this organ. This wound
corresponded exactly with the aperture in the pericardium.
The costal pleura was lacerated at the level of the eighth and
ninth ribs, and the fragments of the eighth were driven in-
wards. The anterior fragment was sharp and pointed, and
projected considerably into the cavity of the pleura; this
evidently caused the wound in the pericardium. The frag-
ments of the ninth rib were scarcely displaced. The left lung
showed a slight ecchymosis at its base. The air, when intro-
duced into the parenchyma, did not escape at any one point,
nor reveal any wound. The pulmonary tissue crepitated
throughout. There was no laceration of the diaphragm, and
consequently no communication between the thoracic and
abdominal cavities. There was, however, some extravasated
blood in the left hypochondrium, proceeding from the spleen,
which was lacerated transversely at the upper part of its in-
ternal face. This laceration could only be occasioned by a
violent contusion. The liver was pale; the stomach contained
some half-digested food; the mucous membrance was dis-
coloured. All the organs were partially exsanguineous.

Where the sternum is forced in or fractured, accidents
similar to those which arise from fractured ribs may be
observed. The instance which I shall now recite, proves that
the pericardium and the heart itself may be injured; I have,
therefore, thought it right to publish and place side by side,
these two cases. J. L. Petit says, that he opened the body
of a man who had died from a fracture of the sternum, and
that he found the heart compressed and contused by the pres-
sure of the second bone of the sternum; the pericardium was
filled with bloody serum, as well as the cavities of the two
pleure.

Cast I1V.—Fracture of the ribs. Laceration of the pericar-
dium. Superficial wound in the right ventricle of the heart by
a fragment of the fractured sternum. Emphysema. Death on
the twelfth day. Autopsy.—Mahuet, aged 41, of robust con-
stitution, had been squeezed laterally against a wall by the

18
274 TRAUMATIC EMPHYSEMA.

pole of a carriage, and he was brought to the Hétel-Dieu on
the evening of the 9th of July, 1827. His breathing was ex-
tremely short and laboured; on the left side there was no
visible injury ; but the sternum was fractured transversely at
the junction of its superior two thirds with the inferior; and
the upper fragment was rather deeply depressed towards the
mediastinum, On the right side, on a level with the fourth,
fifth and sixth ribs, and at four or five fingers’ breadth from
the sternum, there was a considerable depression, at the bot-
tom of which crepitation could be felt, indicating a fracture of
these bones, and probably of their cartilages also. The finger
could likewise plainly distinguish the projecting extremities of
the external fragments. A little below the seat of these frac-
tures, there was an ecchymosis as large as a five-franc piece.

The features of the patient expressed deep anxiety; his
speech was short and interrupted; pulse frequent, small, and
almost imperceptible; skin cold.

The fingers, when carried in front of the seat of fracture,
detected a crepitation similar to that produced by air travers-
ing the cells of the cellular tissue; but that which was most
worthy of remark was, that, at every inspiration, this tumour
increased considerably, and extended from the inferior part of
the sternum to the seat of the fracture; whilst it diminished,
on the other hand, at every expiration; on a level with the
depression resulting from the fracture of the ribs, the skin rose
and fell alternately in the same manner, but forming a much
more extensive tumour. The slightest pressure detected
emphysematous crepitation, and sufficed to disperse these
tumours. In the inferior two thirds of the right cavity of the
chest, the stethoscope detected a distinct gurgling sound. The
patient was bled, and the chest was enveloped in a moderately
tight bandage.

The patient was at first relieved by this support, as it
diminished the pain from which he was suffering; but on the
fourth day the oppression all at once increased, the cheeks
became flushed, the pulse very quick and hard, but still small.
He was bled again. The patient continued, for ten days,
alternating ; the tumours had disappeared; there was not a
trace of emphysema in any part; but a broad and very black
ecchymosis extended from the base of the chest to the superior
A

TRAUMATIC EMPHYSEMA. 275

external part of the thigh; the breathing became more and
more distressed, and death ensued on the twelfth day.

At the autopsy, some old and very strong adhesions were
discovered between the two pleure; the superior fragment of
the sternum was entangled in the pericardium; the right ven-
tricle of the heart was torn by this fragment through two thirds
of its thickness. There was a large quantity of bloody serum,
and in some parts black blood, almost without any mixture,
in the right pleura; the fourth, fifth, and sixth ribs were frac-
tured, and further, their cartilages were detached from the
sternum. Between them there was a lacerated aperture large
enough to admit a finger easily.

Traumatic EMPHYSEMA oF THE EYELIDS.

The introduction of air into the sub-cutaneous or inter-mus-
cular cellular tissue not only complicates perforated wounds of
the chest, but it may take place in every region near to the
breathing apparatus. Emphysema of the eyelids is not an
uncommon disease ; many authors allude to it, but I have seen
only one case at the Hétel-Dieu in Paris.

Casz V.—Emphysema of the eyelids, in consequence of a sup-
posed fracture of the flat plate of the ethmoid bone, or of the
os unguis.—A terrace-maker, aged 25, was struck by a fall of
earth on the right anterior part of the head, neck, and chest ;
on recovering himself, he felt only a slight pain at the root of
the nose, to which he paid little attention, and continued his
work. About a quarter of an hour afterwards, on trying to
blow his nose, a considerable swelling of the eyelids appeared
all at once on the left side, and it was carried to such an
extent that the eye was completely closed. Let us inquire
into the cause and nature of this swelling. Was it erysipelas ?
The skin, indeed, was bright and stretched as in this affection,
but there was not the bright redness, nor the burning heat
which characterise it; and the eyelids preserved their natural
colour and temperature. Was it ccdema? This does not
form so rapidly, and there was not that doughy feel of the
tissues which is observable in serous infiltration. Was it ex-
276 TRAUMATIC EMPHYSEMA.

travasation of blood? Such an extravasation would have been
recognized by the existence of violet-coloured ecchymosis, and
by the general brown colour, more or less deep, of the eyelids.
These negative signs led me to the ‘belief that the swelling was
produced .by the infiltration of air; and on carefully touching
the affected parts, I ascertained most positively that there
existed emphysematous crepitation, not-only at one point, but
throughout their whole extent. Not wishing to decide entirely
on my own judgment, I begged others to examine the patient,
and they all confirmed my opinion. It would be useless to
demonstrate that this crepitation is the characteristic sign of
the presence of atmospheric air in the cellular tissue of the
swollen part. Whenever, in similar cases, the skin has been
divided by a bistoury, a certain quantity of air has escaped at
the apertures. In the bodies of persons who had died from
serious emphysema, or from the effect of the attendant organic
lesions, the presence of air has been recognized wherever cre-
pitation had been ascertained during life. Having had under
my care a case in which there was positive proof of the exist-
ence of this phenomenon, I was determined, by peculiar cir-
cumstances, to use the bistoury at the swollen parts, and a
pretty large quantity of air instantly followed the incisions:
there was not, therefore, the smallest doubt in that case; but
in the present one, it was to be ascertained how the infiltration
could have been brought about. I imagine that the fall of
earth occasioned great compression of the face, causing the
fracture of the flat plate of the ethmoid or the os unguis, through
which aperture the air passed from the nasal cavities to the
interior of the eyelids. It is strange that the emphysema was
not developed immediately after the accident, but after a cer-
tain lapse of time, on the patient attempting to blow his nose :
but this peculiarity may ‘be explained; for the fracture of the
ethmoid or os unguis was undoubtedly not accompanied by
laceration of the soft parts which cover them, and these
opposed the passage of the air; but afterwards the patient,
in blowing his nose, having driven a column of air against
these parts, they were lacerated, and a communication was
formed between the nasal cavities and the eyelids. I was de-
sirous of knowing if he had, after the accident, passed any
blood from the nose, which had happened in all similar cases
TRAUMATIC EMPHYSEMA. 277

that I had seen; but it appeared from the answers of the pa-
tient, that this did not occur.

The treatment consisted of a general bleeding, and the
application of compresses dipped in a discutient wash to the
base of the orbit. The patient was particularly recommended
not to blow his nose, to avoid coughing, or any other effort
that might renew the passage of air through the supposed
aperture ; by which means I expected he would be well in a
few days. On the third day, the crepitation had very much
diminished ; on the fourth, it was almost imperceptible; and
on the fifth day the eyelids were nearly in their natural state.

The following case is very analogous to the preceding, from
which it is only distinguished by a slight difference in the seat:
of the lesion which caused the emphysema.

Cass VI.—Emphysema of the eyelids, caused by a supposed
rupture of the pituitary membrane.—Another young man re-
ceived a violent blow on the nose, by the fall of a plank, and
it was followed by great pain; but some hours afterwards,
having blown his nose violently, he felt as if a train of fire shot
up from the sides of the nose to the inner angle of the eye,
which spread to both the left eyelids. They became imme-
diately so puffed that the eye was completely closed and light
was intercepted. The patient was received into the Hotel-
Dieu. The eyelids were very rigid and resisting, but the skin
was not discoloured. Emphysematous crepitation was detected.
The same means as in the last case effected a cure in four or
five days. I considered that the blow had caused laceration.
of the pituitary membrane, opposite the upper border of the
alar cartilage of the nose, which was detached from the inferior
edge of the nasal bones.

EMPHYSEMA OF THE TEMPORAL REGION, ARISING FROM
FRACTURE OF THE FRONTAL SINUS,

Emphysema may occur at the most elevated parts.of the
respiratory channels, from causes far more serious than the
preceding. The following is an example.

A man fell on the anterior part of his forehead. Some
time afterwards a rather large tumour was formed in the tem-
278 TRAUMATIC EMPHYSEMA.

poral region. Its character appeared obscure ; but on compres-
sing it lightly, I found that it moved to the anterior part of
the forehead and disappeared entirely. It proceeded from air
passing into the surrounding tissue from the frontal sinus,
which was fractured and laid open beneath the skin.

It would be easy to multiply examples of traumatic em-
physema resulting from punctured wounds of the chest; or
from a ¢ommunication of another kind, occasioned by external
violence, with other portions of the air passages. But the cases
already reported, and the considerations for which they served
as a text, appear sufficient to give an exact idea of this singular
affection, so as to make known the basis of the diagnosis, as
well as the appropriate treatment. It only remains to add a
few words relative to the infiltration of air into the highest
points of the respiratory apparatus.

Besides the so-called emphysematous crepitation and the
negative signs already indicated, it may be observed that when-
ever the patient is desired to blow his nose, to ascertain the
nature of the complaint, the swelling of the eyelids or other parts
affected increases considerably. Ifthe case be one in which
the patient is in a state of complete unconsciousness, on pinch-
ing his nose, an instantaneous increase of the swelling is ap-
parent ; which is occasioned by the column of expired air being
obstructed at its natural outlet of the nostrils, and finding vent
by the new channel accidentally formed. In every case of em-
physema of the eyelids, the development is extremely rapid,
arising no doubt from the great laxity of the cellular tissue
contained in them.

The prognosis of traumatic emphysema is in general serious ;
in two of the preceding cases it terminated fatally. It is of
course more dangerous when the circulating centre and the
pulmonary system are injured; in which case the patient is a
prey to extreme agitation ; the suffocation and convulsive move-
ments are at times very violent, and asphyxia soon follows.

The treatment should be energetic. In the first case it was
seen that the emphysema yielded quickly to bleeding, discu-
tients, and a body bandage; and you must have recourse to
these remedies in most cases. When there is great difficulty
in breathing, the chest must be relieved from the extravasated
air, and a passage must be made for that which is infiltrated
TRAUMATIC EMPHYSEMA. 279

into the cellular tissue. An incision is then made on the spot
over the fracture ; and when the balance is well established, the
air has no longer any tendency to insinuate itself beneath the
skin. When the infiltration is very extensive, it is sometimes
necessary to scarify the body in various parts. This advice is
good when the air introduced into the cellular tissue spreads
quickly over the whole body, and life is threatened ; but it is
not equally sound when the emphysema is limited. Ambroise
Paré, Hunter, and Sabatier cite cases where deep incisions
saved the patients; but these extravasations of air more fre-
quently disperse of themselves by absorption. Dry or aromatic
fomentations, compression, repose, proper diet, and mild drinks,
are auxiliary measures which ought not to be neglected,
Before closing this subject, I may remark that there is
another species of traumatic emphysema occasioned by the bite
of some insects, and especially of some reptiles. And I may
add that traumatic emphysema is sometimes voluntary. Dr.
Jacquemin and I have seen several examples amongst prisoners,
who, to feign having a painful swelling of the face, pricked the
inside of the mouth with a needle, and by firmly closing the
nostrils and lips, forced the air from the lungs through the little
wound into the cellular tissue. The cheek becomes, in such
cases, enormously distended by emphysema, and the eyelids
swell, presenting a shining appearance; so that an inattentive
medical observer, or one not well acquainted with such tricks,
might be imposed on. Other persons, to excite pity, perform
the voluntary operation by forcing the air through a small tube
introduced into a puncture.
SECTION VIII.

ON NERVOUS DELIRIUM.

An operation is skilfully performed ; the assistants applaud
the dexterity of the surgeon, and yet the most serious accidents
may threaten the life of the patient: sometimes violent inflam-
mation appears in the limb subjected to operation, or in some
internal organ, and carries off the patient at the very moment
when success seemed certain; sometimes there is purulent
absorption, which is ushered in by chills and febrile disturbance,
the cause of which is almost always beyond the resources of
art; again, the troubled state of the irritated nervous system
is indicated by painful spasms, which frequently degenerate
into fatal tetanus; or lastly the brain, being excited by pain,
by fear, or even by joy, the conceptions of the mind cease to
have any connexion with surrounding objects, and the patient
loses his reason at the very moment when he most requires it.
To these last-named accidents I wish now to direct attention.
Obscure in its origin, variable in its progress, and frightful in
its symptoms, nervous delirium is nevertheless rarely fatal,
when met in time by proper remedies.

No author, that I am aware of, has taken any notice of this
form of delirium. Celsus, Paré, Dionis, and numbers of others
since them, who have written on surgery, have not noticed it.
Books have furnished me only the following example.

A woman, aged 28, cut her throat, in consequence of being
suspected of participating in a robbery committed in her master’s
house. The wound, somewhat superficial, had opened the
larynx at the cricoid cartilage. The patient was robust, which
promoted cicatrization ; but her imagination was so excited, that
she was seized with violent delirium, which continued for ten
days, without fever or inflammatory symptoms; it yielded to
soothing remedies. The wound could not be dressed during
this time, and forty days elapsed before it cicatrized.

Many surgeons, it is true, give accounts of patients who
NERVOUS DELIRIUM. 281

delighted in tearing open their wounds, and thus destroyed
themselves ; but none have considered the cause, or have ever
dreamt of applying other means than force to cure this species
of insanity. In treating persons otherwise healthy, these means
might suffice; left to itself, the only effect it would have would
be more or less to exhaust the patient, according to its duration
and intensity ; but in almost every case, this affection is com-
plicated with wounds which require the greatest care and ab-
solute quiet. How can the most simple fracture be cured under
constant movement ? What dressing can be applied to a wound
which is unceasingly irritated by continual agitation? How
can we expect an union of parts, which can take place only by
constantly keeping them at rest, as where callus has to be de-
posited near to joints? What grievous results might arise
from pain and inflammation, especially if the injured part were
near to animportant viscus? The danger is still greater after
a serious operation, such as cutting for stone, amputation, or
removal of a cancer; and I have more than once seen nervous
delirium supervene in these cases. ‘Trifling shocks may pro-
duce hemorrhage; and, even if stopped, it might immediately
recur, and endanger the success of the operation.

Before entering on the considerations which these questions
suggest, I will cite several examples of this unfortunate com-
plication occurring with wounds or operations, so that a more
accurate idea may be formed respecting it.

Casz I.—Eztensive sarcocele. Operation, followed by
nervous delirium,.—-C: , a trader, aged 25, of lymphatic
temperament and low nervous power, was operated upon in
June, 1817, for a large sarcocele. Impressed with fear of
hemorrhage, he was in a constant state of disquietude during
the day following the operation, and this aggravated an
indocility which was natural to him. On the following day,
the agitation increased; he was distressed by a movement, a
gesture, or a word ; the slightest impression redoubled his fears.
His general condition was, notwithstanding, satisfactory; but
he soon began to complain of pains in the limbs and the chest ;
his eyes became animated, he breathed hurriedly ; he asked for
food, and would get up. His mind wandered, he repelled his
attendants, and called out for his family, whom he had left far

 
282 NERVOUS DELIRIUM.

away. His whole body was in motion. His cries, his brilliant
eyes, the immovable pupil, his face covered with sweat, and his
pulse quiet and regular in the midst of this disturbance, assured
me that this was nervous delirium. The patient complained
of very severe pains in the chest; but a most careful examina-
tion did not detect any lesion. I prescribed what I have
usually administered so successfully in such cases; namely, an
injection containing six drops of laudanum, which was given
at once. Some friends who were about him were sent away,
and he was left quite alone. An hour afterwards he ceased
talking, and fell into a sleep from which he did not awake till
the next day ; and then the delirium had ceased. In twenty-
five days he was completely cured.

Casz II.—WNervous delirium following fracture of a rib—
Langlois, a mason, aged 26, came to the Hétel-Dieu, in the
month of May, with a fractured rib, which was occasioned by
a fall from a first story. His chest was tightly enveloped in a
body-bandage, to prevent any motion of the thorax, which was
requisite for the cure. The facility with which such fractures
unite, was the reason why little attention was paid to him;
but, on the third day, he was seized with delirium without
intermission. He was agitated in a thousand ways; all his
muscles were in a state of constant tension, the eyes bright,
the skin covered with sweat; but the pulse alone was quiet.
He fancied he saw figures dancing in the air, that experiments
were being performed on his bed, and that all the patients in
the ward were undergoing the same ordeal. This idea
disturbed him excessively ; he was fearful of the effects, and
hesitated whether he should remain or get away. This man,
who was of sanguine temperament, was at once bled, which
had no quieting effect; an injection, containing ten drops of
laudanum, was then administered, which produced a slight
amendment. On the following day the dose was doubled,
without any greater improvement. His cries disturbed those
around him; and as he was, on the other hand, disturbed by
the continual movement in the ward, he was removed to a
place where he was alone. The dose of laudanum was increased
to forty drops, and then this treatment took effect, and the
delirium ceased.
NERVOUS DELIRIUM, 283

You may readily conceive the serious consequences of such
continued disturbance to a patient whose case specially required
rest and quiet. The pleura, irritated by the rough edges of the
fractured rib, became inflamed, and the lungs were affected ; a
cough, and expectoration tinged with blood, showed that we
had to deal with severe peripneumonia, which was the more
serious, inasmuch as the exciting cause was incessantly aggra-
vated by fits of coughing. He was bled, and had soothing
drinks. He appeared to be cured; but convalescence was
far from complete; his countenance became pale, and his
strength did not return. He coughed often, felt oppressed
and feverish, and when he left the hospital, after remaining
there two months, he had every appearance of being the
subject of chronic pneumonia.

Case II].—Atitempted suicide. Nervous delirium.—Vin-
cent, aged 32, Chasseur in the 3d Regt. of Guards, of bilious
nervous habit, being embroiled in a dispute, determined to
destroy himself. He got drunk on the 18th of April, 1817,
entered the Church of Nétre-Dame, and there cut his throat.
He was immediately brought to the Hétel-Dieu. The skin
was divided from one angle of the jaw to the other ; anteriorly
some of the muscles were cut, and the instrument had pene-
trated into the pharynx between the os hyoides and the thyroid
cartilage, The wound was dressed, and he was watched. On
the second day he was seized with delirium, which had no
special character, but which was likely very much to retard
recovery. He was confined in a strait-waistcoat, and he
had a soothing draught with half an ounce of syrup of poppies,
which had but little effect. At length he came to himself;
but the efforts he had made for 24 hours were attended with
mischievous consequences. He felt a smarting and a sensa-
tion of strangulation, and was besides tormented by a violent
cough, accompanied by purulent expectoration. On the fourth
day, the wound had an unfavorable appearance; and on the
seventh day delirium returned, which was successfully com-
bated by the same means, These and some other accidents
were very critical, but the man recovered after 50 days’
treatment.
284 NERVOUS DELIRIUM.

Casz IV.—Attempted suicide. Nervous delirium.—Le N—,
aged 35, a hair-dresser, Rue St. Antoine, having in a short
time dissipated a considerable sum of money which he had
amassed with great labour, became excessively despondent,
The loss of his place increased this feeling of depression, and in
a moment of despair he wounded himself in seven places with a
pair of scissors. Three of the wounds appeared to be deeper
than the rest. Brought to the Hétel-Dieu, he was imme-
diately bled, and had administered a soothing draught, contain-
ing laudanum, which did not lessen the delirium. On the
second day he was again bled without any good effect; he
fancied that he was pursued by police-officers, and tried to
escape ; it was found necessary to tie him down. In spite of
this agitation, the pulse was not quick, the tongue'was clean,
the body covered by abundant moisture, and the appetite was
good; but he would not eat, as he was constantly pursued by
the idea of the police. For two days he remained in the same
state, though he was again bled twice, and took antispasmodics,
On the fifth day he was ordered two injections, each contain-
ing ten drops of laudanum; and these had scarcely been
administered when the delirium abated; and with the aid of
injections it entirely ceased in six days. A fortnight after-
wards he was again brought to the Hoétel-Dieu for a fresh
attempt at suicide, and the wounds he had inflicted with the
scissors were so numerous that they looked like the punctures
made in scarifying. The nervous delirium having again shown
itself, he was treated and cured by administering laudanum in
injections.

Casze V.—Cataract. Operation by keratonyxis. Nervous
delirium.—Marianne R—, at the age of 58 years, found her
sight getting weaker, and at 61 she could no longer distinguish
between light and darkness. When received into the Hétel-
Dieu, the crystalline lenses were completely opaque. All the
conditions being favorable, the operation by keratonyxis was
performed, after 14 days of preparatory treatment, as usual.
In the course of the day she had frequent vomiting, which
subsided by the next day, under the influence of antispasmodic
draughts. On the third day there was cephalalgia and scald-
ing tears; foot-baths and two injections were ordered. On
NERVOUS DELIRIUM. 285

the succeeding days intense inflammation of the eyes and eye-
lids supervened. A portion of the cataract rose at the back
of the right pupil, and formed an opaque half-moon, The.
left pupil took a square form, and behind it were seen portions
of the crystalline lens and of its membrane of a bright red
colour; other portions of the same bodies were in the anterior
chamber; the patient could not see, and suffered extreme
pain ; a seton was introduced into the nape of the neck.

During the night of the fifteenth day, intense nervous deli-
rium came on, and it was found necessary to put on a strait-
waistcoat. On the following day the patient recognized her
attendants, but complained of some imaginary ill-treatment
she had received, and answered questions incoherently: anti-
spasmodics were ordered, and mustard plasters to the legs; no
improvement. On the seventeenth day, an injection with eight
drops of laudanum; drowsiness towards evening. On the
eighteenth, fresh delirium: injection with ten drops of lauda-
num. On the nineteenth day the delirium ceased, and did
not return.

Here terminates what relates to our present subject ; but I
may add that, after various accidents to the organs of sight,
the patient left the hospital in a most satisfactory state.

Case V1.—Fracture of the inferior extremity of the fibula,
and of the internal malleolus. Nervous delirium.n—M—, aged
54, when very drunk, was descending a step seven or eight
inches high, in doing which he placed his foot in such a manner
that one-half was on the step and the other half over its edge ;
he fell on his left side, and was unable to rise. He was con-
veyed to the Hétel-Dieu, where the surgeon on duty recog-
nized all the symptoms of a fracture of the inferior extremity
of the fibula, with rupture of the internal malleolus at its base.
The common splint for fractures of the leg was at first applied :
there was great pain, and swelling round the joint. On the
following day, I applied my own apparatus and evaporating
lotions.

On the third day, the pain subsided, and the swelling dimi-
nished. On the fourth, violent delirium supervened, which
made it necessary to use a strait-waistcoat : an injection with
8 to 10 drops of laudanum was administered. On the follow-
286 NERVOUS DELIRIUM.

.

ing day the delirium had ceased, and the remedies were dis-
continued. On the sixth day it returned, and continued till
the eighth, but yielded at length entirely to repeated injec-
tions. This complication in no way retarded the cure of the
fracture, notwithstanding the involuntary movements of the
patient. In thirty-six days the consolidation of the fracture
was perfect, and the limb was not in the least deformed.

Caszt VII.—Comminuted fracture of theleg. Nervous deli-
rium. Death. Autopsy.—On the 5th of December, 1831, a
man was brought to the Hétel-Dieu, who had been engaged in
a quarrel, and had his leg fractured. The limb exhibited great
deformity ; the superior fragment had lacerated the soft parts,
and made a triangular aperture through the skin. The frac-
ture was reduced, but during the whole night the patient
screamed frightfully. On the following day, he appeared to be
in a sort of intoxication, and during the dressing he never
ceased, crying out. I considered this want of courage or
excessive sensibility of the patient a very bad symptom, from
which serious consequences often arise. He was bled three
times successively. On the succeeding day he appeared a little
better, but on the third day he had delirium, and his ideas
were incoherent and confused. It was the day on which the
relatives of patients are admitted to visit them; and it fre-
quently happens on such occasions that they have some improper
food, or receive some disagreeable news ; at least it often hap-
pens that their condition is worse during the succeeding even-
ing and night. The change that took place in the general
state of the patient in question may have arisen from one of
these causes. It was ascertained that he was deeply engaged
in some affair of interest, and had been in great trouble;
indeed, he was continually repeating, during his delirium, that
his remaining in the hospital would ruin him. He was ordered
to have leeches, a soothing draught, and an injection of assa-
foetida. All these measures were unavailing, and on the morn-
ing of the 9th, the patient died.

The death of this man raised several important questions.
Had he fallen a victim to one of those internal inflammations
which are often indicated only by fever or delirium? Or had
he died from the consequences of the fracture, or from a lesion
NERVOUS DELIRIUM. 287

involving the nervous system? Further, it was required by
the ministers of justice to solve this question, namely, whether
the fracture was occasioned by the patient falling during the
quarrel in which he was engaged, or directly caused by kicks
on the leg,

At the autopsy, which took place the next day, I observed
that it was very difficult to conceive how such a fracture could
be produced by the man falling simply from an erect position ;
that, under the actual circumstances, this was not probable,
and, if not absolutely impossible, at least it required concurrent
facts to prove it, which we were unacquainted with. On the
other hand, such a fracture might result from a variety of
causes, such as a fall from a first story, a wheel passing over
the limb, &. It may be imagined, then, that there was great
difficulty in deciding by what means this had been caused. An
examination of the fractured limb showed that the parts had
been violently crushed; the tibia was broken into several
pieces, the fibula was fractured, and the soft parts were con-
tused and lacerated: the left pleura contained a quantity of .
blood: the brain was healthy.

These particular facts naturally lead me to the consideration
of this complication of fractures and operations with nervous
delirium, which cannot be considered altogether as traumatic
delirium.

Up to a certain point the diagnosis of this form of delirium
may be established according to the nature or duration of the
operation, the character, moral energy, and physical condition
of the patient; but there are certain indications which precede
it with greater certainty.

If the patient, during the evening or the day or two suc-"
ceeding any fracture, dislocation, attempted suicide, or opera-
tion, should show symptoms of unnatural cheerfulness; if he
talks much; if his eyes are bright, his speech short, his move-
ments sudden and involuntary; if he affects a courage and
resolution now no longer necessary, be upon your guard ; keep
the patient perfectly quiet; keep him from light, from noise,
and from all intrusive visitors. You may, perhaps, succeed in
keeping down the nervous excitement; but in spite of all these
precautions the disorder may break out. Amongst persons
under most favorable circumstances, it shows itself more fre-
288 NERVOUS DELIRIUM.

quently in a sudden and unexpected manner by gestures, by
extravagant and unmeaning movements, and by incoherent
remarks, in which a singular confusion of ideas prevails as to
places, persons, and things. A prey to sleeplessness, they are
usually possessed of some fixed idea, almost always having
reference to their profession, their passions, their tastes, age
or sex. They are continually throwing themselves about ; the
upper parts of the body are covered with sweat; the eyes
become bright and injected, the face animated and suffused ;
and they give vent, with extraordinary loquacity, to menaces
and fearful clamour. Their insensibility is often so great, that
individuals with comminuted fractures of the lower extremities
have been known to tear off their splints, and attempt to walk
on their crushed limbs without manifesting the slightest suf-
fering. Others, with fractured ribs, have moved and sung
without apparent pain; whilst some, who had been operated
upon for hernia, have introduced their fingers into the wound,
and coolly handed their intestines as if they belonged to a
. dead body. This was the case with a rich old man on whom
I operated for strangulated hernia in 1812, He was in bed,
and so quiet that every one was congratulating himself on the
success of the operation; when, on examination, it proved that
he had removed the dressings, and seemed to be taking a
savage pleasure in tearing his own intestines, which he had
drawn out of the wound made at the operation. He died, a
victim to this horrid mania, from the consequences of very
acute peritonitis.

Notwithstanding the gravity of these symptoms, the pulse
is tranquil and calm, showing no alteration, except such as is
produced by the movements of the body; there is no fever;
the excremental functions proceed with regularity ; but there
is no appetite; and in five or six days the disorder generally
terminates either by death, or more frequently by a complete
cure. If the latter happily take place, tranquillity is re-
established, without any apparent crisis, as suddenly as the
disorder commenced. Worn out by fatigue, the patients fall
into a sound and quiet sleep, and, in ten or fifteen hours at
the most, they wake up with their reasoning powers quite re-
stored, not remembering anything that has passed, but weak and
sensible to pain: the appetite returns, the primary disease
NERVOUS DELIRIUM. 289

takes its course, and everything goes on in an ordinary manner.
The delirium may return two or three times, after one or more
days’ remission, but always more feebly at each relapse.

The most decisive sign is the calm circulation and the ab-
sence of all febrile symptoms, in the midst of this mental
disturbance. You see a patient furious, and quite out of his
mind, the sweat running down his face, with sparkling eyes,
and screaming loudly; and you would fancy he was in a
violent rage. Examine his pulse; it is quiet and regular, and
the state of the skin leaves no suspicion of inflammatory action.
It is true mania, and differing only in its duration, which
seldom exceeds five or six days.

Nervous, faint-hearted: persons, and those whose brain is
affected by some strong and deep-seated resolution, are the
most liable to this delirium. Thus, it is frequent in cases of
attempted suicide, so much so, indeed, that some persons have
thought it peculiar to them. Athletic individuals are not
exempt from it, and it may take place without reference to age,
sex or habit. It is consecutive to dislocations and fractures,
reduced or unreduced, well or ill managed; to hernias, to
wounds, to operations of every kind, and generally to nearly
every kind of surgical disease; and at any period, during in-
flammation, suppuration, cicatrization, &c.; in a word, to
diseases and consequences of operations so perfectly different,
that it is impossible to assign any single cause for it. It
cannot, for example, be attributed exclusively to traumatic
affections, for we have seen it without them; nor to inflamma-
tion, for it exists where there is none; nor to the accidents
attending this process, for it comes on when this is going on
in the most regular manner; neither can it be attributed to
the formation, abundance, absence, or suppression of suppura-
tion; for, in most cases, these processes go on with the same
regularity before, during, and after its subsidence. Women
are less subject to it than men, and it has never been known
to occur in children.

Nervous delirium may become very dangerous in itself. I
remember a young man who suffered from it, in consequence
of a simple excoriation of the great toe, and who died in eight
and forty hours, the original malady not having, apparently,
contributed in any way to his death. In the great majority

19
290 NERVOUS DELIRIUM.

of cases, however, I consider the extent of the delirium to bear
a proportion to the gravity of the diseases which give rise to
it. Thus a fatal termination is much more to be apprehended
when delirium follows a fracture of the limbs or the chest, or
after severe wounds in the neck, than in simple wounds which
are not in themselves of a dangerous character. Examination
of the bodies after death does not give evidence, either in the
cerebro-spinal centre, or in any other organ, of any lesion
explanatory of the disorders that had occurred, or of the cause
of death.

After much reflection on the cause of this delirium, I am
unable to give any good account of it; but the following is
the result of my observations: In every individual there exists
an amount of moral force, analogous in many respects to the
physical power, equally susceptible of being increased, dimi-
nished, excited, or even destroyed by the imagination alone,
and exhausting itself by pain, as the latter is exhausted by
loss of blood. The fear of an operation, which is always worse
in imagination than in reality, the sight of the necessary in-
struments and apparatus, a peculiar nervous susceptibility, and
that state of excitement which leads to suicide, are so many
causes which act the more surely in proportion as the pain
has been small and the apprehension more acute.

A person undergoing an operation without losing a drop of
blood, would be much more liable to inflammatory action than
one who has lost a moderate quantity. It is necessary, if I
may so express myself, that the power should not be greater
than the resistance, in order that the equilibrium be main-
tained. To apply these considerations morally: when the
excitement has not been restored to its natural tone by pro-
longed endurance, when the imagination has, as it were, been
cheated, and no longer finds its counterpoise in physical
energy; this excess of activity flies to the brain, whence it
emanated, reacts upon it, and induces nervous delirium.

It would be absurd, on this principle, to pretend that pain
ought not to be regarded, and that no notice should be taken
of a patient’s cries; but it may be understood, on these
grounds, why the most brilliant operations, those which occupy
. the shortest time, are not always the most successful.

It may not be without interest to say a few words here
DELIRIUM TREMENS. 291

respecting delirium tremens, which so much resembles nervous
delirium. Indeed, a very little observation will show, that
patients suffering from either generally have the same current
of ideas. A carman, a mason, or a carpenter, attacked by
nervous delirium, is evidently impressed with ideas relating to
his business. Some time ago, says Dr. Ramon, I saw a carman
who was crushed by his own cart, whilst drunk; even when
under the restraint of a strait-waistcoat, the patient was con-
tinually urging on his horses by words and oaths; at one
moment he fancied he was going into a public house, and
called for something to drink; then he called to his comrades,
chatted with them, and asked them for help; in fact, he was
always a carman. This same persistance of ideas frequently
occurs with those who are affected with delirium tremens from
drunkenness; which will be placed beyond doubt by a rapid
sketch of the symptoms of this form of mental aberration. The
first period is characterised by unusual agitation, anxiety, and
sleeplessness ; by want of appetite, nausea, and even vomiting,
to which great drinkers are generally subject. The patient has
. hallucinations of sight, hearing, and touch; he is, however, able
to convince himself that the objects he refers to are imaginary ;
he considers himself seriously ill. Little by little he believes
in the reality of the fantastic images which are passing before
his eyes.

This delirium frequently assumes a character of gaiety. The
patient laughs heartily at his own jokes; he talks, gesticulates,
and busies himself unceasingly with some imaginary work,
At times these conceptions relate to his ordinary occupations,
and at times they refer to obstacles which are always coming
in his way. The extraordinary exertion he uses appears to
account for the sweat which exudes from his whole body. The
tongue is usually tolerably clean; the patients have scarcely
any fever, and seldom suffer from thirst. In fortunate cases,
after from one to seven or eight days, the patient feels a
disposition to sleep, which at length he indulges. Restless at
first, he falls at last into a sound sleep, and wakes in perfect
health. The trembling is not considered, by most authors, as
a constant and pathognomonic symptom; I have not alluded
to it, nevertheless it exists in a great many cases.

Post-mortem examinations have not shown any appreciable
292 DELIRIUM TREMENS.

lesions. In general there may exist a mere trace of vascular
injection, which also occurs in many other diseases. Very
often, however, the brain and membranes are in their normal
condition,

We may conclude, then, from this account, that there is a
great similitude between these two species of delirium, both
in regard to their symptoms and their anatomical lesions.
Particular cases, also, establish a similar analogy. Delirium
tremens, like nervous delirium, is successfully treated by
laudanum. It has been pretended that the disuse of spirituous
liquors, bleeding, and water, would cure delirium, without the
necessity of using opium; which may be true under certain
-circumstances; but I have seen so many cases treated suc-
cessfully by opium, as to lead me to place reliance on its
powerful influence.

Soothing medicine of every kind, and under every form,
bleeding, even to syncope, and every other means that I have
seen employed, or employed myself during a long practice,
have always appeared to me to be inefficacious in this disease,
neither stopping its progress nor diminishing its gravity.
Narcotics, or the liquid laudanum of Sydenham, produce no
favorable effect when taken into the stomach. This want of
action is easily explained physiologically. The stomach, whose
duty it is to elaborate the first elements of nutrition, is endowed
with digestive power, and contains juices which, more or less,
change the nature of the substances with which they come in
contact ; many medicines taken into the stomach are ineffective,
because they are mixed with the food: this is the reason why
many, especially of the vegetable kind, are so uncertain, very
often producing uo effect whatever.

The uselessness of many of these agents, and a knowledge
of the modifying power exercised by the stomach on medicines,
led me to use other means, which have invariably succeeded,
and to which I attribute a sort of. specific power. They are
simple and energetic, consisting of a few drops of laudanum
administered in an injection. Five or six drops, in a small
enema, produce a greater effect than three times the quantity
introduced into the stomach. The reason of this I have
explained ; but it may be added that the rectum, appointed
to receive the residuum of digestion, absorbs, and does not
DELIRIUM TREMENS. 293

digest ; and it may be conceived that remedies so administered,
when not expelled, must reach their destination more directly.
These injections should be repeated two, three, or four times,
at intervals of six hours; and, when retained, they will subdue
the most furious delirium. One precaution is essentially
necessary, namely, to empty the bowels previously, by means
of a common enema.
SECTION IX.
ON ABSCESS OF THE RIGHT ILIAC FOSSA.

I observed, some time ago, that tumours were developed
in the right iliac fossa, which appeared to be intimately con-
nected with the walls of the cecum. These tumours are often
attended by remarkable disturbance in the functions of the
large intestine. In a great many cases they terminate by
dispersion, and in others by abundant suppuration ; sometimes
they are the foci of inflammation extending to the whole
surface of the peritoneum. In all these different points of
view, they ought to be carefully studied.

One of the first questions which naturally suggests itself is
this: Why are they almost always formed in the right iliac
fossa? Why is the left fossa so seldom attacked? No reason
can be given except the form of the intestine and the sur-
rounding parts. Immersed in a mass of cellular tissue, the
cecum, at its junction with the small intestines, presents such
a marked contraction, that, in this spot (the ileo-czcal valve)
we frequently find collections of foreign bodies, which may
sometimes be themselves the cause of these abscesses. In the
same way splinters, fish-bones, pins, &c., are collected at the
pylorus, and in the lower extremity of the rectum.

The relations and arrangements are not the same on the
left side; the sigmoid portion of the colon does not present
any contraction at either extremity, and the division of the
intestine here is quite conventional. In explaining the different
courses which these abscesses take, when existing on the right
or the left side, it is necessary to remember the anatomical
arrangement of the parts; and it will be seen that, on the
right, the cecum, free from peritoneal covering behind, offers
less resistance to the pressure of the pus, and that its thin,
wasted, ulcerated parietes must readily give way. On the
other hand, on the left side, being hermetically enclosed in the
peritoneum, and guarded by this membrane, as well as by the
ABSCESS OF THE RIGHT ILIAC FOSSA. 295

aponeurotic expansion over the iliacus muscle, the pus cannot
reach the intestine without raising up the meso-colon.

A readier exit is offered towards the crural arch and the
inguinal ring; and, in this case, there is some difficulty in
distinguishing this form of suppuration from hernia and other
abscesses. I may add that, in this part of the intestines, the
alimentary matter assumes an excrementitious character, and
is forced onward against the laws of gravity ; in many diseases,
also, this portion of the intestinal canal is frequently the seat
of inflammatory attacks. Now all these natural or morbid
influences are quite sufficient to account for the production of
congestion outside the intestine, and for its frequency in the
right iliac fossa.

The appearance of these tumours is often preceded by
precursory symptoms,—such as constipation or diarrhea, or
colic, habitual or otherwise; at other times, without any of
these premonitory symptoms, the patient has violent colic and
pains in the bowels, which tend to a concentration in the right
iliac fossa ; they may also take the course of the large intestine,
or spread over the whole of the abdomen. These attacks of
colic are generally accompanied by constipation, and more
rarely by vomiting. Such are the indications of the first
appearance of the tumour. The duration of these premonitory
symptoms is very various: some persons have them for six or
eight weeks, or even more, whilst others experience them only
for a few days before inflammation takes place. It will be
understood, of course, that these symptoms are only of relative
importance, as they frequently occur in persons without any
tumour forming.

The distinguishing symptoms of the disease are, the per-
sistence of the pain at some particular part of the iliac fossa,
and a swelling at this point. On feeling this part, it is found
to offer resistance and to be in a state of tension; and a
tumour may very often be detected, of considerable hardness,
more sensitive to the touch than any other part of the
abdomen, and appearing to rest on the cecum. The patient
complains of constipation, colic, and difficulty in voiding gas
from the bowel. At times there is a great deal of fever, but
more commonly, where there is no complication of diseases, no
serious general symptoms are observed. Fever and inappetency
296 ABSCESS OF THE

are due to gastric affections, as also may be constipation and
diarrhoea ; or these may proceed from the greater or less size
of the tumour.

The predisposing causes are of different kinds; but adult
age has an undoubted influence. Of sixteen patients whose
cases have been recorded, eleven were under 30 years of age ;
therefore more than two thirds are at an age when gastric
disorders are most frequent. The constitution does not appear
to have any influence, but the sex does, as the records of the
Hétel-Dieu show that men are much more subject to this
affection than women. It is difficult, no doubt, to account
for this ; but it is the case, not only in hospitals where the males
predominate, but also in private practice, where generally the
reverse is the case. It very rarely occurs either in children
or old people. The season does not seem to exercise any very
direct influence on the appearance of these tumours; but they
more generally occur towards the end of summer or begin-
ning of autumn, when abdominal disturbances are most fre-
quent; and this would tend to support the opinion of those
who believe in the pre-existence of some lesion of the mucous
membrane,

The occasional causes are both numerous and important.
And first, the profession has proved in many cases a direct
cause, by producing a lesion in the digestive canal, and, con-
sequently, in the cellular tissue of the right iliac fossa, House-
painters, colour-grinders, and brass-turners, who are constantly
exposed to the dust and emanations from irritating metals,
have experienced colics and diarrhcea, which, after a time, have
led to the formation of the tumour we are considering. Many
students have also been affected in the same manner, after
great disturbance in the digestive functions.

The place of habitation is not unimportant; as I have seen
many persons whose sufferings were due to their residence in
Paris, after having been there but a short time. It is easy to
conceive all that may happen to a person on his first arrival
from the country. The food of the poor workmen, especially
in summer, is so bad, that a large proportion of those who
come to the hospitals with serious intestinal disorders, owe
them to the food they are compelled to eat. Now all the
causes which produce irritation of the mucous membrane, have
RIGHT ILIAC FOSSA. 297

a tendency also to produce inflammation of the iliac fossa.
Drink will also give rise to the same disorders, and the reports
of cases prove that most of the patients have been in the habit
of taking alcoholic liquors, rendered irritating by the admix-
ture of acrid infusions; whilst many others have taken purga-
tive medicines in immoderate doses.

The progress and termination of these tumours is not always
the same; the most fortunate and most common issue is by
dispersion. M. Méniére has given a report of sixteen cases of
abscess of the right iliac fossa, eleven of which dispersed under
the influence of proper medical treatment. This dispersion is
generally a slow process, and a hardness remains for a long
time afterwards, indicating the seat of the original disease.

In other cases, painful pulsations are frequently felt in the
inside of the tumours, which grow, soften, and end by opening
into the intestine. This result is known by a pressing desire
to go to stool, which is followed by purulent alvine evacua-
tions, coinciding with the decrease of the tumour. The re-
covery is usually very rapid. These abscesses do not end only
in the evacuation of the purulent matter by the cecum;
they sometimes open into the bladder or the vagina; and,
again, they may discharge by an external opening, as happened
in the case of M. Malus, to whom I was called in by M. Nac-
quart.

Casz I.—Perforation of the cecal appendix, with an external
communication, by a fistulous wound, with the right iliac fossa.
—M. Malus, inspector at reviews, aged 45, of short stature
and indifferent health, was subject to rather frequent and pro-
longed catarrhal affections. In 1812 he was seized with ex-
tremely acute pains in the iliac region, accompanied by a rather
large tumour, sensible to the slightest pressure; he was suffer-
ing also from obstinate constipation, abdominal distension, and
fever.

This disorder, which was referred to an affection of the
cecum, with consecutive fecal obstruction, was treated with
diluents, by long-continued baths, topical emollients, and a
very spare diet. The pain and the fever gave way, but the
evacuations did not resume their course. The constipation
was then gradually overcome by purgative injections, and more
298 ABSCESS OF THE

especially by the continued use of infusion of senna, the result
of which was that an enormous quantity of feces came away.

Sulphurous douche baths, horse exercise, ass’s milk, and a
strict regimen completed his recovery, or rather very materially
improved his general health.

These favorable conditions continued till early in February,
1815, when he was attacked by a pulmonary affection, with
expectoration, at first bloody, afterwards rust-coloured. He
recovered from this, and had even resumed his usual occupa-
tions, when he had a return of the pain in the ileo-czecal region
to a violent extent; there was a tense tumour of considerable
size and exquisite sensibility; constipation as before. The
treatment was repeated; baths, acidulated drinks, with gum,
and castor oil in small doses. The patient was unable to bear
the weight of the smallest plaster.

There was but little change up to the 13th of March; not-
withstanding the evacuation of fecal matter, the tumour did not
decrease to any extent; and this, combined with the nature of
the evacuations, led to the belief that the tumour was seated
outside the intestine.

The inflammatory condition became more and more decided,
the tumour was hard, lobulated and uneven; it projected into
the iliac fossa, and was five or six inches in size in each direc-
tion. M. Jacquemin and myself detected deep-seated fluc-
tuation on the 14th of March. I made an oblique puncture,
from which flowed a rather large quantity of reddish pus, of
little consistence and fetid odour; the relief was instan-
taneous.

The fistulous wound continued to discharge a rather large
quantity of pus; the patient became gradually weaker, and
expectoration continued abundant. Three fresh openings, a
short distance from the first, were successively made, commu-
nicating with the great sac: the pus was thin.

He remained nearly in the same condition till the end of
the winter of 1816. The chest then became worse, the ex-
pectoration more abundant and decidedly puriform, and there
was infiltration of the lower extremities. I should not omit
to state here, that it had been observed on several occasions,
when the wounds ceased to suppurate, that diarrhoea came on,
and that this disappeared again as soon as the fistulous open-
RIGHT ILIAC FOSSA. 299

ings resumed their discharge of pus, which, moreover, was
inconsiderable.

At length, on the 15th April, the patient, having been ex-
posed to a current of cold air, experienced pain over the whole
abdomen, accompanied by fever, and expired on the 22nd, of
acute peritonitis.

The autopsy, which took place on the following day, pre-
sented the undermentioned results.

The body was completely discoloured, and to the highest
degree emaciated ; the extremities were cedematous ; the thorax
was resonant at almost every part; the abdomen was but little
distended.

A widely spread purulent collection occupied the whole
summit of the right lung. The remainder of this viscus, as
also the left, were healthy and crepitant.

The peritoneum contained about three pints of reddish
serum, with flakes of soft and discoloured fibrin ; a similar ex-
udation united a greater part of the convolutions of the intes-
tines, the surface of which was rather injected.

That part which had been the seat of the tumour was care-
fully examined: the skin thin, and denuded to the extent of
nearly two inches in diameter, was perforated by four apertures,
which communicated with each other, and opened together
into an empty cavity or sac, situated between the muscular
fibres of the abdominal parietes and the external surface of
the peritoneum ; a portion of the cecum adhered to this sac,
and the cecal appendix opened into it. This circumscribed
disorganization, however, gave but an imperfect idea of the
form and size of the tumour; it was a sort of cloaca, in which
the appendix was expanded and blended with the parietes of
the sac, to which it was attached by a rather compact cellular
tissue. The cellular tissue of the iliac fossa was healthy, as well
as the colon and the cecum ; it may be said, indeed, that near
the intestinal fistula, the whole mass seemed to be in a fair
way of doing well.

Notwithstanding the evident communication between the
interior of the intestinal canal and the wound, by means of
the appendix, no pus was ever noticed in the stools; nor was
any fecal matter ever detected, either by the smell or colour,
in the discharge from the wounds,
300 ABSCESS OF THE

The course which the disease took in this case has always
proved unfortunate, for the base of the abscess and its lowest
part, resting on the iliac fossa, whilst the aperture is in front
and towards the highest point, the evacuation of the purulent
matter can take place but slowly and incompletely ; hence that
spreading of the pus in various directions ; further, the aperture
admits air, which decomposes the purulent matter. I would
recommend, in such cases, that the patient should lie on his
belly, so that the opening of the abscess should be the lowest
part.

Inflammation and the diseases of the cecal appendix, of
which I have seen a great many cases, have scarcely been
noticed by authors; but Dr. Melier, one of my pupils, has
written an excellent work on the subject.

A remarkable fact. connected with these abscesses is that
the purulent matter may discharge itself into the intestine,
without the fecal matter finding its way into the cavity of the
abscess. For this, three reasons may be adduced. First,
these abscesses empty themselves gradually, and the abdominal
pressure, which is constantly in action, prevents the existence
of an empty space into which fecal matter might be introduced.
The second has reference to the obliquity of the aperture; and
the third to the detached relation of the intestine, which per-
forms the office of a valve.

Finally, under certain circumstances, which happily are of
rare occurrence, the inflammation extends rapidly. from the
iliac fossa to the peritoneum, sometimes also to the peritoneal
sub-cellular tissue. It is probable indeed, in some cases, that
the inflammation, having attacked the peritoneum primarily
but locally, is merely propagated from the iliac fossa to the
rest of this membrane. This is a cause for considerable
uneasiness, as death may result from such an extension of the
disease.

With these preliminary remarks, I now proceed to cite some
cases in illustration of my views.

Case I].—Tumour in the right iliac fossa. External aper-
ture. Death. Autopsy—A young man, aged twenty-three,
fair, not robust, of scrofulous appearance, and working hard,
experienced various symptoms, in December, 1828, of entero-
RIGHT ILIAC FOSSA. 30]

colitis, which were at first left to themselves, and afterwards
treated by purgatives ; but the patient would not submit to any
regimen. A phlegmonous tumour then appeared in the right
iliac fossa, which was treated by topical emollients. The
patient came to the Hétel-Dieu when the abscess was on the
point of bursting; the skin was immediately opened at the
back of the iliac crest, towards the insertion of the quadratus
lumborum, at the spot where a sense of fluctuation was felt,
corresponding with that of the anterior tumour. The bistoury
was plunged in to a great depth, and an abundant flow of pus
followed. Although the sloping position of the wound should
have prevented the pus from stagnating in the cavity of the

abscess, it did not empty itself completely, and the tumor
situated inside the crural arch continued to enlarge. A
counter-aperture was made, but the increased discharge did not
bring any relief. The patient grew weaker; the right thigh
became infiltrated, diarrhoea came on, with hectic fever, and
he died, after suffering for five months.

On opening the body, a large purulent sac was found, situa-
ted in the cellular tissue surrounding the cecum, with burrow-
ing channels following the direction of the psoas and iliac
muscles, In some parts the bone itself was denuded. The
cecum did not communicate with this mass, but at the back
part it was evidently attenuated; its mucous membrane was
thickened, of a slate colour, and softer than in its natural state.
There was chronic pleurisy, and hepatization commencing in
the inferior lobes of the lungs. All the other organs were free
from disease.

Cast III.—Inflammation in the right iliac fossa, Large
abscess opening into the intestine. Recovery.—A young man,
aged twenty-five, of good strong constitution, had experienced
dull colic pains for three weeks, especially after eating, when he
was exposed to rain for an entire day, and found himself much
worse. At length he felt a rather violent pain in the right
iliac fossa, and came to the Hétel-Dieu on the 24th of October,
1825. He appeared to suffer from pain, tension, and swelling
in the right iliac fossa, the rest of the abdomen being supple
and insensible ; he had dull colic pains, frequent, but of short
duration, during which the patient appeared to suffer acutely ;
802 ABSCESS OF THE

the pulse was, however, nearly in its natural state, as well as
the temperature of the skin; the urine was passed freely, but
the bowels were confined; the tongue was moist, and the
appetite small. He was bled, and thirty leeches were applied
on the painful part ; a low diet was prescribed.

On the following day, the attacks of colic were less frequent
and less acute, but the pain on pressure, the tension and swelling
in the right iliac fossa continued. Sixty leeches were applied
to the same spot.

On the 26th, violent colic, returning in paroxysms and
tending to the seat of the inflammation ; constipation, difficulty
in voiding gas from the bowel; extension of the swelling in the
right iliac fossa ; slight acceleration of the pulse, without febrile
heat or alteration of countenance. The patient was again bled,
and twenty more leeches were applied on the same spot; a
purgative injection was administered.

On the 27th, the congestion increased, and had the appear-
ance of a hemispherical tumour in the iliac fossa, extending from
the iliac crest to the pubis and umbilicus; painful pulsation
internally, and great pain on pressure, continued constipation.
No serious general symptoms were observable. Ordered a
hip bath ; syrup of buckthorn and castor oil, of each one ounce.

28th.—The swelling of the iliac fossa seemed larger to the
eye, and passed beyond the median line of the belly, forming
a sort of hard circumscribed globe, like the uterus at the seventh
month of pregnancy; the protuberance was the more apparent,
as the rest of the abdomen was flat, as in its natural state;
fluctuation was obscurely felt in the interior. The patient had
frequent desire to go to stool, but without any result. Two
drachms of sulphate of soda were ordered. Light diet, bath,
and poultice,

29th and 30th.—Four copious stools, attended with great
relief; no change in the swelling ; no general symptoms mani-
fested themselves,

On the succeeding days the swelling of the abdomen
diminished sensibly, and withdrew little by little towards the
right iliac fossa, where it had originated. The patient said at
the same time that, during the last three days, he had observed
something of a whitish colour in his motions. They were imme-
diately inspected (6th of November), and one motion was found
RIGHT ILIAC FOSSA. 803

to consist entirely of white purulent matter, thick, and in large
quantity. It was then apparent that the decrease of the tumour
took place from the time these motions commenced. The
tumour was now confined to the iliac fossa; it was harder,
and more sensitive on pressure than at first, and was scarcely
larger than the fist.

Until the 14th of November, the motions, which were abun-
dant, contained a mixture of purulent and feculent matter ; the
swelling continued to diminish.

Finally, on the 20th of November, the patient quitted the
hospital; he was quite well, and was able to bear a half ration
of food without indigestion ; the motions no longer contained
purulent matter, but a deep-seated induration could still be
felt in the iliac fossa.

A few days afterwards he came to the hospital again, with
symptoms of dysentery brought on by bad food, and too much
of it. Proper diet and anodynes completely restored him.

In reviewing the symptoms in this case, in the order in which
they occurred, we find that dull, frequent and transient at-
tacks of colic preceded and accompanied the inflammatory
swelling in the right iliac fossa; that, at a later period, this
swelling was converted rapidly into a large abscess, to which
the inflammation was confined, without extending to the peri-
toneum, as occurred in the previous cases; and that the puru-
lent motions coincided with, and betokened, the discharge from
the abscess into the intestine. |

From these data it appears clearly that the seat of the disease
was without the cavity of the peritoneum ; for acute inflamma-
tion of this membrane is commonly accompanied by general
symptoms, of which there were none in this case. The con-
gestion seems to have arisen, and the purulent collection to
have been formed, in the cellular tissue which covers the right
iliac fossa, and envelopes the cecum posteriorly. The colic,
constipation, and difficulty in voiding gas from the bowel, were
probably dependant on the pressure of the tumour on the cecum,
on the interruption of the peristaltic motion, and perhaps on
the irritation and spasm of this portion of the intestinal canal,
surrounded as it was by inflammation.

The evacuation of the purulent matter into the intestine,
proved that the cavity containing it was deeply seated, and in
804. ABSCESS OF THE

contact with the parietes of this hollow viscus. Had it been
nearer to the skin, it would have discharged itself externally ;
but, being opposed in front by the abdominal parietes, it found
an easier channel of discharge in the céecum, which was de-
prived of its serous envelope at the spot where the purulent
collection was formed; hence, again, the obstacles to the per-
foration of the intestine were diminished.

However that may be, this favorable termination is an
example of the resources of nature, in cases where art is usually
much more uncertain in its results.

Cast IV.—Philegmonous tumour of the right iliac fossa.
Fistulous openings, Discharge of feculent matter. Recovery A
young man, a tailor, aged 24, came to the Hétel-Dieu, in 1829,
having in the right iliac region several fistulous openings, from
which escaped pus, and afterwards feculent matter. The
primary disease, for which he had been under treatment at the
hospital at Orleans, was a phlegmonous tumour, at first neglected
by the patient, and afterwards treated by emollient local ap-
plications. He had discharged pus in his motions; and his
health had been partially re-established. He came to Paris to
complete his recovery ; but he found that his illness increased,
the swelling augmented, and abscesses opened above the crural
arch. These were accompanied by considerable emaciation,
cough, diarrhoea, and cedema of the lower extremities ; so that
after he came to the Hétel-Dieu, he was several times at the
point of death.

At length, after some months’ treatment, this patient’s
general health improved; he became convalescent, and quitted
the hospital, after having a great many douche and other
baths.

Cast V.—Inflammatory swelling in the right iliac fossa, end-
ing in an abscess opening into the cecum. A young man, aged
20, came to the Hatel-Dieu, on the 6th of September, 1827,
with the following symptoms, which he had felt for a fortnight;
—frequent desire to go to stool, simulating the tenesmus of
dysentery, but without the discharge of fecal matter or intestinal
gas; transient colic accompanied by borborygma and pains in
the bowels ; pain with circumscribed swelling in the right iliac
RIGHT ILIAC FOSSA. 305

fossa, but without fever or general disorder. At first he had
nausea, and afterwards scalding and difficulty in passing his
ure. These symptoms had arisen without any special cause ;
the patient was not subject to constipation, and had not been
guilty of any excess; he had merely had diarrhcea for two days
before the disease appeared. He was bled before he came to
the hospital, and thirty leeches had been applied to the iliac
region,

On the day he entered the Hétel-Dieu, the patient had a
copious purulent motion. On the 17th and 18th, he had several
bloody evacuations of the same kind; on the 29th there was
still some pus mixed with portions of feculent matter ; the iliac
tumour had in great measure disappeared ; the motions began to
assume their natural character ; the colic had ceased; and the
fourteenth day after the bursting of the abscess, the patient was
convalescent.

The conclusions to be drawn from the seat, the symptoms,
and the termination, of the disease in these cases are, that they
are true inflammatory swellings in the neighbourhood of the
cecum, occurring external to the cavity of the peritoneum, but
capable of involving this membrane in the inflammation.

The diagnosis of these tumours, and phlegmonous abscesses,
seems to be sufficiently important to deserve some consideration.

It is not uncommon to see in the right or left iliac fossa,
inflammatory swellings, which, to all appearances, have the
same seat as those we have been considering ; but which really
have their origin in the cellular tissue uniting the fibres of the
psoas and iliac muscles, and below the aponeurosis which has
been named the fascia iliaca. This is a variety of the disease’
called by authors psoitis.

Cass VI.—Abscess in the substance of the psoas and iliac
muscles. Retraction of the thigh on the pelvis. Death in con-
sequence of ulceration of the colon. Autopsy.—A woman, aged
45, exhausted by long-continued diarrhoea, was brought to
the Hétel-Dieu, on the 15th October, 1825. She was found
to be in a most deplorable state, and reduced to the last degree
of emaciation. On examining her, 1 discovered a tumour in
the left iliac fossa, large, painful to the touch, and extending
from the bend of the groin to the lumbar region; the thigh

20
806 ABSCESS OF THE

on the same side was half bent, and could not be straightened
without great pain; the purging was abundant, the motions
fluid and very fetid. The patient had not quitted her bed for
four months, and sores had formed on the sacrum; she died
very soon. On opening the body, besides a great number of
ulcerated spots in the colon, we found a purulent sac with
greyish parietes lined with a condensed cellular tissue, situated
in the thick part of the left psoas and iliac muscles; this took
its course along the lumbar region of the spine, and penetrated
to the upper and inner part of the thigh, taking the direction
of the tendons of the above-mentioned muscles. The muscles
were softened and, as it were, dissected by the suppuration ;
there was no alteration in the bones, nor in the fibro-cartilage
of the vertebral column ; and the pus was secreted at the very
spot where the purulent sac existed.

After child-birth, we often see congestions in one or other
of the iliac fosse ; but they appear in the thick part of the
round ligaments, following their direction; or they arise in
the cellular tissue interposed between the broad ligaments of
the uterus, whence they may extend to the whole of the neigh-
bouring cellular tissue, and protrude into the iliac fossee. Some-
times these abscesses open into the womb ; in other cases they
penetrate through the parietes of the vagina. I have seen
several cases of this kind, and have foreseen this termination ;
and, under some circumstances, I have been enabled to fore-
stal it by an operation.

Less frequently the pus is discharged through the bladder.

Case VII.—Immense collection of purulent matter after child-
birth, occupying the pelvis, the left iliac fossa, and the upper
part of the thigh, opening spontaneously into the bladder, and
giving rise, for twelve days, to a large evacuation of pus with the
urine. Complete recovery—A young woman, a servant, aged
28, was received into the Hétel-Dieu, on the 6th of July, 1819,
and placed in a medical ward, where she was delivered of her
first child. Until then she had enjoyed good health, and her
pregnancy had given rise to no illness; but a few days after
her delivery, she had a shivering fit followed. by heat and
fever, and complained of swelling of the left leg and thigh.
Soon after, she felt pains at the bottom of the pelvis; and
RIGHT ILIAC FOSSA. 307

they became constant and so violent that the patient was pre-
vented from sleeping. These pains were accompanied by oc-
casional shivering fits alternating with fever, by excessive
thirst, obstinate: constipation, and complete retention of urine.
A thickening was detected in the left iliac fossa, and a hard
tumour could be felt, without fluctuation, which was supposed
to be déveloped in the ovary of the same side.

Bleeding, baths, poultices, and emollient drinks were tried
without success; the pain and fever continued, and to the
constipation succeeded purging, which reduced the patient:
to a state of extreme debility. She was then removed to a
surgical ward, (14th of October), when she was in that wasting
condition which usually is the precursor of death. The face
emaciated, pale, and yellowish, having the appearance.of long
suffering ; eyes dull and hollow, skin dry and cadaverous, voice
feeble and languid, continued fever, increasing towards evening,
and copious diarrhoea. Moreover, there was a broad, fluctua-
ting swelling in the left iliac fossa, seeming to raise up the
erural arch, accompanied by oedema and retraction of the thigh,
the movement of which was painful, and extension impracti-
cable. Poultices were applied, and astringent drinks prescribed.

On the fifth day the patient discharged from the bladder
such a quantity of purulent matter, that it exceeded the quan-
tity of urine that was passed with it. This evacuation continued
for twelve days, during which time the swelling in the iliac
fossa diminished, and at length disappeared, the pains and
diarrhoea ceased, the fever decreased, and the appetite returned.
A short time after, a point of fluctuation was observed above
and in front of the left thigh. JI opened it, and a large
quantity of pus was discharged; this soon assumed a serous
character, which usually precedes the adhesion of the parietes
of an abscess ; the wound healed, and the patient left the hos-
pital perfectly recovered, forty-five days after her admission to
the surgical ward.

We rarely meet with such immense sacs of matter, and still
more rarely see them terminate so favorably. The cellular
tissue near the bladder and the rectum appears to have been
the seat of this abscess, whence arose the constipation and
dysuria which happened at the same time.

The cellular tissue of the left iliac fossa also took part in the
308 ABSCESS OF THE

suppurative process, and by degrees this suppuration extended
behind the crural arch to the upper part of the thigh. To this
extension of the disease we must refer the presence in the iliac
fossa of the hard and afterwards fluctuating tumour, also the
retraction of the thigh on the pelvis, and the cedema of this
part of the limb.

The long retention of the pus within the tumour was followed
by hectic fever, which brought the patient to the verge of the
grave, when suddenly the urine became purulent : this plentiful
evacuation was coincident with the subsidence of the tumour,
the decrease of the fever, and the cessation of the other
symptoms. Thus the parietes of the bladder were perforated,
and by this channel the purulent matter found exit with the
urine ; an extraordinary event, and the more so as showing the
efforts of nature under the most desperate circumstances.

In some cases the iliac fossa may contain purulent collections,
the source of which may be in a distant part; such are
symptomatic abscesses, accompanying caries of the bones or in-
flammation of the neighbouring ligaments. The pus then
burrows along the course of the psoas and iliac muscles ; it is
deposited in a fluid form in the iliac fossa, and the tumour to
which it gives rise is soft and fluctuating from the first ; a cir-
cumstance which will sufficiently distinguish the latter from
the tumours previously described.

Errors of diagnosis may occur. Thus I have known this
inflammation mistaken for internal strangulation, and for
hepatitis, as happened with young B—-—, to whom I was
called in by the late J. Ray; also for metritis, or peritonitis,
as I witnessed in the case of Madame B—-—, of Pontoise. In
these two cases, the precise circumscription of the disease to
the right iliac fossa, the retention of fecal matter, and a just
appreciation of the other symptoms which were present, retrieved
the error ; and the evacuation of the pus, almost at the moment
predicted, confirmed the correctness of the diagnosis.

The prognosis generally is not very serious, for out of six-
teen very different cases, one only proved fatal. When the
symptoms give way quickly to the means used, when the bowels
act freely, when the fever disappears and the tumour diminishes,
a speedy recovery may be looked for. On the other hand,
when the symptoms continue, when the gradually increasing
RIGHT ILIAC FOSSA. 309

tumour becomes the seat of fluctuation, at first obscure but gra-
dually becoming more perceptible, and of throbbing and shooting
pains, it may be expected that the pus will be voided by the
anus. And in these cases the prognosis is not unfavorable ;
for it has been shown by experience that recovery is as complete
as when the disease ends in dispersion. It is probable that in
this case a mucous conduit is formed, which, in its organization,
progress and termination, is very similar to the artificial mucous
canals which I have described in speaking of the symptomatic
abscesses which accompany caries of the vertebral column. If
general peritonitis supervene, a fatal termination may be appre-
hended, because the development of this disease is a sign of
the rapid increase of the primary affection ; and the two united
are heyond the resources of art.

The treatment should be at first conservative, and when
called in at an early stage, it is generally practicable, if not to
prevent the formation of the tumour, at least to stop its pro-
gress. When pain in the iliac region is accompanied by
alternations of diarrhoea and constipation, when you can
detect by the touch a deep and ill-defined swelling, the
symptoms will generally yield to local bleeding, emollients,
and gentle laxatives, in the form of drinks or injections.
Absolute rest, frequent and long-continued baths, will be
efficacious, and a spare diet is indispensable. If the tumour
should already have attained some size, it must be prevented
from increasing by local and general bleeding. With a robust
patient, if the febrile action be strong, bleeding at the arm
may be practised at once; then a great number of leeches
may be applied in front of the tumour, which may afterwards
be covered by a large poultice; emollient injections should be
administered morning and evening, and the patient should
take veal broth with sulphate of soda or magnesia. Oily juleps
should be taken during the night. The leeches should be
repeated as often as the state of the pulse, the strength of the
patient, and the amount of inflammation in the tumour, seem
to require them.

When the diminution of pain and the decrease of the
tumour testify to the dispersion having commenced, it should
be encouraged by emollient applications, rest, and regimen,

If the tumour, on the contrary, retain its size and sensibility,
310 ABSCESS OF THE RIGHT ILIAC FOSSA.

notwithstanding all appliances, fluctuation will soon be mani-
fest, and afterwards become more distinct. Absorption should
then be encouraged, continuing the antiphlogistic treatment if
the state of the patient will admit of it; otherwise, applying
topical emollients, until the bursting of the abscess. Some
patients have then found relief from the use of laxatives, which
gently stimulate the action of the bowels, and encourage the
evacuation of the pus. If peritoneal inflammation appear
likely to ensue, the necessary means must be adopted to
combat it.
SECTION X.

ON CENTRAL LACERATION OF THE PERINEUM DURING
PARTURITION, AND THE BIRTH OF THE CHILD BY
THE RENT.

Laceration of the posterior commissure of the vulva,
extending more or less into the perineum, is a very common
accident in child-birth. It is a very simple lesion, which
seldom requires surgical assistance. But it sometimes extends
to the inferior extremity of the posterior wall of the vagina,
and the whole length of the perineum, including the sphincter
ani, and the anus itself partially ; it may then be considered
as amongst the most serious surgical cases, on the treatment
of which I may take another opportunity of enlarging. On
the present occasion, I shall confine my observations to central
perforation or laceration of the. perineum, without injury to
the commissure of the vulva or the sphincter ani; and the
birth of the child by this accidental opening.

There are accounts of many cases; nevertheless, certain
writers, whose opinion in obstetrics is of high authority,
consider a birth of this kind to be mechanically impossible,
from the disproportion between the dimensions of the perinzeum
and the size of a full-grown child ; and, therefore, they infer that
the cases reported are imaginary, and undeserving of any
confidence. It is, indeed, difficult to conceive, at first sight,
how a part, not usually exceeding eighteen lines in extent,
can be so far stretched as to admit of the passage of a child.
But such reasoning is almost an insult to nature; for daily
occurrences come under our observation, of which the causes
and mechanical details are totally beyond our comprehension.
If facts can be proved, the ways and means by which they
are brought about are but a secondary object, though, at the
same time, they should not be neglected. One case, of recent
occurrence, and of which an account will be given, can leave
no doubt in the minds of the most sceptical, and will corroborate
312 LACERATION OF THE PERINEUM

previous records on which some doubts have been thrown. The
earliest case known did not occur in a woman, but was witnessed,
by the immortal Harvey, in a white mare belonging to the
Queen of England, which had been rung to prevent her being
covered bya horse. But, in spite of this precaution, or because
it was taken too late, the mare was impregnated; and the foal,
being unable to escape by the vulva, was expelled through the
perineum.

In 1778, Nédey, a surgeon of Besancon, sent’ to the
Academy of Surgery a case, in which a full-grown child had
passed through a ruptured perineum, without lacerating the
commissure or the sphincter ani. This case, which excited
the astonishment of the Academy, would be doubted, says
Baudeloque, only by those who are ignorant of the state of
distension which the perinzum is capable of at the period of
child-birth.

The following is an extract of the well-known case of
Coutouly. This eminent accoucheur was sent for, on the
13th January, 1788, to attend Madame de Ja Luizerne, aged
25 or 26, whom he had attended the year before, when she
gave birth to twins at five months and a half of pregnancy.
This woman, says Coutouly, was in strong labour, and the
head of the child pressed against the perineum, which was so
much distended, that my whole aim was to prevent its lacera-
tion. But every precaution was useless; the central part of
the perinzeum gave way; and the head being pressed violently
against my hand, I was compelled to allow it to pass through ©
the opening; the body followed, and, immediately afterwards,
the placenta. I then sought to ascertain exactly what had
happened. An inch above the anus, towards the centre of
the perineum, there was a torn aperture, from which two
lacerations extended,—one, following the direction of the
raphe, had stopped at a short distance from the vulva, and
the other deviated to the right, forming a wound not unlike
the letter Y. Neither the sphincter ani, the rectum, nor the
posterior commissure had been injured. The wound healed up
in the course of five weeks.

Thomas Denman, in his ‘ Introduction to the Practice of Mid-
wifery,’ cites a case of rupture of the perinzeum similar to the
last, in which the, child passed through the perineum contiguous
DURING PARTURITION. 313

to the anus, the latter as well as the front of the perineum re-
maining uninjured. The parts were united in six weeks, and
the same woman was brought to bed afterwards without any
accident.

On the 14th of December, 1812, Dr, Joubert, of Rouen, was
called in, at six o’clock in the evening, to a lady, aged 23, who
had reached the ninth month of her first pregnancy. The head
of the child was presented in one of the three last positions.
The labour was slow, and the -delivery did not take place till
the evening of the 15th, by the rupture of the centre of the
perineum, which was distended to the extent of at least five
inches. The after-birth also came away through the wound.
It healed in five weeks. This woman became pregnant a
second time, and was brought to bed naturally three years after-
wards, without the slightest accident. (‘ Journal de la Société
médicale d’Emulation ’).

Meckel, in the ‘ Neues Journal fir die Chirurgie, &c.,’ vol. iv,
1811, has reported a case of central laceration of the perineum,
and parturition by this aperture, without injury to the vulva or
the sphincter ani. It was the woman’s first child, and the
wound healed quickly. Gravis and Lebrun, in the Annals de
la Médecine physiologique, for July, 1825, have given a case of
parturition by the perineum, without injury to the vulva or the
sphincter ani. In 1822, Dr. Merriman attended woman at a
first birth. The labour proceeded quickly, and the perineum
was excessively distended by the head of the foetus. He sup-
ported it with the palm of his left hand; when he suddenly
felt something slip past his hand: it was the foetus, which had
been expelled through a lacerated opening. The placenta was
brought away a few seconds afterwards by the natural passage.
The anus and the posterior commissure of the vulva were not
injured. The mother got well, and was afterwards confined
without any accident (‘ Synopsis,’ &c., 4th edition, 1826).

An account of a similar case has hon given by Dr. John
Douglas in the ‘ Dublin Hospital Reports,’ &c., vol. iii, 1822.
He was called to a woman in labour, and found the child on
the point of passing through a laceration of the perineum, the
head resting against the side of the left thigh, and inclined
backwards. A strong uterine contraction sufficed to expel the
remainder of the body. The perforation comprised the lateral
314 LACERATION OF THE PERINZUM

portion of the perineum, part of the integuments of the left
thigh, and the corresponding labium : the lower commissure was
not divided. The umbilical cord was withdrawn by the vulva,
but the placenta came away through the wound. It was found
necessary to cut through the stricture formed by the posterior
commissure of the natural outlet, as it became gangrenous.
The recovery took place readily.

On the 21st of May, 1824, Marter, a surgeon of Kénigsberg,
was hastily called toa woman, aged 25, in her first labour. The
midwife told him that the child was passing by the rectum;
and it appeared indeed, at first sight, as if the anterior wall of
the rectum, and the posterior wall of the vagina, had been
torn at the same time as the perineum, and that the feetus was
about to be expelled through the opening. The vertex presented
at this abnormal opening; it was useless to attempt to return
it into the vagina. The child was expelled through the wound
after a few strong contractions, without any injury to the
vulva; the after-birth followed soon afterwards by the same
opening. After the delivery was finished, Marter found that
the anus and the sphincter ani were also uninjured. The
rupture commenced immediately in front of the anus, extend-
ing in the direction of the raphe to within an inch of the
vulva. Corresponding with this was the rupture of the pos-
terior wall of the vagina, which also terminated in front an
inch behind the vulva. In the middle of the perineum there
were also two transverse lacerations, so that the wound was
of a crucial form. There was about an inch of skin remain-
ing between the posterior commissure of the vulva and the
anterior extremity of the longitudinal rupture of the perinzeum.

Considerable hemorrhage took place shortly after the de-
livery, which was soon stopped by cold applications. But the
perineum became the seat of a considerable inflammation and
swelling, which it required a fortnight to reduce. On the
sixteenth day a suture was applied, so as to keep together the
four angles of the wound. Union did not take place for a long
time, and the woman was afflicted with a vagino-perinzal fistula,
by which the menses passed for two years. In 1827, she was de-
livered again very quickly, and in the natural way. (‘Rust’s Maga-
zine, &c.,vol. xxvi, 1828 ; and ‘Siebold’s Journal fur Geburtshulfe,’
vol. ix, 1839).
DURING PARTURITION. 315

In the following case, extracted from Moschener’s work
(‘Conspectus partuum in Lechodochio pragensi, &c.,’ Prague,1826),
and which will also be found in the above-mentioned volume
of Siebold’s Journal, the child came away through the perineum,
after gangrene had taken place in consequence of great and
prolonged distension, the vulva being at the same time very
narrow. In 1823, a woman aged 35, pregnant for the second
time, came to the lying-in hospital at Prague. The liquor
amnii had been escaping for six hours, and the pains, which
were very severe at the beginning, had ceased for half an hour;
when the top of the head of the foetus was found to be lodged
in the vulva, which was rounded and very narrow. The perinzum,
very much distended and pressed down, was attacked with
gangrene from the anus to its centre. There was a communi-
cation between the rectum and the posterior part of the vagina,
and by introducing the finger into the rectum, it just touched
the face of the foetus. The lower commissure had been lacerated
two years previously at the first accouchement, and presented
a hard, resisting cicatrix, which was ascertained by Professor
Jungmann to be the principal obstacle to the present delivery.
He determined on seizing the head with the forceps, incising
the cicatrix, and extracting the child by the dilated vulva;
but he had scarcely introduced one blade of the instrument,
when there was a large discharge of sanious fetid pus; the
contractions came on again immediately, and the head made its
way through the sloughing perineum ; the body soon followed,
and the after-birth eight minutes afterwards. In two months
the patient was sufficiently recovered to be able to quit the hos-
pital; but it is not stated in what condition the injured parts
were at that time.

There is also a case in ‘Der neue Chiron, vol. i, 1822,
published at Sulzbach, in which Dr. Franck gives an account
of a perforation of the perinzeum behind the posterior com-
missure of the vulva, through which the left arm of the foetus
made its way; the head came by the vagina, and the child
was at last extracted by the vulva. This case is merely
mentioned owing to its peculiarity, but it proves nothing on
the point in question. It may be well, however, to report the
principal details of a case which occurred in the private practice
of M. Evrat. This case was published in the ‘ Revue Medicale,’
316 LACERATION OF THE PERINEUM

June, 1880, and formed part of a memoir read at the Academy
of Medicine by M. Moreau, who attended the patient from the
period of the accident until her complete recovery.

Case I.—Fourth position of the head. Central laceration
of the perineum. Recovery—Mme. D , aged 19, living
at Paris, having arrived at her full time in her first pregnancy,
sent for M. Evrat, on the 3d of March, 1815. The presentation
was in the fourth position of the head, which came down into
the pelvic cavity without much trouble; but when it was on
the point of passing through the lower strait, there was some
obstacle which prevented it from getting below the arch of
the pubes.

During a very strong pain, M. Evrat thought he felt the
perineum, against which he held his hand, sensibly give way
before the pressure of the child’s head. Whilst thinking what
was best to be done, a violeut pain expelled the child through
a laceration of the perineum, leaving the commissure of the
vulva and the orifice of the anus uninjured. The irregular
wound resulting from this perforation extended to the right,
in the direction of the ascending ramus of the ischium and
the descending ramus of the pubes. It passed, in front,
rather beyond the posterior commissure of the vulva; and
behind, a little round the anus, and then transversely, from
right to left, between the anus and the vulva, to near the
tuberosity of the ischium on the left side. The placenta
came away soon after, by the same opening. On passing
the finger into the anus, it was ascertained that it was not
injured.

M. Evrat, being obliged to go to England, M. Moreau, with
Professor Désormaux, had charge of the patient until she had
quite recovered. The treatment was very simple. The patient
was ordered to lie on her side, with the legs and thighs close
together, and half bent; the wound was dressed with lint,
and she was kept on‘a spare diet; the bowels were kept open
by means of injections and gentle purgatives, for fear the
passage of any hard matter should interfere with the healing
of the wound, or burst it open again. She pursued this
course with great attention, and in five weeks she was quite
well, and the wound was completely healed.

 
DURING PARTURITION. 317

This lady has since had a second child without any accident,
except a slight laceration at the posterior commissure, which
very often happens in first deliveries.

No one can, I think, dispute the truth of the foregoing
statement ; but I will give an analogous case, which occurred
recently under my own observation, and which is not less
conclusive; I will then proceed to the practical considerations
on the causes and treatment of such accidents.

Case II.—First position of the head. Central laceration of
the perineum. Suture of the wound. Rupture. Recovery.—
Mrs. B , aged 38, of middling height and well formed,
had been married about a year, and, being pregnant for the
first time, she felt the pains of labour on the morning of
3d of September, 1832. The child’s head was presented in the
first position; and the labour proceeded quickly till the head
appeared at the vulva, which was very narrow. Four hours
after the labour commenced the patient had two very violent
pains, and the midwife felt the perinzum, which she was
supporting, give way. Nearly at the same moment, the head
and body of the foetus passed through this abnormal opening.
It may be added that the patient was placed immediately
opposite a window, therefore the sexual parts were clearly
seen, and the midwife was able to give a good account of what
happened. The umbilical cord being tied and cut, she gave
the child to an attendant, and proceeded to complete the
delivery. The umbilical cord was hanging between the lips of
the wound, and the placenta was engaged in the same aperture,
by which it was also brought away; there was no hemorrhage.
The child was of middling size, and is now alive and well.

In her first fright, the midwife sent for an accoucheur ; but,
perceiving that her patient was going on well, and was not
aware of the accident, she told the doctor that it was all over,
and did not say anything about the laceration.

All went on well for two days, but an injection which she
administered having come away immediately, she was fearful
that the anus was lacerated; and she even fancied that part
of the injection returned through the wound. She felt obliged
to confess what had happened; but some days passed without
any fresh occurrence. The child was sent to nurse.

 
318 LACERATION OF THE PERINEUM

On the tenth day, M. Guersent, jun. was consulted. He
first tried astringent lotions, and touched the parts with
caustic; and at length, on the twelfth day, he brought the
edges together with a twisted suture; the bights of the thread
were held by two ends of a probe. After five days had passed,
the edges of the wound appeared to have united, except a small
fistulous opening near the rectum, and M. Guersent removed
the suture. The union of the parts continued for two days,
when it was destroyed by some effort of the patient.

She then determined on entering the Hétel-Dieu, on the
6th of October, when the parts were found in the following
condition, The skin of the abdomen presented the usual
appearance noticed in women recently delivered; the pelvis
was of the usual dimensions, and the sexual parts were scarcely
at all swollen. On separating the labia and nymphe, the
aperture of the vulva was perceived to be very forward; a
circumstance of some importance, as it explains the difficulty
she experienced in sexual intercourse. At the back of this
opening was another of an irregular circular form, capable of
admitting the ends of the three fingers; it was situated a little
to the left; and between the two apertures was a fleshy com-
missure about the substance of the little finger. Behind this
second opening was a third very small one—the anus; and
lastly, there was the os coccygis, which was not much prolonged
in front, as some accoucheurs have affirmed to be the case
where the perineum is lacerated.

Here is a case in which all the details are well confirmed ;
the midwife attended throughout the delivery, and what she
saw has been seen also by Siebold, Moreau, and many others.
And yet when Coutouly, a man much respected for scientific
attainments, reported an analogous case, it was alleged that he
was frightened, and had seen imperfectly. Even admitting
that such a man could be alarmed, this must have happened
after, and not before the accident.

But it may be said, how can such a case be imagined? A
sufficient answer is, that it has taken place; and it is not so
difficult of explanation. They who haye seen first accouche-
ments, in which the vulva is dilated with difficulty, and the
perineum has such a tendency to stretch and yield, have no
doubt been in dread lest the head of the foetus should force
DURING PARTURITION. 319

its way through the latter. Further, I have reason to believe
that this accident is not so unfrequent as has been represented ;
but in most cases the vaginal commissure is ruptured, and
thus the accident is called laceration of the fourchette.

Let us now see what may be the causes of a delivery taking
place in this way.

Persons who pay especial attention to anatomy, to accouche-
ments, or to affections of the genito-urinary organs, must
frequently have seen the vulva or external orifice of the vagina,
in an elevated position towards the pubes, whilst the perineum,
from before backwards, is very long. The vulva appears, in
such cases, and is, in fact, very narrow ; and they who are not
acquainted with this condition of the parts, judging of the
diameter of the vagina by that of the external orifice, consider
the vagina ill-formed, and are alarmed at the chances of an
accouchement. But it is not so; the narrowness is only in
the vulva, whilst the vagina is of the usual size. This narrow-
ness arises from a prolongation of the perineum, which cur-
tails the orifice of the vulva by a quarter, a third, and even
sometimes one half its ordinary dimensions. In examining
the internal organs of women who are thus formed, it is neces-
sary to carry the finger obliquely downwards and inwards, in a
line which forms more or less of an acute angle at its junction
with the pubes; and the same precaution is to be observed in
the use of the speculum, instead of introducing it horizontally,
as in ordinary cases.

This vice of conformation gives rise to many inconveniences.
Sometimes it is so exaggerated, that sexual intercourse is imprac-
ticable, until the vulva is enlarged downwards with a bistoury.
The catamenial secretion is discharged with difficulty from
the vulva, and lodges partially behind this sort of pent-house
formed by the prolongation of the perineum; it is the same
with leucorrhceal discharge. But in accouchements and in
operations on the neck of the uterus, this formation is particu-
larly inconvenient. It may easily be imagined what an obstacle
such a condition of the parts will present in parturition. The
head of the child meets the greatest difficulty in forcing its way
through the lower outlet, and rests upon the perineum ; and
if the posterior commissure of the vulva offers less resistance
in proportion than the centre of the perinzum, the child can-
820 LACERATION OF THE PERINEUM

not make its way through the orifice, without producing a more
or less extensive laceration, which the accoucheur cannot possibly
prevent. If the commissure, on the other hand, should be
very strong, the centre of the perineum will yield, and the
child will be expelled by this abnormal aperture. We have
no doubt that most of the perinzal accouchements of which I
have given an account, have arisen from this cause.

This vice of conformation may be congenital, or accidental :
that is, by union of the soft parts in consequence of burns, of
laceration in a previous accouchement, or any sort of wound.
It is clear that the only remedy is to cut through the con-
striction to a proper extent, to order the patient to be quiet,
and to watch particularly that no fresh adhesion takes place in
the healing of the wound. These means should be adopted
especially in the case of a woman pregnant for the first time,
if it could be known in time to allow the cicatrix to become
firm previous to the accouchement; it may, indeed, be done
without hesitation during labour, if it be clearly seen that the
delivery cannot be accomplished without a serious laceration,
or perforation of the perineum. Dr. Champenois has reported,
in the fourth volume of the ‘ Journal général de Médecine,’ the
case of a young woman, in whom he prevented this perforation
by cutting, with a bistoury guided along a grooved director,
through a hard, thick, callous cicatrix, resulting from a burn of
the external parts, which she had suffered from when a child.
The cicatrix had contracted the vulva in a singular manner,
and the resistance which it offered overcame all the efforts of
the patient, and all other means tried during the labour. Dr.
Buet has inserted in the thirty-ninth volume of the ‘ Journal
complémentaire des Sciences Médicales,’ a curious case of acci-
dental constriction of the vulva.

Casz III.—Accouchement. Laceration of the labia and the
perineum.—A young girl got into trouble, but she concealed
her pregnancy, and delivered herself without assistance. The
labour was most painful, and gave rise to extensive laceration
of the labia and the perineum. Union took place, but to such
an extent that the orifice of the vulva was reduced to a small
opening into which the little finger could scarcely be introduced.
She afterwards married, and it was necessary to call in a sur-
DURING PARTURITION. 321

geon, to whom she had confided her secret. The orifice was
enlarged, by incision, in proportion to the diameter of the
vagina ; the woman was kept quiet; tents of lint were placed
between the edges of the wound to prevent any new adhesion,
and it very soon healed. I shall presently narrate the par-
ticulars of a similar case, which occurred in my own practice.

If this prolongation of the perineum should exist, there
is an additional circumstance which may have great influence,
namely, the position of the woman whilst in labour. In the
case cited by Nédey, perceiving that the pains diminished, and
that the woman wished to go to stool, the midwife turned
over a wooden chair, between the legs of which she placed
a chamber utensil, and the patient was seated on this new kind
of close-stool. In this position the pains returned, the child
was heard to cry, and was withdrawn from beneath the chair.
A patient, now under treatment in the hospital, was in a similar
situation ; she was so raised up by pillows, that she was almost
in a sitting posture. In such a position, the head of the child,
pressed downwards and backwards by the arch of the pubes,
must come with much greater force against the perineum.
It is moreover ascertained experimentally that the child is pre-
sented in a much better position at the lower opening of the
vagina, when the woman is-lying horizontally. Another cause
may be too great a curvature backwards of the inferior ex-
tremity of the sacrum and the coccyx, or, which is the same thing,
too great a prominence of the sacro-vertebral angle. This
vice of conformation,—by enlarging the coccy-pubic diameter
of the perinzal outlet, by carrying too low and too far back the
axis of this passage, and by diminishing the inclination of the
plane in which the head of the child should be directed forward
beneath the symphysis of the pubes,—forces it to remain longer
in the perineum, and brings it with increased violence against
this part. In fact, a great many other causes might be assigned
as tending to such accidents, depending on some malformation
of the pelvis, or the position of the child’s head; but it is far
better to be guided only by facts; and it is a matter of regret
that authors, who have given the cases we have alluded to,
have not detailed all the particulars relative to the child and
the mother, which might have helped to solve the difficulty.

I will now come to that which is of the greatest interest,

21-
322 LACERATION OF THE PERINEUM

the remedies to be employed in such cases of central laceration
of the perineum. In the patient now under treatment, an
attempt at union was made with the twisted suture; and it did
not succeed because it was removed too soon, and was not
applied till the tenth day. In recent wounds, union may take
place in four or five days; but in suppurating wounds, much
longer time is required. And this extension of time was still
more important in the present instance, as the lochial discharge
was acting on the wound, and interfering with the adhesive
process.

I have very often had occasion to apply sutures to suppura-
ting wounds, but they required a much longer time than
recent wounds. Lacerations of the perineum in child-birth
are of the former kind. The following is a case which I will
give from memory.

Casz [V.—Laceration of the perineum. Suture. Contraction
of the vulva,—Many years ago I was called in by M. Gardien
and another medical man, to see a young girl who had been
secretly brought to bed away from her home. The delivery
had given rise to a rupture of the perineum, extending to the
anus, and involving about an inch of the anterior wall of the
rectum. Several days had elapsed since the accident. I re-
commended and applied the interrupted suture; I should now
prefer the twisted suture. A month afterwards, the young
girl was obliged to return to her home, and the union was not
yet accomplished ; this was delayed by continued suppuration.
I had not cut the threads, nor had the threads cut the flesh.
My advice was to leave the suture in its place, as I felt assured
that the union would take place, and I heard nothing more of
the case.

Three or four years afterwards, a man and woman came to
my house ; and the woman, keeping rather in the back ground,
made a confidential signal to me. The man, who was her
husband, informed me that he had been unable to consummate
the marriage, and he wished to know whether it was his or
his wife’s fault. I examined her, and found the aperture of
the vagina very narrow, situated high up towards the pubes,
and directed forwards; behind, the perineum presented a
firm and long cicatrix. I advised the husband to make an-
DURING PARTURITION. 823

other attempt, which was successful. The woman became
pregnant, and was delivered without any fresh laceration. It
will have been conjectured, no doubt, that this was the same
woman on whom I had operated some years previously. I
learnt that she had confided her secret to a medical man, who
removed the suture when the union was complete.

In the case, however, which gave rise to the foregoing re-
marks, what was to be done? After refreshing the edges of
the wounds and bringing them together with a twisted suture,
it might be left to take its course; or it might be necessary to
cut through the fleshy part which separated the wound from
the vulva. Before taking either of these steps, however, I de-
termined to make the patient lie on her back, with her thighs
drawn close together by a bandage, desiring her not to move
from this position. She had remained in this posture about
ten days, when I perceived a sensible diminution in the dia-
meter of the abnormal aperture, the edges already adhering at
some spots. There was every reason to hope, therefore, that
the union would be accomplished without any operation.

This woman left the hospital on the 30th November, quite
recovered. The whole surface of the perineum was cicatrized,
and though there might still be some separated parts at the
surface of the vagina, as far as its junction with the perineum,
these would, no doubt, soon close up.

This case fully confirms what many authors have said, as to
the practicability of curing such solutions of continuity without
any operation. It has been seen, in the cases reported, that
patients recover in five or six weeks, which also happened in
the present instance. I recommended her not to engage in any
work to fatigue her, to walk as little as possible, to avoid sexual
intercourse, and everything else likely to destroy the adhesions,
which were not quite firm. I requested her to come to the
hospital from time to time, and not to fail in doing so if she
should again become pregnant.
SECTION XI.

ON VITAL AND MECHANICAL DILATATION OF THE
URETHRA.

Tue most opposite opinions have been entertained respecting
stricture of the urethra, and the treatment has been as various :
of this any one will be convinced by merely casting his eye
over the long list of authors who have written on the subject.
I do not intend to give a complete account of these diseases,
nor of the means proposed to cure them; but I shall confine
myself, for the present, to the case of a patient in the hospital,
by which I shall be able to exemplify the improvements that
have been introduced into this branch of our art.

This man was a coachman, aged about 40; and he was
getting up to his seat when his horses suddenly started, and
he fell astride upon the wheel. He immediately felt great
pain in the perinzum, and lost a considerable quantity of
blood by the urethra. Being unfit to continue his employ-
ment, he came to the Hétel-Dieu, in March, 1832, with the
following symptoms: swelling of the parts which were the seat
of the contusion ; acute pain all along the passage; the skin
of the penis, the scrotum, and the perineum, extensively
ecchymosed; and he was unable to pass his urine. On
questioning him, it appeared that he had had gonorrhea
several times, that he had frequent desire to make water, and
that it did not pass readily.

The accident that he was suffering from did not admit of a
doubt ; a catheter was introduced, but it would not penetrate
more than three inches. A fine bougie was then tried, but
without success. It appeared, therefore, that there were two
lesions; stricture, and a laceration, of the urethra. It was
necessary to remove or dilate the first; and, if the second
were left to itself, the healing would, almost to a certainty, be
DILATATION OF THE URETHRA. 325

accompanied by contraction. It was, undoubtedly, a case of
great difficulty ; and in twenty or thirty similar cases, I have
always met with great obstacles in their treatment. To avoid
contraction, it was necessary that the cicatrix should be formed
on a catheter of the largest size.

About five months ago, a person, engaged in some family
quarrel, had provided himself with a pair of pistols, which he
carried at his waist. In falling, one of the pistols went off,
and the ball passed through the urethra, pierced the testicle,
and lodged in the thigh. If any one was ever exposed to the
risk of stricture, it was this man. I introduced a catheter
into the urethra; in three months, the wound was quite
healed, and he has passed his water since quite freely. The
only consequence was atrophy of the testicle.

But to return to the patient before us. It is evident that
the previous stricture, from which he was suffering, required
dilatation ; and that a catheter was necessary, on account of
the laceration. These means were tried, but the instrument
at first would not pass. I recommended the attempt to be
‘repeated every hour; and on the following day the catheter
had made way, and the patient passed his water. Three days
afterwards, a middle-sized catheter was introduced into the
bladder.

It was formerly considered necessary, in cases of stricture,
to force the obstruction, so as to enable the patient to make
water ; such was the practice of Desault; and there appeared
to be a sort of triumph in overcoming every obstacle. I do
not hesitate to say, that, out of ten cases so treated, one half
of them would suffer from laceration of the urethra, false
passages, swelling of the penis, infiltration of urine, or gan-
grenous inflammation; and that death itself might often be
the consequence of such imprudent measures. Force must,
therefore, be considered improper, not only on account of the
pain, but of the danger of the proceeding ; and I think I have
done good service in changing the system which formerly
prevailed in this hospital. When the consequence of a stric-
ture is limited to difficulty in passing water, force should be
avoided; and I have learnt from experience that it is best to
temporise. Force should be resorted to only when retention
might give rise to rupture, infiltration, or inflammation, putting
826 VITAL AND MECHANICAL

the life of the patient in danger. The observations made at the
Hotel-Dieu prove, that, out of thirty cases of stricture, it is not
necessary to proceed to violent measures in more than one at
most; in the other twenty-nine cases, several hours, if not
days, may be allowed to elapse. I have followed this plan for
eighteen years, and always with success.

Let us recur to our patient. He had had gonorrhcea three
or four times, which gave rise to stricture; the contusion of
the perineum and the laceration of the passage had produced
retention of urine. I did not use any force, yet I succeeded
in penetrating to the bladder; and, on the third day after his
entrance into the hospital, I was enabled to introduce a middle-
sized catheter; whereas, on the first day, I could not pass the
smallest bougie. The contact of the catheter gave rise to an
abundant secretion of mucus, which increased still more on the
following day; and at length, on the third day, a catheter ten
or twelve times as large at its extremity as that tried on the
first day, passed the obstruction. As a general rule, therefore,
no force should be used when you can wait some hours, and
still less when you have some days before you. It is sufficient
to introduce a bougie or a catheter, and to fix it at the spot
where it will go no farther. I have named this method,
gradual or vital dilatation.

I may here remark, that, where there exists contraction
without laceration, and the urine flows between the catheter
and the parietes of the urethra, it is a favorable sign, as its
passage tends to increase the dilatation; in such case, the
catheter should be closed, to encourage the flow of the urine
by its side. But, if the passage be lacerated, the passing of
the urine may give rise to infiltration, and urinary or sloughing
abscesses ; in which case the urine should not be allowed to re-
main in the bladder, and the catheter should therefore be open,
the patient lying on his back.

That plan of proceeding, therefore, by which stricture is
overcome patiently and gradually, is the best in the great
majority of cases; but there is also another mode of treatment,
of which I shall speak hereafter, and which I have distinguished
as mechunical dilatation, —

I will cite the following case, especially as it may be con-
sidered the first in which I adopted the method I recommend.
DILATATION OF THE URETHRA. 827

Casr I.—Stricture with dysury, treated by vital dilatation —
About eighteen years ago, I was called in by arick man of ex-
cessively nervous and excitable temperament, who was suffering
from difficulty in making water. I advised him to keep a
bougie in the urethra, but the mere proposal alarmed him, and
he had all sorts of exaggerated ideas about the pain and incon-
venience of such treatment, affirming that it must injure him,
and that it would altogether stop the passage of urine, which
he could void only guttatim. After some explanations, which
gave him encouragement, he consented to allow me _ to
introduce a bougie with a rounded extremity; but it had
searcely entered the urethra when all his apprehensions re-
turned; he wished me to withdraw it, and I had much trouble
in prevailing on him to keep it in. I inserted it as far as the
obstruction, but I there found an insurmountable obstacle, and
the patient showed so much apprehension, and complained so
much of pain, that I thought it best to desist for the present ;
but I fixed the bougie where’it was, that is, against the
stricture. The patient only consented to this on condition
that I would see him every two hours, to withdraw it if neces-
sary. After a few hours had elapsed, I paid him another
visit; he had voided urine without pain, and the bougie easily
passed the obstruction. A few hours later I inserted it still
farther, and in the course of the day I reached the bladder.
A few days afterwards a larger one was substituted, and sub-
sequently the treatment was continued in the ordinary manner,
by gradually increasing the size of the bougies, the dilatation
making rapid progress. In a fortnight the patient passed his
water with ease, without pain, and in a full strong stream.

This case was not lost upon me; I perceived that dilatation
of the urethra might be effected without forcing a bougie into
the contracted part, and, moreover, I foresaw that it would be
an advantageous mode of proceeding with faint-hearted or
susceptible patients, as well as in all cases in which the neces-
sity for introducing a bougie immediately is not imperative.
Since the above instance, I have pursued this plan with num-
bers of patients, as will be seen by the hospital registers. In
the following two cases a similar plan of treatment was

adopted.
328 VITAL AND MECHANICAL

Case II.—Stricture of the urethra. Dysury and incontinence
of urine. Vesical catarrh symptomatic of the stricture. Vital
dilatation.—Castiaut, aged 49, was admitted into the Hétel-
Dieu, on the 20th of February, 1827. He complained of being
unable to pass his water, except by drops, even with great
-effort ; also that these efforts were frequently followed by an
involuntary discharge. He experienced great pain in the
hypogastric region, the perineum, and the urethra, especially
during the passage of the urine; and he compared the pain
to the sensation of a red hot iron passing along the canal;
this did not continue long: after the urine had passed; the
water when cold deposited a mucous and purulent sediment.
This man had had eleven attacks of gonorrhoea, the last of
which had continued four years; and it was at the period
when this discharge ceased that he found difficulty in passing
his water; the stream diminished in volume, did not flow
straight, became filiform, and in three years he was unable to
pass his water at all. Dilatation was then employed, and for
six years he was relieved, until six months ago, when the
dysury re-appeared, A bougié was introduced into the urethra,
which penetrated to the bulb, where it was arrested by a hard
resisting stricture; no effort was made to force it past this
obstacle; but it was left in the urethra for four and twenty
hours, when it penetrated with ease into the bladder. An
elastic catheter of small size was then substituted. The patient
suffered no pain. Four catheters were successively used of gra-
dually increased dimensions, being left each time in the urethra ;
and in thirty-two days the patient made water with ease, and
in a large stream. He quitted the hospital quite cured.

Case III.—Contraction at the commencement of the mem-
branous portion, accompanied by extraordinary spasm, of the
urethra, and incontinence of urine. Dilatation.—Colomb, aged
36, of good constitution, was admitted into the Hétel-Dien, on
the 6th of February, 1827. He had had gonorrhoea but once,
but it had lasted ten years. Six or seven years since, when it
entirely ceased, he perceived that the stream of urine diminished
by degrees, till at last, four or five months ago, he passed his
water only by drops, and with considerable effort; after this
exertion the urine continued to flow involuntarily, and he was
unable to stop it. On the 7th of February, a catheter of
DILATATION OF THE URETHRA. 829

medium size was introduced into the passage, and it penetrated
to the fore part of the membranous portion, where it was
arrested by a hard stricture, which the catheter could not
penetrate, whichever way it was turned. A bougie was fixed
in front of the obstruction, but the patient withdrew it an hour
afterwards. In the afternoon an attempt was made to intro-
duce it again; but the urethra was in such a state of spasm,
that it could not be made to penetrate beyond the fossa navi-
cularis, and it was so tightly grasped by the sides of the canal,
that some force was required to withdraw it. On the 9th of
February I tried a silver catheter of medium size, and then a
small one, but both were stopped in the fossa navicularis, and
grasped with the same force as the bougie had been two even-
ings before. The end of a catheter, rounded at the extremity,
was introduced, and fixed in the fossa navicularis; at first it
made but little way, but in four and twenty hours it had
penetrated ; it was replaced by an elastic catheter of medium
size, which was fixed, and the dilatation was continued for
twenty days. Three catheters were successively used, the last
being of the largest size. The patient passed his urine freely,
and in a large stream, when he quitted the hospital.

These two methods of dilatation have each their different
mode of action; mechanical dilatation operates by continued
pressure from within on the parietes of the obstruction ; vital
dilatation accomplishes the distension either by exciting a sort
of expansive force, or by determining a secretion of mucus,
and, consequently, by relieving the congestion of the parts.

Vital dilatation is so potential, that catheters are often found
to penetrate to the bladder in two or three hours; and its
action is facilitated by occasionally turning the instrument in
the passage. This process does not require catheters of any
peculiar form; one of silver or of india-rubber, or a bougie,
whether the extremity be thin or thick, may be used indiffe-
rently for this purpose. I give the preference, however, to
elastic gum catheters, or bougies, with a rounded blunt extre-
mity, and of a length proportioned to the depth of the obstacle.
They have a smooth surface, bend easily, and accommodate
themselves to the shape of the urethra, without incommoding
the patients in their movements.

Whatever instrument may be used, it is to be introduced as
330 VITAL AND MECHANICAL

far as the obstruction, and fixed there by the usual means.
No endeavour need be made to thrust it into the strictured
part, for, by remaining a certain time in the urethra, it will
have the desired effect. In fact, in a few hours, or,.in worse
cases, in a few days, it will assuredly pass the obstacle without
any difficulty, and without force, laceration, or bleeding. The
dilatation is such, that the catheter or bougie will sometimes
of its own accord penetrate the contracted part; in other and
more numerous cases this is accomplished by a very slight
effort ; and under other circumstances the dilatation will admit
of the introduction of the extremity of a conoidal bougie, which
thenceforward must be employed mechanically, as I shall pre-
sently explain.

I conceive that there is nothing mechanical in the action of
these instruments; and I feel convinced that some vital power
must be admitted. But whether it is by a sort of expansive
force opposed to the contractile force, and arising from the
presence of a foreign body; or whether it is by a secretion
which produces a sort of resolution, and thus diminishes the
density of the parietes of the obstacle, I will not venture to
affirm. I observed at the beginning of this subject, that a
secretion takes place which facilitates the passage of the cathe-
ter. Let us examine into this, and take, for example, the
contact of foreign bodies with the lachrymal puncta. The+
first effect of this contact is so violent a contraction of the
orifices, that a very fine probe cannot penetrate; but when
this is repeated or continued, the contraction ceases, and. they
even dilate, so as to admit the probe which they had previously
rejected ; at the same time, there is almost always a mucous
secretion around these puncta.

The same thing takes place in strictures of the urethra; the
first contact of the bougie causes the canal to contract to such
a degree, that an effort is required to disengage it, so great is
the spasm which it produces; this soon subsides, and in a few
hours the bougie may be freely moved., Another circumstance
attends the dilatation to which I have already called your
attention, namely, a more or less abundant secretion of mucus,
and sometimes of purulent matter. This secretion is occa-
sionally so great, that it gives rise to a discharge which may
alarm the patient, but which always subsides of itself, either
DILATATION OF THE URETHRA. 331

whilst the catheter is in the canal, or after its withdrawal.
Under the influence of these two phenomena, the stricture
gives way; and after a few hours, or at most-a few days, the
canal, which at first would not admit a bougie of the very
smallest size, will admit one a whole line in diameter.

Vital dilatation is not the only means used to overcome
strictures ; recourse is often had to another mode of dilatation ;
which consists in’ introducing a fine-pointed bougie into the
obstruction. This foreign body dilates and separates the oppos-
ing tissues by pressure. I have called this mechanical dilatation.

The instrument I commonly use in such cases is a conoidal
bougie, of elastic gum material; the end being very pointed
and almost filiform. From this point it increases gradually
in substance to the other extremity, which forms the base of
the cone. It is thus fitted to insinuate itself into the smallest
opening, and to dilate it as the thicker part is gradually
pressed forward. The manufacture of these bougies is of
the greatest importance, for if they are badly made, serious
accidents may arise.

These bougies are introduced in the following manner: the
penis being slightly raised and elongated, and the sides of the
glans held between the thumb and the fore finger, a bougie well
greased, and held between the thumb, fore, and middle fingers,
is inserted into the urethra, and pushed forward by slight pres-
sure, and with a rotatory motion. By this combined move-
ment it will soon reach the obstruction. When it is unable
to penetrate this, it bends back upon itself if the least force be
used; and as soon as the effort is discontinued, it resumes its
previous straight form. These signs, therefore, will be
‘sufficient to enable a practised hand to determine when the
point of the bougie has penetrated the obstruction; and such
is the tenuity and flexibility of this portion of the instrument,
that it cannot under any circumstances occasion laceration,
perforation, or any other injury to the parietes of the urethra.

But when the filiform extremity has passed the stricture,
the instrument gradually penetrates to a greater or less
depth, that is to say, till the bougie, the size of which in-
creases almost insensibly, fills up the opening at the contracted
part. When the bougiée bends back on meeting an obstacle,
without penetrating it, it has always a tendency to escape from
332 VITAL AND MECHANICAL

the urethra without the least effort; but in the contrary case,
when it has penetrated the obstruction, not only.has it no
tendency to return, but it is forcibly retained by the spasm or
contractility of the tissues, to such an extent that some exertion
is necessary to withdraw it. As soon as a conical bougie has
penetrated a stricture, and has been sufficiently pressed for-
ward, it must be fixed by attaching it to the penis or a sus-
pensory bandage.

In fixing the bougie, the object is to keep it in its place,
until it may be practicable or necessary to push it forward
with the hand; or to admit of its exercising a continuous
pressure against the walls of the stricture. In the first case I
do not endeavour to press it forward, but fix the bougie just at
the required point. In the second case I bend the hougie,
and fix it higher up, towards its base, so that the tendency to
straighten itself may exert a continued force against the
stricture.

The manner in which these bougies act may be easily
conceived. They operate mechanically as a wedge, surrounded
by the parts which they are designed to separate; but, whilst a
wedge acts only on inert bodies, the bougie operates ou living
ones, and it exerts not only a mechanical action, but also
a vital action, on the parietes of the obstructing body.

In regard to their effect, experience has shown that, when
the filiform extremity has once penetrated a stricture, the
remainder of the bougie will sooner or later pass forward,
however large it may be. In many cases, it may be passed
in entirely at once; but in others, it is necessary to wait some
hours, or even days; and this is not so much a consequence
of the extent of the stricture, or the size of the bougie, as of
the variable extensibility of the tissues which form the con-
traction. This extensibility is sometimes very great, and at
others very small. Thus, in some persons, after much trouble
in making the point penetrate, the whole bougie will pass at
once into the bladder; whilst in other cases, the spasmodic
contraction of the tissues offers great resistance; but after a
few hours, you will generally find a bougie, that was at first
tightly grasped by the stricture, free and moveable; it seldom
happens that this does not come to pass in a few days, even
in the most severe cases.
DILATATION OF THE URETHRA. 383

The mobility of the bougies, which is observed after a few
hours, or at most a few days, is one of the most extraordinary
circumstances, and the best fitted to establish the fact, if it ad-
mitted of doubt, that what takes place in living bodies, however
it may appear to be the effect of mechanical causes, is always
more or less dependent on the vital principle; or, in other
words, that, in living bodies, the vital principle is mixed up
with mechanical phenomena, which it changes and modifies
according to rules which are beyond the power of physical
calculation. I will give two cases in illustration.

Cass IV.—Stricture of the urethra. Dysury. Mechanical
dilatation—A man named Devoisse, aged 61, came to the
hospital on the 19th of February, 1827, complaining of difficulty
in passing his water, which had commenced two years previously.
He had contracted a gonorrheeal affection sixteen years before,
and the discharge had continued ever since to the time of his
entering the hospital; the difficulty in making water had
gradually increased, and the urime now came away a drop at
a time, and with considerable effort; the secretion from the
urethra was large. He took some baths; the urine was care-
fully examined, but it deposited no sediment; the patient said
that it was supposed there was stricture of the urethra.

On the 23d of February, a bougie was introduced into the
passage, and was arrested in front of the membranous portion ;
soon after, by gentle pressure, the small extremity penetrated
the obstruction, and, although grasped by it, the instrument
was pressed onward, and thus effected a purely mechanical
dilatation of the stricture. This bougie remained in for four-
and-twenty hours, when it was replaced by an india-rubber
catheter of small size; the scrotum was supported, and the
dilatation was persevered in for thirty-nine days; five catheters
were used, of increasing calibre, the last being one of the largest
size ; the whole of the urine passed between it and the parietes
of the passage. It was removed on the thirty-ninth day (4th of
April); the jet of urine was free and large; and no accident
whatever occurred during the treatment.

Case V.—Siricture at the bulb of the urethra, treated by
mechanical dilatation.—Pino, aged 42, of good constitution,
334 VITAL AND MECHANICAL

entered the Hétel-Dieu on the 28th of February, 1827. He
was suffering from difficulty in making water, of which he had
felt the first symptoms ten years previously, succeeding two
attacks of gonorrhoea; the first, contracted when he was 20,
lasted three months, and was suppressed by a drastic purge ;
the second, two years afterwards, still continued. A white,
opaque, mucous discharge came away on pressure of the urethra,
which had persisted for twenty-two years, and was probably the
cause of the stricture. However this may be, the dysury
commenced with a smarting sensation, and a feeling of con-
traction of the urethra, at the time of making water; the
stream gradually diminished, became crooked, and at last came
away only by drops, especially after he had been drinking spirits.
The dysury had greatly increased during the three months
preceding his admission into the hospital; great exertion, and
sometimes traction of the penis, were necessary to promote
emission of the urine, which at other times came away involun-
tarily, by a sort of overflowing. On the lst of March, a bougie
was introduced into the canal; towards the end of the bulbous
portion it entered a firm stricture, and was so grasped by it,
that sufficient force was used to raise up the penis without
withdrawing it; the bougie was fixed at this point, and eight
hours afterwards it passed, with very moderate pressure, into
the bladder. On the 4th of March, an elastic catheter,
of medium size, was placed in the passage; after which,
other larger ones were introduced and left in the urethra.
In twenty-two days the patient passed his water freely, aud
in a considerable stream.

I will conclude this subject with some remarks applicable to
the different modes of treatment by dilatation.

In the course of ten to twelve days, at the utmost, you may
pass from the smallest bougie to a catheter of the largest size ;
or, in other words, the most firm stricture may be dilated to
the fullest extent, by a daily augmentation of the size of the
catheters.

But the dilatation is less persistent in proportion to the rapi-
dity with which it is accomplished; whence it follows that,
instead of hastening the process, it should rather be retarded ;
for the dilatation is the more lasting when it has been obtained
gradually.
DILATATION OF THE URETHRA. 835

Rapid dilatation of strictures of the urethra is subject also
to other more serious consequences, such as very acute pain,
laceration at the point of contraction, acute inflammation,
gangrene, and a greater or less destruction of the canal,—acci-
dents which are also seen to occur when force is used in
passing the catheter. It would appear that the tissues which
compose these strictures, as all other animal tissues, are ex-
tensible to a certain point, beyond which you cannot pass
without danger of laceration, but are susceptible of almost in-
definite extension, if proceeded with gently and in a gradual
manner.

Whatever precautions, however, may be used in dilating
strictures of the urethra, the cure in the great majority of
cases is only temporary, and the stricture has always a great
tendency to return. Dilatation does not destroy strictures,
nor does it alter the nature of the tissues of which they are
composed; it merely extends them. After this mechanical
dilatation, there succeeds, sooner or later, a vital re-contraction
which brings back the parts to their previous state.

This effect is produced sooner with some than with others.
The return of the disease has induced me to pass a bougie
occasionally, say every ten, twelve, fifteen, or twenty days,
leaving the bougie in the urethra for two, four, or six hours,
or even during a whole night. This has materially retarded, if
not prevented the recurrence of the complaint.

But, whether it take place in spite of every precaution, or
because it has been neglected, this recurrence is one of the
most serious evils attending the treatment of strictures by
dilatation. I have therefore been induced to try whether
cautery would not prevent the return of strictures of the
urethra, and experience has been rather in favour of it; but
many surgeons are still satisfied with the process of dilatation.
SECTION XII.

ON HYDROCELE, AND ITS PRINCIPAL VARIETIES.

Notuine is easier than the diagnosis of simple hydrocele,
nothing more simple than its treatment; therefore, I should
not dwell long on this disease, were it not that the varieties
and complications which sometimes present themselves are
deserving of attention. It is familiar to all that the name of
hydrocele is given to aqueous tumours of the scrotum, and
that these tumours are of two kinds; in one the water is
diffused through the cells of the cellular tissue; this is hydro-
cele by infiltration: in the other, it is collected in a sac, which
is circumscribed hydrocele of the tunica vaginalis. In practice,
a third kind is also met with, which is distinguished from the
others by the fluid being accumulated in accidental serous
cavities, developed either in the middle of the cord, in the body
of the testicle, or in the epididymis. In making this classifi-
cation, I should state that each kind may offer many varieties,
of which I will mention the specific characters.

Having pointed out these divisions, I will say a few words
about hydrocele by infiltration ; but, in the first place, I would
direct attention to the characteristics of the principal varieties
of cellular tissue which are met with, for this is an important
consideration as associated with this form of hydrocele.

I recognize four varieties in the cellular tissue: Ist. The
fatty cellular tissue, which exists almost alone in certain ani-
mals, as, for instance, in the omentum of the sheep, and which
is very abundant in some individuals. When inflammation
occurs in this tissue, it almost always terminates by a sort of
decay and putrefaction of the inflamed parts. This is seen in
strangulated hernia, where the omentum is left in the sac, and
in sheep, which are inoculated or vaccinated to preserve them
from certain diseases.

2d. The fibrous cellular tissue, which contains neither fat
nor serum. In man, this tissue exists especially around the
HYDROCELE, AND ITS VARIETIES. 337

articulations; and the inflammation developed in it is almost
always complicated with strangulation. In the dog, and some
other carnivorous animals, the cellular tissue is nearly all
fibrous.

3d. The elastic cellular tissue, which does not comprise any
of the elements alluded to. It is seen round the tendons,
which are not provided with synovial sheaths. The inflamma-
tion which affects it has a strong tendency to extend itself; as
may be remarked in the palm of the hand, whence it is pro-
pagated so readily along the tendons to the fore arm, &c.

4th. The serous cellular tissue, which never contains fat, is
not elastic, and is always moistened by a certain quantity of
serum. It is seen particularly in the eye-lids, the genital
organs, &c. The inflammation which occurs in this often
ends in suppuration. It is this tissue which is the seat of
hydrocele by idiopathic or symptomatic infiltration.’

Considered in respect of its seat, this hydrocele may be
found in the spermatic cord itself, or in the deeper cellular
tissue, or occupying the sub-cutaneous serous areole. In the
first case the tumour is circumscribed, fluctuating, and confined
to one of the cords; in the second it is prolonged, extending
from the ring to the bottom of the scrotum, retaining the
impress of the finger, and occupying only one side of the
scrotum ; in the third the tumour is large, and doughy, and.
diffuses itself rapidly over the entire scrotum, without stopping
at. the median line. An acquaintance with these differences is
of importance ; for, supposing that it is desirable to discharge
the infiltrated fluid, it will be necessary in the first two cases
to make incisions of some extent, whilst in the last a simple
puncture in the skin will often suffice to withdraw the whole
of the fluid contained in the areole of the sub-cutaneous
cellular tissue, in consequence of the free communication that
exists between them. Hydrocele, by idiopathic infiltration,
occurs only in newly born infants, and in old men. It may
be confined to one side, or may invade the whole scrotum.
When the infiltration is accompanied by pain, redness and
active swelling of the part, it is necessary to employ soothing
applications.

' [It need scarcely be remarked that these observations are not introduced into
the translation for the sake of their histological value—T.]

22
338 HYDROCELE,

Circumscribed hydrocele of the tunica vaginalis, of which
I have chiefly to treat, is fluctuating ; from the bottom of the
scrotum it rises towards the inguinal ring, is almost always
developed in front of the testicle, and offers but little resistance,
until the serous sac and the other distended tunics resist the
effort of the fluid and react upon it. The most unequivocal
sign of hydrocele is the transparency of the tumour; the
absence of this sign almost constantly indicates, either an
opaque fluid or some deep-seated alteration in the texture of
the cyst. This sign may also be wanting when the testicle is
in front, or directly internal or external. The weight of the
hydrocele should be noticed ; it is generally less than might be
imagined ; it is greater when the testicle is swollen, or when
any solid deposit has taken place in the vaginal tunic. The
fluid is usually pure serum, of a light-lemon colour; but it
may be yellowish, whitish, or greenish; any other alteration
of colour depends on a mixture of blood, or on decomposition.

Cast I:—Hydrocele. Puncture. Testicle in front. No
fluid. Fresh puncture. Cure-—A man came to the Hotel-
Dieu, after having been punctured for hydrocele at another
hospital. The operation, he said, was very painful ; blood only
came away, without any serum; and the scrotum, instead of
diminishing, immediately increased in size. It had become
hot, painful, and distended; and it was only after severe anti-
phlogistic treatment that it was reduced to its previous state.

Having placed a candle behind the tumour, I found the
posterior part transparent; but there was an opacity in front,
towards the point where the puncture had been made, evidently
occasioned by the testicle. Laying hold of this gland, in
which the point of the instrument had been arrested at the
first operation, J made a puncture farther back, and emptied
the tunic.

Case I].—Hydrocele. Puncture. Testicle, in front, pierced
through. Injection. Cure——Hildebrand, aged 28, was admitted
into the Hétel-Dieu, on the 17th of March, 1816, with a double
hydrocele. The form of the tumours, and their transparency,
left no doubt of the nature of the affection. That on the
right being the larger, I decided on operating on this, leaving
AND ITS PRINCIPAL VARIETIES. 339

the other till a future time; fearing that, in operating upon
both at once, the inflammation might only take place on one
side, and leave ‘the other uncured.

The operation was performed on the 24th of May. After
again satisfyimg myself of the transparency of the tumour, I
made a puncture towards the anterior and lower part; but the
testicle was there, and was pierced through by the trocar;
the pain was not very acute. After disengaging the canula
from it, I injected three times. The pain was very bearable,
and the inflammation which supervened was moderate; no
accident occurred, and the patient left the hospital on the Ist
of July, thirty-four days after the operation, nearly cured.

I have already stated that this disease presents complications
and varieties which require attention; thus, for example,
hydrocele of the vaginal tunic may be complicated with
encysted hydrocele of the spermatic cord. This kind has
frequently led to errors of diagnosis; being situated very often
opposite the inguinal ring, and prolonged sometimes into the
canal, it very much resembles inguinal hernia, and has often
been mistaken for it. When these two forms of hydrocele
are distant, they may be readily distinguished. The tumour
of the cord is above, and that of the serous tunic of the testicle
below. When they are close together, the hydrocele of the
vaginal tunic passes in front of the other. Under certain
circumstances, the greatest care is necessary in ascertaining
the nature of the disease. By placing the patient on his back,
it will be seen that the tumour (hydrocele of the cord) which
is usually rounded and circumscribed, is isolated and distinct
from the intestine or omentum; to which may be added the
transparency and fluctuation which these tumours invariably
present. Notwithstanding, the diagnosis is at times extremely
difficult ; and it will be seen by the next case, that, although
all the differential signs were apparent, yet I could not help
‘entertaining some doubts as to the real nature of the disease.

Case IlI.—Encysted hydrocele of the spermatic cord—A
boy, twelve years of age, was operated upon, in 1828, at the
Hotel-Dieu, for hydrocele of the vaginal tunic of the left side.
It was treated by injection, and he went out quite cured. A

» few months afterwards, a small, indolent, fluctuating tumour
340 HYDROCELE,

appeared in the groin, in front of the inguinal ring; the colour
of the skin was unchanged. This disease appears to have been
taken for a hernia, as a truss was recommended. In spite,
however, of its use, the tumour continued to increase, and the
patient came to the Hétel-Dieu for advice, in the month of
October, 1829; and the following was the condition in which
he was found.

Opposite the inguinal ring, he had a rounded but somewhat
elongated tumour of the size of a pigeon’s egg; it commenced
half an inch from this region, and terminated near the
epididymis. Notwithstanding its state of tension it was
fluctuating, and the colour of the skin was unchanged.
Coughing did not occasion any impulse which could be felt
by the hand when placed on the tumour. It could be made
to pass within the inguinal ring, but it was ascertained to be
isolated, and was manifestly transparent. The existence of
encysted hydrocele appeared, therefore, undoubted, and I
determined on treating it by incision.

This operation was performed on the 13th of October, 1829.
The patient lying on his back, an incision was made in the skin
covering the tumour, which was done with great care, as if it
had been a case of hernia. I could not act otherwise, for there
were two difficulties to be avoided,—an error in the diagnosis,
and the lesion of one of the constituent parts of the cord, the
relation of which to the sac it was impossible to determine. The
subjacent layers were successively cut through, and the cyst was
at length reached,—a jet of lemon-coloured serum indicating
that it had been pierced. ‘The opening was enlarged with the
bistoury and scissors; and the finger being introduced into the
cyst, no communication with it was detected. Having been
completely evacuated of the serum which it contained, it was
filled with lint, with a view of promoting inflammation, and,
consequently, the adhesion of its parietes.

No accident occurred. The lint was changed, and, in the
course of a few days, a moderate amount of inflammation
spread throughout the cyst, accompanied by plentiful suppura-
tion. In twelve days the wound had cicatrized.

I have seen hundreds of cases of encysted ‘hydrocele of the
cord mistaken for hernia, and for which the patients had been

told to wear trusses. In the case of one patient whom I. .
AND ITS PRINCIPAL VARIETIES. 341

attended, who had worn a truss as for hernia, the tumour,
being continually pushed back, had risen into the inguinal
canal, where it continued to extend itself, and had acquired ‘a
great size.

The uncertainty that exists as to the nature of the tumour,
whatever symptoms may be present, induces me to cite some
further cases. —

Case 4.—Encysted hydrocele.—Gallois, aged 21, of healthy,
strong constitution, had a considerable tumour on the left side
of the scrotum, which had existed from early childhood, and
was attributed by his nurse to violent screaming; it had
increased gradually as he grew up. Its peculiar heaviness,
the sensation of rapid fluctuation which was perceptible when it
was held in one hand and compressed by the other on the
opposite side, its transparency in front of a candle, after taking
care to make tense the scrotum; all these characters left no
doubt as to the aqueous uature of the tumour. Taking, also,
into consideration the seat of this hydrocele, which appeared to
have extended itself from above downwards; its conical shape,
the base rising high up towards the inguinal ring; and its
isolation from the testicle, which was immediately beneath it,
forming a sort of second tumour in the lower part of the
scrotum, it was evident that the fluid was inclosed in a peculiar
cyst or serous sac, which had been spontaneously deve-
loped in the cellular tissue of the spermatic cord. Further, the
position of the latter could be easily ascertained when it was
grasped at the ring and towards the testicle, either by simple
tact or with the aid of a candle, which proved ‘that it had been
thrust towards the anterior and external part of the cyst, which
was quite opaque at this spot. It may be suggested that there
might have existed a hernia, non-congenital or with a sac
peculiar to this period of life, and which, being cured, and
having its communication with the peritoneum cut off, may
have been the seat of this collection of water. But it is
impossible to determine this point, which, moreover, is not
probable. It would be needless to enter into the particulars,
and to state the reasons, for preferring the method of injection
in the cure of this sort of hydrocele, or to call attention to the
necessity of ascertaining the position of the cord and the testicle,
342 HYDROCELE,

as we have a recent case demonstrating this, where the testicle
was placed high up in front, and it was necessary to make an
incision laterally and externally.

This uncertainty ought, in a manner, to indicate the mode
of treatment to be adopted: injection is one of the best, the
most prompt, and the most simple remedies, for encysted
hydrocele. But if an error in diagnosis should lead to the
injection of an irritating fluid into a hernial sac, serious
consequences would ensue. Nor is this an imaginary accident ;
such an injection into the abdomen has not unfrequently
occurred in operations for hydrocele of the vaginal tunic, where
the communication with the peritoneum had been preserved.
In one case, the injection was not followed by fatal inflamma-
tion; but in another it brought on peritonitis, and the patient
soon died. Great caution is therefore necessary, that the life
of the patient be not placed in jeopardy; and where injection
is required, it should be done cautiously, by applying the
fingers to the inguinal ring, with a view to interrupt the
abnormal communication.

When there is the slightest doubt or uncertainty as to the
nature of the disease, recourse should be had to another mode
of treatment. Incision of the cyst at once removes all uneasi-
ness in this respect, and appears to deserve the preference in
most cases. I have, however, observed, in some instances, that
by injecting one part, the inflammation has spread to the other,
followed by the formation of an abscess, and the consequent
adhesion of the parietes. In such case, one operation may
effect a radical cure of the two diseases; but such treatment
is not always desirable.

It may also be well to call attention to the difficulty, not to
say the impossibility, of precisely determining the relation which
the spermatic vessels may bear to the encysted hydrocele of
the cord. For this reason, when incision is resorted to, the
operation should be performed slowly and cautiously.

As regards shape, hydrocele presents many important varie-
ties. Thus the tumour, which is usually even and regular in
form, is sometimes contracted in the centre, presenting a double
sac, with a communication between the two.

Case V.—Hydrocele with hour-glass contraction.—-In 1824,
AND ITS PRINCIPAL VARIETIES. 843

aman came to the Hétel-Dieu, with this singular affection. A
portion of the tumour occupied the scrotum, whilst the other
part was within the abdomen, and spread itself above the ring,
which latter was the seat of constriction in the centre. When
the patient stood up, the visible portion of the tumour filled, and
when he coughed, it became distended ; but it emptied itself, on
the other hand, when he was in a horizontal position, or when it
was pressed. Under the latter circumstances, the abdominal
portion of the tumour, and the right iliac region, became raised
and distended. The transparency of the external tumour, and
its mode of development, were characteristic of hydrocele, in
which the vaginal tunic had extended itself upwards towards
the ring, on passing which it had again expanded in the abdomen.

In the interior of simple hydroceles, chambers sometimes
exist, and a sort of cellular arrangement obtains by which the
fluid is retained, so that when a puncture is made, a very small
portion of the extravasated fluid escapes; and it is necessary
to puncture each separate division before the tumour can be
thoroughly emptied. In cases of this sort, which are analo-
gous to that which I have observed in hernial sacs, and which
I have called multilocular, incision is. preferable, as in the
preceding case, to any other mode of treatment ; but even this
rule is not unexceptional, as will be seen by the following
example.

Case VI.—Multilocular hydrocele. Double puncture. Cure.
—Harly in May, 1833, a man came to the Hétel-Dieu, with
a tumour in the left side of the scrotum. A year and a half
before he had received a blow on the testicle, from which time
it began to swell unequally. When I examined it. the tumour
was uneven, fluctuating and transparent. As I attributed
this unevenness to the resistance of the vaginal tunic, I
plunged the trocar into the largest part of the tumour; some
yellowish serum came away, but the tumour did not subside,
and did not appear to. be half emptied. On touching the part
that was full, I detected distinct fluctuation; I might have
passed. the trocar across, but this would have given some
trouble, therefore, I preferred making a second puncture,
There was a copious discharge of a cloudy fluid, and the left
side of the scrotum then subsided to its usual size. The first
344; HYDROCELE,

discharge, when heated, coagulated readily, but the second re-
mained unaltered; on examination, however, in the laboratory,
it was found that the latter fluid was strongly albuminous.
The spermatic cord was in the same state as that on the other
side, and showed no indication of extravasation.

This case appears to me deserving of great attention; for
it sometimes happens that hydroceles, which have been con-
sidered as multilocular, have proved to be hydroceles of the
vaginal tunic, complicated with encysted hydrocele of the cord.
Dr. Loir, on the 19th February, 1830, exhibited a dissection
which can leave no doubt on this point. In fact, the sper-
matic cord was distended with fluid; or, in other words, the
hydrocele of the cord floated in the lemon-coloured serum
which filled the vaginal tunic, and formed the base of the
tumour: this, therefore, consisted of two distinct hydroceles,
but which were very difficult to distinguish from each other.
If it is proved by experience that the complication of these two
hydroceles may sometimes be mistaken for a multilocular
hydrocele, observation has equally demonstrated the existence
of hydrocele, the sac of which could not be thoroughly emptied
by a simple puncture, owing to a multiplicity of chambers, and
a sort of cellular structure in which the fluid was retained.

Hydrocele of the vaginal tunic presents marked differences,
when occurring in adults, or when it is congenital. It is well
known that in the immature foetus the testicle is within the
abdomen, and that it very often does not descend till after
birth. The peritoneal prolongation which accompanies it, and
which forms the vaginal tunic at a later period, is usually
closed a short time after its descent; but previously to this
taking place, it may happen that serum may pass down from
the abdomen. This gives rise to a hydrocele which is called
congenital, and which disappears on pressure, the fluid return-
ing into the abdomen.

I have ascertained that this species of hydrocele may occur
when the testicle is still within the abdomen, and behind the
internal ring. The mechanism of its formation may be easily
comprehended. The peritoneal prolongation which forms the
vaginal envelope of the testicle, and which corresponds with
the abdominal aperture of the inguinal canal, being pressed
either by the fluid contained in the abdomen, or by the intes-
AND ITS PRINCIPAL VARIETIES. 845

tines or omentum, insensibly yields to the pressure, becomes
elongated, and forced into the passage by which the testicle
passes and descends to the bottom of the scrotum. A fluc-
tuating, translucid, soft, pyriform tumour, is then observed
in this sac, which disappears almost entirely on pressure, or in
a horizontal posture, but which reappears, as before, when left
to itself a few moments, after the patient has assumed an up-
right position. I have also seen a second variety of congenital
hydrocele, which is characterised by the same elongation of
the peritoneum that is hereafter to form the vaginal tunic ;
whilst the testicle, which has already descended into the in-
guinal canal, is approaching the completion of its exit by the
external ring.

The body of the tumour, in these two varieties of hydrocele,
is covered only by the integuments of the scrotum, by the
subjacent cellular tissue, or by the cellulo-fibrous lamina of the
fascia superficialis. The upper part is entangled in the ex-
ternal ring, and the testicle is found adhering to the posterior
part of its neck, as it would be at the bottom of the vaginal
tunic. The abdominal orifice of the hydrocele communicates
with the peritoneal cavity by a small opening.

These two varieties should be considered with great care, as
they might be mistaken for hernia, which is in the same way
developed from above downwards.

Amongst the diseases which are frequently found in con-
nexion with hydrocele, hernia should not be omitted, especially
amongst old people. Hydrocele commonly appears in front of
hernia; it very seldom passes behind. Some surgeons recom-
mend, in such cases, to leave intact the vaginal tunic, and to
open only the hernial sac. Experience has proved to me that
this is inexpedient, as the results of such a proceeding are
obstinate inflammation and other accidents, which might have
been avoided by opening at the same time the serous tunic of
the testicle. By the last-mentioned treatment the strangula-
tion is relieved, and a radical cure of the hydrocele is accom-
plished.

When the hydrocele is situated in front of the hernia, it
sometimes happens that a portion of the omentum or intestine
passes through the areole of the tissue which envelopes the
vaginal tunic, and finds its way into the midst of the water

 
846 HYDROCELE,

forming the hydrocele. These secondary tumours are covered
by the hernial sac, and also by the serous investment of ,the
testicle. In six cases of this sort, which have come under my
observation, I have twice seen symptoms of strangulation
depending on the constriction of the contents of the sac, at
the point where they were engaged in the serous sac of the
testicle. In such cases the hernia was soft and insensible at
its upper part, whilst below, on a level with the hydrocele, it
became tense and sensitive, and manifested all the symptoms
of strangulation. It became, therefore, necessary to lay open
the vaginal tunic distended with serum, which was detected by
the discharge of the fluid, by the immediate presence of the
testicle, and by the absence of a superior opening towards the
rmg. The prominence of the secondary hernia was then per-
ceptible ; and having opened the hernial sac, the aperture
through which the viscera passed into the cavity of the vaginal
tunic was relieved, and, without touching the ring, the parts
were easily reduced. In no case have I seen the vaginal tunic
project into, and become entangled in, the hernial sac.

As the hydrocele may be covered partially or entirely by a
hernial sac, more or less filled with omentum, great care must
be taken, when a puncture is made, not to prick the hernial sac
or the testicle. It is very important, in such a case, to be
well acquainted with the relative position of the two sacs,
which is far from being always the same; thus, although
in some cases the hydrocele forms the most posterior and
inferior portion of the entire swelling, frequently the aqueous
tumour is placed in front and to the outer side of the hernia.
Under other circumstances, the vaginal tunic penetrates into
the hydrocele,’ and forms a true aqueous hernia in its cavity.
The reverse may also occur, when the vaginal tunic gives way
at some point corresponding with the hernial sac, and a rent
is formed through which a portion of the hernia protrudes.
The resistance and elasticity of the edges of this laceration, as
well as its narrowness, are such, that the parts which constitute
this sort of hernia are frequently found to be irritated, con-
tused and compressed in their passage, exhibiting all the

' [This passage has been literally rendered: the context and sense would appear
to require that “hernial sac” should be substituted for “ hydrocele ;” and yet, this
would be inconsistent with the remark at the conclusion of the last paragraph.—T.}
AND ITS PRINCIPAL VARIETIES. 347

symptoms of strangulation, whieh is attributed, although in-
correctly, to stricture at the ring.

I have seen several such cases. It is very necessary to. be,
acquainted with them, and to bear them in mind when
operating for hydrocele and strangulated hernia, in order to
avoid plunging the trocar into a hernial sae, or cutting through
the envelopes of a hydrocele for those of a hernia, or attempting
to relieve the constriction at the ring, when the strangulation
is really produced by the contraction of the lacerated opening
in the vaginal tunic on the parts which have penetrated into
its cavity.

Amongst other complications, we must not omit sarcocele,
of which the following is an interesting case.

Cast VII.—Hydro-sarcocele : extraordinary case as regards
the difficulty of the diagnosis—A short time back a naval
physician came to consult me for an affection of the left
testicle. It had been considered a hydro-sarcocele by some of
our profession, who had examined it. The following are the
circumstances: The left testicle had never descended into the
scrotum. <A tumour of variable size frequently appeared along
the course of the spermatic cord, descended more or less, at:
times even to the scrotum, and afterwards rose again gradually,
disappearing at the inguinal ring. At length it became sta-
tionary without the abdomen. It was supposed to be hernia,
and the patient from his youth had constantly worn a truss.
Now, observe this fact, for it no doubt materially influenced
the subsequent .modifications of the organs. It may be ad-
mitted as a principle, that when a truss is unnecessary it is
almost always injurious, by exercising constant, sustained
pressure, the effects of which are nearly at all times bad; it
has not unfrequently been known to give rise to swellings of
a scirrhous nature. For some years, however, the patient had
discontinued wearing it, and he was now thirty-two years of
age. Another circumstance, also to be taken into account, is
the frequent variation in the size of the tumour. During a
long voyage, which he had been compelled to take a year ago,
it increased considerably ; and, on his return, fluctuation was
detected at the anterior and inferior portion; and above and
behind this fluctuation there was a hard substance. The first
348 HYDROCELE,

time I saw the patient, I thought there was a collection of
fluid; but it was difficult, taking into account the antecedent
circumstances, to determine what organ was the seat of the
hard substance to which I have alluded. I inclined to think
that it was a swelling formed by a hernia with adhesions; and
I confined myself to recommending rest, baths and topical
emollients, and afterwards endeavouring to reduce it, but I
met with no success.

The patient, who was again on the eve of another long
voyage, was desirous of getting quit of the affection at any
cost. It was a most embarrassing situation for an operator.
There was undoubtedly a collection of fluid, but with this all
certainty was at an end, and beyond was nothing but doubt
and obscurity. In the first place, it is often very difficult to
distinguish sarcocele from hydrocele, complicated with carti-
laginous thickening of the vaginal tunic; but further, I had
to ascertain whether this hydrocele existed alone, or whether
it was accompanied by sarcocele, by congestive swelling of the
testicle, or by hernia, and whether this hernia had contracted
any adhesions or not; for either of these hypotheses might
prove correct. We daily meet with this sort of complications,
and we must regulate our proceedings in accordance with the
results which we observe. J thought at first of making an
exploring puncture, but I had still to decide on the mode of
doing this. The use of the trocar, which is harmless, and
an appropriate instrument in a case of simple hydrocele, would
have been very dangerous, if the tumour should prove to be
simple swelling of the testicle, without actual disease, or to
result from the presence of intestine. In either case, there
would be great risk of injuring one or other of these organs.
Further, if sarcocele existed, puncturing would be useless.

I determined, on these considerations, to open the tumour
with a bistoury. I made an incision, about an inch long, in
the lower part of the integuments, and prolonged it a little ob-
liquely backwards, carrying it gradually and carefully down to the
sac containing the fluid, which presented a blueish tint, and was
resisting. Having punctured it with the point of the bistoury,
some serum escaped exactly like that which occurs in simple
hydrocele. With the view of preventing the infiltration of
this fluid into the cellular tissue, I enlarged the incision ; the
AND ITS PRINCIPAL VARIETIES. 349

quantity discharged may have amounted to eight or ten
ounces. The tumour was thus diminished to about one third
of its former size. It was then quite evident that the re-
mainder of the tumour—the hard substance of which I have
spoken—was formed by the testicle itself; but it remained to
ascertain in what condition it was, and whether the swelling
was due to a venereal affection, to scrofula, or rather to some
external cause. In reply to questions put to the patient, it
appeared that he had only once had gonorrhcea, which lasted
five or six days. Although he had some slight symptoms of
scrofula, yet they were not sufficient to warrant the belief that
the disease was due to it. The patient was of good consti-
tution, and had otherwise always enjoyed good health. Every-
thing, therefore, combined to make me believe that the tumour
had arisen from pressure on the testicle by the truss, which
he had worn for many years for the supposed hernia. Finally,
in case it might have arisen from venereal affection, would it
have been right to limit the operation to what had already
been done, and to treat the disease by antisyphilitic remedies ?
This must have depended in great measure on the knowledge
to be acquired of the condition of the testicle; whereas, the
circumstances already enumerated only served to assist me in
forming an opinion as to the propriety of removing the organ.

Having carefully examined the testicle, I found several
knotty prominences and inequalities on its surface; it was
hard and almost insensible, and the hardness was most re-
markable in the epididymis, which had acquired considerable
size.

There were, therefore, strong reasons for believing that the
testicle was in great part diseased, and I determined on re-
moving it. But, in the first place, being desirous of ascer-
taining the state of the upper portion of the spermatic cord
and the inguinal canal, I reached the latter without any
difficulty, and found it widely open and perfectly free. This
circumstance explained satisfactorily the varying size of the
tumour, which was due to the occasional descent of a hernia,
and its spontaneous reduction. JI also discovered why the
tumour which contained the fluid could not be returned into
the abdomen; this was owing to the disposition of the epidi-
dymis, which occupied the entrance of the ring, whither it had
350 HYDROCELE,

been pushed up by the tumour, and thus effectually blocked
this aperture. It is well known that in dogs a peritoneal
fold, placed there as a kind of valve, prevents the return of
injections made by the vaginal tunic. With our patient the
epididymis fulfilled, abnormally, the natural function of the
peritoneum in dogs.

In this peculiar condition of the ring, the operation might
be attended with two accidents equally serious. A portion of
the intestine might pass out of the abdomen, and become
entangled in the wound, as sometimes happens in operations
for strangulated hernia. Again, if hemorrhage supervened, the
blood extravasated into the peritoneum might give rise to
violent inflammation of this membrane. To prevent these, I
took the precaution to tie the vessels of the cord with great
care, and I endeavoured to do the same with the vessels of the
integuments,

I will recapitulate the circumstances of this interesting case.
The tumour was formed by a collection of fluid, and the ab-
normal size of the testicle; and, incidentally, by the hernia of
an intestinal fold. The collection of fluid, which I estimated
at eight to ten ounces, was produced by a morbid secretion of
the vaginal tunic, and formed a true hydrocele. Although
the inguinal ring was largely open, the communication of the
vaginal tunic with the peritoneal cavity was not free, owing to
the peculiar disposition of the lower part of this canal, and it
was found impracticable to reduce the sac which contained the
fluid. As regards the determination at which I arrived, to
remove the testicle, it appeared to me the most prudent course.
The operation, it is true, was painful, long, and difficult ; but
this was not to be compared with the accidents which would
result from the ulterior course of the disease, or with an opera-
tion having in view an entirely different object. Moreover, an
inspection of the preparation will determine whether I came to
a right decision or not. The testicle, which was more than
three times its natural size, being cut open with a bistoury,
presented a carcinomatous condition, but in its first stage, that
is to say, without degeneration or softening ;—a fortunate cir-
cumstance, as the patient thereby enjoyed a better prospect of
radical cure. The epididymis, at least four times its usual size,
was in the same state. The general constitution of the patient,
AND ITS PRINCIPAL VARIETIES. 351

the integrity of the cord, and the presumed cause of the affec-
tion, all lead me to believe that he will be perfectly cured.

I must now briefly direct attention to several cases of less
frequent occurrence, and which are less perfectly understood.
Serous cysts may be developed in one side of the scrotum,
which then assumes a very considerable size. In these cases
scirrhous degeneration has been suspected, and the testicle has
been removed; at other times these cysts appear in the midst
of the organ itself. This is connected with what Morgagni calls
hydatids of the testicle, and he attributes hydrocele to the rup-
ture of these cysts. Having, he says, observed, in every case of
this disease, hydatids of the testicle either entire or ruptured, or
vestiges of old hydatids, he considered himself bound to con-
clude that the rupture of these hydatids was the most general,
if not the sole, cause of hydrocele. In the present state of
science I shall not discuss the value of this explanation, but will
merely observe that an hydatid cyst, developed in the body of
the cord, or in one side of the scrotum, may, from its softness,
its elasticity, its greater or less transparency, and other
characters, lead to the belief in the existence of hydrocele of the
cord or of the vaginal tunic. They are more easily confounded
with hydrocele, when the cavity is separated into chambers. I
have seen several individuals of the same family affected with
this strange disease, and I cured them all by incision of the
cyst.

Purulent or melicerous cysts, scrofulous disease, and other
results of chronic inflammation of the testicles, which have
been sometimes called encysted hydrocele of this organ, are
morbid changes wholly different from that now under con-
sideration. These or other purulent collections require either
incision of their parietes, or extirpation of the organ which
incloses them.

The texture of the vaginal tunic undergoes various stages
of disorganization, which it may not be unprofitable to examine.
At the commencement of the disease, it is thin, transparent,
and easily cut through. At a later period, when the affection
is of old standing, this envelope, or rather the cellular tissue
of its external surface, frequently acquires great thickness, and
a consistency almost resembling cartilage. It is then seldom
transparent ; and after puncture, the tunic, instead of collapsing,
352 HYDROCELE,

remains like a shell around the organ. At times I have seen
this serous sac become the seat of sanguineous extravasation,
more or less abundant, or present osseous plates of variable
size. The three following cases will give some idea of these
alterations of the vaginal tunic, and of the difficulties which
such cases create in practice.

Case VIII.—Hydrocele. Cartilaginous degeneration of the
vaginal tunic. Bloody extravasation—An old man came to
the Hétel-Dieu, in 1815, having a tumour in the scrotum larger
than the two fists. This tumour fluctuated sensibly in front,
and behind it presented two very hard tubercles; it could be
easily isolated from the ring, and was considered to he a
hydrocele, or a hydro-sarcocele: the patient having died from
weakness, the parts were examined. Beneath the skin and the
dartos was a very thick fibrous expansion, covering a cartila-
ginous membrane which was the vaginal tunic; it was carefully
opened, and there came away immediately a large quantity of
fluid of the colour of wine-lees, a portion remaining behind of
the same colour, without consistence or cohesion, which proved
to be decomposed blood. On splitting the cartilaginous mem-
brane in various directions, it was found to be half a line thick ;
and attached to it was the testicle, converted into a thin plate,
and forming a portion of its parietes. The two small tubercles
which had been felt, were formed by a circumscribed thickening
of the cartilage, the centre of which was osseous.

Cast IX.—Hydrocele. Cartilaginous degeneration of the
vaginal tunic.—During the year 1820, Ch , of Lille, aged
about 40, came to me, having in the scrotum a rounded,
uneven, hard, resisting, opaque tumour, the size of which might
be equal to the fist of a child ten or twelve years old, and
which, uniting with the testicle, was, like this organ, movable
and suspended by the cord. These signs might equally lead
to the suspicion of a hydrocele complicated with cartilaginous
degeneration of the vaginal tunic, of a sarcocele, or of a hydro-
sarcocele. Such was the condition of the affected parts;
and had it been necessary to determine the nature of the
disease upon mere inspection, it may be easily imagined into
what a state of irresolution the surgeon might have been thrown.

 
AND ITS PRINCIPAL VARIETIES. 358

This difficulty, however, did uot occur, as the information ob-
tained from the patient solved the question at once.

The disease had commenced twenty-two years previously, at
an age when carcinomatous degeneration rarely occurs; it was
not painful, but only inconvenient from its weight; finally,
puncturing had been several times unsuccessfully tried, both
with and without injections; and every time the sac was emptied
it was observed that the testicle was healthy, but that the tunic
was gradually becoming thicker and harder.

After these details it was impossible to be deceived ; the
patient was affected with hydrocele, complicated with cartila-
ginous degeneration of the vaginal membrane. Excision was
the only course to be adopted. On cutting into the cyst, a small
quantity of lemon-coloured, transparent serum was discharged.
The cavity of this sort of cartilaginous shell into which the
membrane had been transformed, and of which the parietes
were at least four or five lines thick, was divided by fibrinous
productions, the rudiments of partitions which might hereafter
have become more organized, and have separated the principal
cavity into several secondary chambers. The patient was com-
pletely cured in a month.

Caszr X.—Hydrocele with cartilaginous degeneratin of the
vaginal tunic. Sanguineous extravasation—D—-——, of St.
Domingo, a man of colour, aged about 40, having seriously
bruised his right testicle, had for several years suffered violent
pain, and perceived that it gradually increased in size. He de-
termined on coming to Paris, and on his arrival the testicle was
hard, heavy and uneven; and, besides being very sensitive at
all times, it was occasionally the seat of those shooting pains,
which are considered as characteristic of carcinomatous de-
generation. I pronounced that he had sarcocele, and proposed
extirpation, which was almost immediately carried into effect.
Having laid bare the organ by an incision, and discovered
a fluctuating point at its surface, for greater surety I plunged
the point of the bistoury into it, and there came away. a jet
of reddish, inodorous fluid, analogous to that which is often
found in degenerated tumours; I had therefore no further
doubt, and the extirpation was completed. The tumour was
then examined: It was found to be entirely formed by the

23
354 HYDROCELE,

vaginal tunic, which had become cartilaginous and of unequal
thickness. The cavity into which the puncture had been made
during the operation, was its own proper cavity, and the fluid
which had been discharged owed its quality and colour to the
mixture of a certain quantity of blood; the latter proceeded
from a perfectly round, regular and even aperture, the edges
of which were smooth and about two lines in diameter, which
was situated at the posterior and inferior portion of the
sac, and implicated both the vaginal tunic and the tunica
albuginea. Through this opening the substance of the testicle
itself was seen, and this was found to be healthy; so that,
although the exact nature of the disease had not been at first
detected, there was no reason for regretting the proceeding
which had been adopted.

The most usual mode of cure, in hydrocele, is by injection ;
but I have been successful in the application of a blister to the
scrotum, It excites an irritation which extends to the va-
ginal tunic, and induces absorption of the fluid contained in
this membrane, as well as the reciprocal adhesion of its adjoin-
ing surfaces. This occurred in the following case.

Casz XI,—Hydrocele cured by the application of a blister.—
J. A. Lobré, a confectioner, aged 19, came to the Hétel-Dieu,
on the 28th of January, 1826, suffering from hydrocele of the
vaginal tunic on the right side. It had commenced five or
six years previously, without assignable cause, and had since
increased very slowly. It was pyriform, rather tense, and of
middling size ; its transparency was manifest, it was unattended
by pain, and was not accompanied by any enlargement of the
cord. The young man was of sanguine temperament, of ex-
cellent constitution, and in good health. It was decided to
operate by injection; and on the lst of February, everything
being ready, a trocar was plunged into the tumour. There
was some difficulty in introducing the instrument, and con-
siderable impulsive force was necessary, which appeared to
arise from the canula not being very exactly fitted to the cir-
cumference of the blade towards its extremity. It seemed
that the canula, after having passed through the scrotum, had
momentarily pushed before it the vaginal tunic; but having at
length pierced it, the trocar, following the greater impulse
AND ITS PRINCIPAL VARIETIES. 3855

given to it, had imbedded itself in an opposite part of the
cavity of the vaginal tunic. The blade of the trocar being
withdrawn, it became necessary slightly to withdraw the canula
also, to admit of the discharge of the serum. The quantity
that came away was by no means proportionate to the size of
the hydrocele, because the testicle was enlarged, and thus in-
creased the dimensions of the tumour. It was besides insensible.

It had been at first proposed to operate by injection; but
as the circumstances mentioned as attending the puncture
occasioned some apprehension that the wine injected might
infiltrate into the adjoining cellular tissue, I thought it best to
desist ; but I did not give up the hope of completely curing
the hydrocele. I had recourse, therefore, to a large blister
applied over the whole surface of the scrotum, and this was put
on the same day. On the following day the blister had risen,
and there was swelling similar to that which follows the
operation by injection. It was thought proper to keep up and
increase the irritation on the surface of the scrotum, and the
part was dressed with blistering ointment. On the third day,
suppuration was established; the swelling had increased, and
it was at least as large now as it was before the evacuation of
the fluid ; this appeared to be partly the result of swelling of
the scrotal cellular tissue, partly of extravasation of the fluid
in. the vaginal cavity, and partly of the enlargement of the
testicle itself. On the fourth day, the appearances were the
same; the suppuration was abundant, and throughout the sur-
face of the scrotum.

During this time the patient had suffered considerable pain
at the neck of the bladder, as well as some fever and tenesmus,
accompanied by difficulty in passing his water ; these symptoms,
however, subsided, and did not last long. The suppuration of
the blistered surface was kept up till the 10th of February, at
which period the dressing was weakened by a mixture of simple
cerate, the blistering ointment being diminished daily. The
suppuration then decreased, and by the 16th or 17th of Feb-
ruary the blister had quite dried up. At this period the
swelling had diminished by one half, and that which remained
appeared to proceed from enlargement of the testicle, and
from the presence of fluid in the vaginal tunic, which was de-
tected by obscure fluctuation.
356 HYDROCELE,

The swelling of the testicle was considered as the result only
of the inflammation intentionally promoted, and which was
requisite to encourage the adhesion of the opposed surfaces of
the vaginal tunic. But the presence of fluid at this advanced
period of treatment created apprehension that it might prove
an obstacle to a radical cure; it was hoped, however, that it
would soon be entirely absorbed. The scrotum was kept
covered with dressings steeped in discutient lotions. On the
27th of February he asked to be discharged, and at this period
there was no longer any sign of fluctuation; the fluid had
apparently been wholly absorbed, and the only remnant of the
inflammation occasioned by the blister, was some degree of
enlargement of the testicle, which had, however, diminished
considerably since the blister had dried up. The surrounding
parts had regained their natural state ; adhesions had probably
taken place between the surface of the testicle and that of the
vaginal tunic, and there was every reason to hope that the pa-
tient would be cured of the hydrocele.

The materials for injections should be selected with dis-
crimination; the following I have found most useful. Boil
two ounces of Provence roses in a pint of strong Roussillon
wine, the strength of which may sometimes be augmented by
the addition of a few spoonfuls of brandy. I make three suc-
cessive injections, each of three minutes’ duration. The only
precaution I invariably adopt, is to observe carefully, before
each injection, that the canula has not been withdrawn from
the cavity of the vaginal tunic. If a lateral movement of the
mouth of the canula is accompanied by a free movement of the
opposite extremity, the injection may be made without appre-
hension; but if, on the other hand, these movements are con-
fined and limited, it is probable that, from the retraction of
the parts, the vaginal tunic may have withdrawn itself from
the canula, and left it in the cellular tissue ; the injection must
not then be made till the tube shall have been properly re-
placed. By neglect of this precaution, it sometimes happens
that the injected fluid passes into the cellular tissue instead of
entering the vaginal tunic, as we shall see presently. The in-
troduction of an injection may give rise to nervous symptoms,
spasms and convulsions, The inflammation which ensues is
frequently very violent, but it is confined to the vaginal tunic
AND ITS PRINCIPAL VARIETIES. 357

and the skin; it is very rare to see it followed by abscesses
in the testicle. M. Pelletan once saw tetanus ensue after the
operation for hydrocele by injection.

Cast XII.—Hydrocele treated by puncture. The fluid in-
troduced into the cellular tissue.—A person suffering from hy-
drocele went to an hospital for advice. The fluid was drawn
off, but the injection, instead of being thrown into the vaginal
tunic, was retained in the cellular tissue; very severe inflam-
mation followed, and it was with great difficulty subdued.
The extravasation having returned, the patient came, in 1833,
to the Hétel-Dieu. I determined on operating by incision.
After four and twenty hours the patient was seized with nausea,
and a short time afterwards hemorrhage took place, which
was twice repeated. I took off the dressing, washed the wound,
and covered it with cloths dipped in cold water; I abstained
from plugging the wound, because the blood came from the
inguinal ring. Every one knows that in Germany, in exten-
sive hemorrhages, they expose the parts to the air and bathe
them with cold water. This treatment is not suitable where
the bleeding proceeds from large vessels, as the ligature is a
much more certain method of arresting it; but in hemorrhage
from small vessels, accompanied by inflammatory symptoms, it
is proper. This was the case with the patient in question;
the bleeding occurred during the period of inflammation, and
did not return. It would have been far otherwise if I had
attempted to stop it by pressure. A man whose thigh had been
amputated, received a blow on the stump, which made it bleed.
I took off the dressings, and found the surface of the wound
grey, but I could not discover the bleeding vessel. I used
pressure, which was followed by pain, and the bleeding recurred.
I again took off the dressings, and both ceased. I renewed
the dressings twice, and each time the bleeding recommenced.
It was manifest that the dressings excited tension of the
parts, and thence hemorrhage, (the form which I have deno-
minated hemorrhage from irritation); I did not apply them
again. I have since had occasion to observe capillary hemor-
rhages produced by irritation, which generally ceased on
throwing aside the dressings. Such forms of hemorrhage
must be treated medically, by emollients, bleeding, cold

*
358 HYDROCELE,

water applications, and the removal of all irritating appli-
ances,

Injection of the tunica vaginalis is very often accompanied
by pain, but it may happen that this symptom is absent. M.
Cruveilhier has given two cases which quite prove this, The
first related to a man, aged 52, who had hydrocele on the
right side. By the advice of a physician, the part was subjected
to the vapour of a solution of elder-flowers, poppies, and some
other ingredients. The effect of this remedy was so rapid,
according to the patient’s report, that the testicle was reduced
nearly to its natural size in the course of seven or eight days.
A month after this marvellous cure, he was attacked by a sharp
pain in the chest, which was subdued by blisters and antispas-
modic draughts. From this time the testicle appeared to the
patient larger than its natural size, but it remained stationary till
the 1st of March, 1813, at which period the hydrocele returned,
and soon reached the same size as on the first occasion. When
examined, the tumour was remarkable for its great weight.
After the patient had been prepared the sac was tapped, and
two injections were made without causing any pain. Its
absence would have appeared a bad sign to many practitioners,
but experience has proved to me that pain is not a necessary
condition to the success of the operation, and that the necessary
amount of irritation may still be produced. The result of this
operation was in no way peculiar, and the patient went out
cured,

The second person was also treated by puncture, without
suffering any pain, and he was cured in the same way.

M. Lisfranc has also given two cases of injection without
pain ; and he is of opinion that nothing can be concluded, as to
the success or otherwise of the operation, by the presence or
absence of pain. It depends entirely on the idiosyncrasy of
the patients.

The passage of the fluid into the cellular tissue may also
lead to gangrene of the scrotum. Such accidents, which are
ascribed to the process of injection, depend altogether on the
manner of operating.

Injection is the proceeding most commonly adopted; and
although it succeeds in ninety-nine cases out of a hundred, I
have seen it fail six or seven times in the course of my practice.

“
AND ITS PRINCIPAL VARIETIES. 859

It is not, however, the only means used, for there are cases
which require different treatment. Thus, when the cavity of
the vaginal tunic is divided into several cells, which is detected
by the unevenness of the surface of the tumour, by the trans-
parency of these prominences and the opacity of the intervening
spaces, and also by a peculiar obscurity in the fluctuation, it is
evident that an incision opening all the cells at once is pre-
ferable to repeated injections ; and incision must also be resorted
to, if it be discovered, after puncturing, that this condition
exists, which may be known by the small quantity of fluid
discharged.

If the disease be of old standing, if the tumour be opaque,
hard, and of small volume, it may be considered that the
vaginal tunic has assumed a cartilaginous structure, in which
case excision is necessary. I perform this operation as follows :
I grasp the whole tumour with the left hand, so as to stretch
the anterior parietes as much as possible; I then regulate my
incision according as it may be necessary or not to remove a
portion of the integuments ; next I press out the vaginal tunic,
as one would squeeze out the stone froma plum. I finally
open the cyst and cut it away. The wound is then filled with
soft lint, and the dressing is precisely the same as in cases of
incision.

The treatment of hydrocele in children presents some pecu-
liarities, which I will mention. In congenital hydrocele it has
been recommended to return the water into the abdomen by
gradual pressure, and to keep it there by means of a truss, the
pad being placed exactly on the ring. Nature closes the
aperture of the prolongation of the peritoneum which forms
the vaginal tunic, just as would have happened if no obstacle
had been interposed; and the patient is relieved from all incon-
venience. This method, which was introduced by Viguerie,
may be dangerous-and lead to mischief, when the testicle is
still within the abdomen or in the inguinal passage.

Cold baths have been beneficial in these cases, corrugating
the parts, and causing a portion of the vaginal tunic to retract :
blisters applied to the swelling have, in some cases, induced
absorption of the extravasated fluid, and adhesion of the
parietes of the sac which contained it. These modes of treat-
ment have the immense advantage of effectually combating
360 HYDROCELE.

the hydrocele, whilst there is no pressure on the testicle, which
may descend freely. When an operation must be resorted to,
a correct knowledge of the varieties which may occur, in the
disposition of the parts, is very useful; the surgeon may then
modify his operation, so as to spare the patient from unnecessary
danger, and make it at the same time more efficacious in the
cure of the disease.

Before injecting, in cases of congenital hydrocele, it is neces-
sary to be well assured that the testicle has descended, and that
the sac does not contain any portion of intestine or omentum.
An assistant should apply pressure on the top of the hydrocele,
at the termination of the inguinal canal, so as to bring the
parietes together. Then the operator, after evacuating the
sac by means of the trocar, may proceed to inject in the
usual way, the assistant preventing the injected fluid from
rising too high up. When the operation is finished, a padded
truss, such as are used in hernia, should be applied over the
external ring. In this way a radical cure of the hydrocele has
been obtained, as well as the separation which ought to exist
between the sac containing the testicle and the abdominal
cavity ; and the risk of the occurrence of congenital hernia,
which is a frequent complication of congenital hydrocele, is
also avoided. It is manifest that, if such a complication should
exist, the hernia must be returned before operating, and should
be kept reduced during the whole course of treatment.
SECTION XIII.

ON A PARTICULAR SORT OF FIBRO-CELLULAR ENCYSTED
TUMOUR, KNOWN BY THE NAME OF NERVOUS GAN-
GLIONS OR TUBERCLES.

Cysts are accidental membranous productions, either
organized around a foreign body, or developed prior to the
contents which they enclose. Cysts formed around extra-
vasated blood, balls, urinary calculi, &c., are examples of the
former class of cysts; whilst serous, synovial, melicerous, stea-
tomatous and gelatiniform cysts, are illustrations of the latter.

There is a third division which includes fibrous productions,
characterised by a dense, white, resisting tissue, often enclosed
in fibrous or fibro-cellular sacs. With this latter class the
little encysted tumours, of which I am about to speak, have
the closest analogy. But, in many of their characteristics,
they differ essentially from all three classes, for they are fibro-
cellular in structure, and rounded in form, not exceeding a pea
in size, and almost always situated beneath the skin of the
limbs, and terminating in cancerous degeneration.

It is difficult, at first sight, to imagine that a little tumour
of the kind I refer to, and which the eye can scarcely detect,
should be the seat of such acute suffering, and the nucleus of
so fearful a disease as cancer ; yet observation has proved such
to be really the case.

Many authors have accurately described these tumours, but
have believed them to be developed in the nerve tissue, or
specially in the course of the nerves. Thus, A. Petit, in his
discourse on pain, after speaking of the extreme sensitiveness
of the extremities of nerves, remarks, that “the nervous
ganglions are very little known; they exhibit themselves in
the form of little bodies about the size of a bean, hard, movable,
colourless ; sometimes resulting from injury, at others occurring
without apparent cause, and being the seat of the most excru-
ciating pain, when touched ever so lightly: tonics are of no
862 NERVOUS GANGLIONS

service to relieve this suffering; extirpation alone can get rid
of them. They present, on dissection, a white, tubercular
structure, enveloped in fibrous membrane, usually adhering
to the skin, movable in the cellular tissue, where it appears
to be connected only to some nervous filaments, of which it is
the expansion ; a large proportion of those I have operated on
were in the leg; one only occurred in the arm.”

Cheselden! mentions having twice met with a small tumour,
about the size of a pea, beneath the skin covering the tibia;
that it was excessively sensitive, and regarded as cancerous;
extirpation effected a cure. Camper and Chaussier speak of
these little tumours in the same strain; and lastly, in 1822,
M. Descot describes them under the title of “ painful’? sud-
cutaneous tumours, and remarks that they seem to be connected
only by nervous filaments to the surrounding parts, or else they
are developed in the body of a nerve, the fibrils of which are
distended and separated by their presence.

Thus, it will be perceived that, hitherto, authors have
associated these little tumours with the nerves, and even speak
of them as being connected with nervous filaments; but I can
find no account of such connection having been verified by
actual dissection.

Now, my own observation has led me to a different con-
clusion. I believe that these tumours have no connexion
whatever with nerves. I have repeatedly dissected them on
the dead body, and examined them, with care, after removing
them from the living, with a sufficient quantity of cellular
tissue around them; yet I never could discover the slightest
trace of any eonneron with nerves. The tissue of these cysts
is evidently fibro-cellular, slightly albuminous, and assuming,
after a time, the character of scirrhus.

Though these tumours usually occur in the limbs, I have
likewise seen them in other parts,—as in the breast. They
are found sometimes of a globular, at other times of an oblong,
form, as large as a grain of wheat, a pea, or a coffee-berry ;
they are smooth, hard, and opaque, and rebound with con-
siderable elasticity if dropped on a resisting surface, They are
homogenous in texture, without cavity or cell, and of a fibrous,
or fibro-cartilaginous, consistence. When cut across, they

' In his ‘ Anatomy,’ where speaking of the structure of the skin.
OR TUBERCLES. 363

exhibit several concentric layers united by a dense cellular
tissue, which is closest in its texture externally. A slight,
crackling sound is audible on pressing the nail into its structure ;
it is enveloped in a dense and opaque fibro-cellular capsule,
constituting a true cyst, which limits its development, and pro-
bably gives rise to the acute suffering which is experienced.

These tumours are never inflamed, nor even reddened. The
cellular tissue surrounding them is unchanged. The superjacent
skin is usually healthy, unadherent, and of natural colour ;
occasionally, however, it is of a purple hue, and is closely
attached to their surface, thus rendering them immovable.
They are quite independent of the nerves, as the following case
will exemplify.

Case I.—Tubercle on the upper and outer part of the thigh.
Excision and cure.—M. Cordier, a washerwoman, aged 55, of
lymphatic temperament, was admitted into the Hétel-Dieu, in
1828, with a small tumour on the upper and outer part of the
right thigh: it could scarcely be felt through the skin, and had
been the seat of acute pain during the previous eighteen months.
She attributed its presence to a blow she had received on the
part; and the pain, which was at first trifling, afterwards
became insupportable, but was never augmented by pressure.
For some time no tumour was perceived; and, as the
pain increased in intensity, the paroxysms were more frequent,
and at shorter intervals; and it was only five months since
that she had noticed the existence of a small, hard swelling,
which, when pressed, felt as if pierced by a needle. Her sleep
was broken by the pain, and she walked sometimes with diffi-
culty. The part was leeched, and blisters were applied over
the hip, thigh, and knee ; but these only increased the suffering,
and drove her to seek admittance into the Hétel-Dieu.

At the time of her admission she could not sleep, in conse-
quence of the severe pain, which was almost continuous, and
extended from the upper and outer part of the right thigh,
over the knee, leg, buttock, loins, and hypogastric region of
the affected side, having for its centre of radiation the small,
hard and movable tumour, which scarcely raised the skin,
and was unaltered by pressure, as regards its form and size;
but the slightest touch aggravated her suffering.
364 NERVOUS GANGLIONS

This tumour was readily extirpated. A small T-shaped
incision sufficed to expose it; and, being drawn out from its
cellular bed, it was excised by one cut of the bistoury. Instant
and complete relief followed, to the great astonishment and
satisfaction of the patient ; and the little wound was dressed.

The tumour was, in size and shape, like a large pea; it was
embedded in healthy cellular tissue; it surface presented no
appearance of inflammatory action, not even redness, neither
did its interior. The texture was hard, elastic, homogeneous,
and whitish, without interval or cavity, easily penetrable by the
nail, and enveloped in a dense, opaque cyst, to which it had
no adhesions, although the latter was immediately applied to
its surface, and presented a fibro-cellular appearance.

The wound healed by granulation, and the patient had no
return whatever -of the pain.

Case II.— Ganglion situated on the fifth nerve. Section of
a branch, without success. Excision of the body, followed by
cure.—A woman came to see me at the hospital, complaining
that, for some years past, she had been the subject of acnte
suffering in the cheek, which had been sometimes regarded as
of a rheumatic character, and at others referred to the infra-
orbitar nerve. She had been bled, leeched, and blistered,
without any relief. One surgeon, who was consulted, was so
satisfied of the neuralgic character of the affection, that he
divided the infra-orbitar branch of the fifth, just as it emerges
from the foramen of that name. Instead of obtaining relief
from this operation, the patient’s sufferings were greatly
aggravated, and she was induced to come to me. On carrying
the finger over the cheek, I distinctly felt a small, hard, and
movable tumour, immediately beneath the skin, which was
healthy. Pressure on it caused acute pain. I extirpated this
tumour, and from that moment the patient was relieved.

It is evident that if the tumour, in this case, had been
developed in connexion with the nerve, or attached to it, the
section of the latter ought to have relieved-the pain; whereas,
on the contrary, the operation only served to augment it, and
the removal of the tumour accomplished a cure.

The following case is one of an analogous nature to the
last.
OR TUBERCLES. 365

Case III.—Ganglion situated on the course of the infra-
orbitar nerve. Error in diagnosis. Extirpation and cure.—
Monsieur ——, formerly in the army, 50 years of age, and
unmarried, had been, when young, frequently the subject of
venereal affections, and occasionally of slight rheumatic attacks.
For the last two years he had suffered from pain in the right
side of the face, extending from the malar region over the
cheek, eyelids and forehead, on the same side. This suffer-
ing, which was intermittent, had increased in intensity and
frequency ; and had been regarded and treated as an affection of
the infra-orbitar nerve. In 1828, the medical man, who com-
municated the case to me, saw the patient. The pain was
then produced by any movement of the jaw, laughing, or
passing the hand over the cheek; and when severe, lachry-
mation, twitching of the eyelids, and a copious flow of the
saliva from the mouth, were excited. A small prominence
was perceptible on the cheek, a little external to the infra-
orbitar foramen; and in this situation, a small, hard, and
movable tumour could be felt rolling beneath the finger: the
pain occasioned by this examination was severe, extending over
the whole of the right side of the face, and lasting for twenty
minutes. An operation was proposed, and eagerly accepted.
The tumour was readily exposed, and then excised with a pair
of scissors curved on the flat. It was about the size of a pea,
and presented all the characters I have noticed in the first
case.

From the moment of its extirpation the patient ceased to
suffer ; and the wound healed kindly, leaving a scarcely per-
ceptible cicatrix.

It is evident that there is a close analogy between these
tumours and the earliest stages of cancer. Cruveilhier ascribes
to them, in his ‘ Pathological Anatomy,’ the same fibro-cellular
character mingled with albumen.

CasE 1V.—Ganglion situated in front of the radius, cured
by extirpation A woman, aged 59, came to me for advice
concerning a small tumour which she had in front of the radial
side of the forearm, a little above the wrist. It was tolerably
movable, about the size of a large pea, very hard, and extremely
sensitive. If not touched, it gave her no pain; but, if pressed,
366 NERVOUS GANGLIONS

the consequent pain extended from the tumour towards the
trunk, and not in the direction of the fingers. It had been
growing insensibly for seven years, and had been stationary
during the last year. It was extirpated by a simple operation,
as in the preceding cases, and proved to be of the same encysted
character as the other tumours.

The slow growth of these little bodies is explained by their
hardness, and the nature of their capsule. Their tendency to
soften, after a varying time, is a confirmatory proof of their
scirrhous character. When this process of degeneration has
commenced, the disease will be reproduced in the neighbouring
lymphatic ganglions, even should the original tumour be ex-
tirpated. I had one case under my care, in which this soften-
ing had begun; and though I removed the cyst, the axillary
lymphatic ganglions became affected, and the disease re-
appeared. ,

Age and sex appear to exercise an influence on the develop-
ment of these tumours. Thus, women are more subject to
them than men; and they are most frequent between the age
of thirty-five and sixty. Most of the patients ascribe them to
injuries, such as blows or falls: in some instances the existing
cause appears to have been a puncture.

Cass V.—Ganglion on the finger. LExtirpation and cure.—
A shoemaker pricked his finger with his awl, and soon after-
wards experienced acute pain in the part. A small tumour
was developed at the seat of injury, growing insensibly, and, at
the expiration of seven years, giving rise to increasingly severe
paroxysms of pain. Caustic was applied in vain; but extirpa-
tion was entirely successful. The tubercle was small, hard, of
a cartilaginous texture, and contained in a cyst.

Sometimes I have seen these tumours developed under the
influence of a rheumatic affection, and disappear immediately
the patient was withdrawn from the causes which had produced
the primary disease.

Cast VI.—Ganglion on the great toe. Change of residence
and cure-—A medical student slept in a recess in a damp wall.
After a time he became the subject of arthritis in the great
toe; and this was soon succeeded by the formation of a hard
OR TUBERCLES. 367

tumour, the size of a grain of corn, beneath the skin, covering
the internal saphena vein and nerve. Every time this was
touched, a darting pain, like an electric shock, was experienced.
Having changed the position of his sleeping apartment, this
young man was soon cured of both neuralgia and tubercle.

In general, the occasional causes of these tumours are very
obscure; and, in the larger number of cases, their presence
cannot be traced to any cause whatever.

Fibrous encysted tumours are most frequently met with in
the limbs, and especially the lower extremities. They have
been met with on the back, scrotum, face, and neck. They
rarely occur except single ; and when there are more than one,
each is distinct and isolated.

Generally patients experience pain in the affected part long
before they notice any swelling. At an early period, the
slightest friction from the clothes, or pressure on the superja-
cent skin, occasions lancinating pains, and these generally are
regularly periodical, and partake of the same character which
pertains to scirrhus. When the pain occasioned by pressure
extends, like an electric shock, to a distance from the tumour,
it is an indication of the proximity of a large nervous trunk,
which is mechanically irritated. In some cases, however, the
suffering is continuous, and therefore more trying to the patient,
who is deprived of rest, and, consequently, suffers seriously in
health. When these tumours exist in the lower limbs, walking
becomes irksome and distressing. In some irritable subjects,
the paroxysms of pain are accompanied by true convulsive
spasms. I was once consulted by a young woman, in whom a
small cyst in the upper and outer part of the thigh was the
seat of extreme suffering, and pressure upon it induced con-
vulsion. The tubercle was removed, and with it the pain
entirely and permanently disappeared. In many instances
these tumours remain insensible, even on pressure, for several
years.

The pain consequent on the presence of fibro-cellular encysted
tumours, which have eluded notice from their small size, has
often been confounded with that occasioned by rheumatic and
nervous affections, and the unfortunate patients have been ac-
cordingly tormented, without benefit, with all the appliances
for these complaints. Some cases illustrative of this error in
368 NERVOUS GANGLIONS

diagnosis have come under my observation. In neuralgia, it
may be remarked, the pain, which is acute, extends along the
whole course of the affected nerve, is more strictly intermittent
in its character, and is not aggravated by pressure.

The name of “ganglion” given to these cysts, may lead to
their being confused with tumours of the same name, which
are met with in the sheaths of tendons, especially about the
wrist ; but the insensibility of the latter, their mobility with
the tendons during the contraction of the muscles, and the
true synovial character of their interior, constitute sufficient
diagnostic distinctions whereby to identify them.

Small lipomatous or steatomatous tumours, which have
undergone a cancerous degeneration, cause acute pain; but the
intervals in their interior, containing a yellow lardaceous or
fibrous matter, impart a very characteristic appearance to
them. .

Lastly, it may be possible to mistake these fibro-cellular
cysts for true nervous tumours. But the latter present a cavity
filled with more or less fluid contents; they also usually attain
a greater development, and are found in the large nervous
trunks ; moreover, several are frequently found in the same
individual. These are all distinctive characters of the true
nervous tumours, as contrasted with the cysts under con-
sideration.

If the encysted tumour is movable, if the skin covering it is
healthy, if it is situated at a distance from important organs,
such as the large vessels and nerves, if, in a word, it is sub-
cutaneous, the prognosis may be a favorable one. But: if,
on the contrary, it is fixed, adherent to discoloured skin, and
has begun to soften, the prognosis is unfavorable. For then,
even if the tumour itself be removed, as I have already re-
marked, the disease reappears in the neighbouring lymphatic
ganglions, and the patients soon present all the symptoms
which characterise the cancerous diathesis.

Caustics have been occasionally employed to destroy these
tumours; but their use hastens the softening process, without
curing the disease. Sometimes, though very rarely, narcotic
applications on the tumour have afforded relief, where patients
have turned away with dread at the mere idea of the knife.
The long-continued use of local anodynes relieved, and ulti-
OR TUBERCLES. 369

mately cured, the pain, in one elderly female under my care ; the
‘cyst, in this case, was on the inner and back part of the knee,

The operation of extirpation is simple, easy of performance,
and the most effectual mode of treating&these cases. If the
skin: should be discoloured and adherent, it should be removed
with the: tumout.

The following case will serve to illustrate some of the pre-
ceding remarks.

Case VII.—Ganglion taken for a rheumatic affection. Cure
by extirpation—M. Hareng, a married woman, aged 55, came to
the Hotel-Dieu, in October, 1828, suffering from acute pain, which
came on at irregular intervals. This patierit, whose constitution
was good, and who had ceased to menstruate, traced her com-
plaint to exposure to cold and wet eighteen months previously.
Various local specifics for rheumatism had been tried in vain ;
still the suffering was unabated, and the slightest fatigue
exasperated it. In this case the pain exhibited two distinct
forms or characters; it was continuous, and occurred in
paroxysms of increased force about four times in the twenty-
four hours, lasting from a few minutes to an hour. These ex-
acerbations might be induced by pressure or a blow on a small
tumour situated on the inner and upper part of the thigh.
The pain was then of a lancinating character, attended by
numbness, and extending downwards towards the knee. The
agony was so great as to make the patient scream out; and it
appeared to her as if the flesh was being torn at the parts
affected. Having detected the existence of one of these sub-
cutaneous fibrous bodies, I removed it by a T-shaped incision
without difficulty.

It was white, surrounded by adipose and healthy areolar
tissue, and about the size and shape of a small filbert. Its
consistence was considerable, and its elasticity caused it. to
bound from the ground when thrown down; it presented no
trace of vessels, nor even of redness; and it possessed neither
cavity nor secretion within. Its texture was fibro-cellular,
with a predominance of the fibrous element, and its capsule
was likewise fibrous.

The wound healed kindly, and the relief was immediate

and permanent.
24
870 NERVOUS GANGLIONS OR TUBERCLES.

It is unnecessary to multiply instances of the affection we
have been considering. Sufficient has been said to indicate the
general characters and anatomical relations of these trouble-
some little tumours %and to demonstrate that they may be
developed in almost any part of the body, and that their re-
moval with the knife is the only remedy upon which any re-
liance can be placed.

Erratum : p. 87, 1. 28, for disappears, read re-appears.
GENERAL INDEX.

ABERNETHY first tied external iliac artery
in 1796, 64.
Abscess may be simulated by aneurism,
34.
surrounding carotid artery, 55.
of the right iliac fossa, 294.
Air-tubes, on the introduction of foreign
bodies into the, 192.
Amputation in case of wounded artery, 4.
not required in wound of artery
complicating fracture, 7.
questions respecting the propriety
of, in symptomatic gangrene, 27.
performed near shoulder-joint in case
of aneurism, 93.
Anastomosis in ligature of arteries, re-
establishment of circulation by,
91.
ANEL’s practice in treating aneurism now
adopted, 34.
Aneurism complicating fractures and fire-
arm wounds, l.
mode of formation of, 2.
as a consequence of gun-shot, rarity
of, 2.
treated by Valsalva’s method, 29.
use of compression in, 30.
case of popliteal, cured by compres-
sion, 31.
cured by compression, rare, 33.
of subclavian artery mistaken for
abscess, 35.
the consequence of violence in at-
tempting to reduce dislocation, 38.
of the internal carotid artery, case
of, 54.
of the external iliac artery, case of,
63.
of femoral artery, case of, 65.
of popliteal artery, treated by liga-
ture, 67
on false, of the brachial artery, 78.

Aneurism, on primitive and consecutive,
78

of the brachial artery, case of false,
81.
mode of operating in false consecu-
tive, 87.
ligature of brachial artery in, 91.
Aneurismal dilatation of temporal and
occipital arteries, case of, 50.
sac, suppuration of, after application
of ligature, 42.
Animals, experiments on the arteries of,
17.
deductions from experiments on,
doubtful, 49.
Anus, possible constriction of, after ex-
cision of hemorrhoids, 139.
anatomical structure of parts about
the, 142.
on fissure of the, 148.
extreme suffering caused by fissure
of the, 148.
case of fissure of the, cured by local ‘
applications, 150.
fissures of the, external to the
sphincter, 151.
different forms of fissure of the, 152.
case of fissure of the, cured by in-
cision, 152.
Aorta, burrowing aneurism of the, in the
neck, 35.
Arterial structure in varicose aneurism,
altered condition of, 84.
Arteries, wound of tibial, in gun-shot, 12.
Arteritis, a cause of gangrene, 16,
treated by bleeding, 18.
case of fatal, 20.
symptoms of, 22. :
cessation of pulse in limb affected
with, 23.
Artery, laceration of anterior tibial, in
fractured tibia, 3.
372

Artery, amputation in case of wounded, 4.
death from wound of anterior tibial,

case’ of wounded tibial, in fracture,
for which femoral was tied, 8.

precautions necessary in tying an,
for aneurism, 34.

ligature of the carotid, for aneurism
by anastomosis, 50.

case of aneurism of the internal
carotid, 54.

case of ligature of the external. iliac,
58.

case of ligature of the femoral, 73.
on false aneurism of the brachial,
- 48.
Auricle, wound of the right, 106.
and ventricle of right side most
obnoxious to injury, 111.
Axillary aneurism, case of, cured by de-
pletion, 29.
ligature of subclavian artery for
false, 38.
alternatives to be adopted in, 40.
signs of, 44.
Axillary artery, lance-wound of, causing
aneurism, 44.
ligature of the, for subclavian aneu-
rism, 75

Bark used in senile gangrene, 24.

Bean was introduced into the trachea,
case in whith a, 192.

removed from the trachea, case of,

196.

BErry, assassination of the Duc de, 106.

Birth of child through lacerated 'peri-
neum, 311.

Bladder, perforation of the, in iliac
abscess, 306.

Bleeding necessary in arteritis, 19.

successful in symptomatic gangrene, '

25, 26
Bones, remarks on the intermaxillary,
162.

Bougie, use of conoidal, in stricture, 332.
Brachial artery, true aneurisms of the,
rare, 78.
false aneurism of the, 78.
case of false aneurism of the, 81.
varicose aneurism of the, 83.
cases of false consecutive aneurism
of, 86, 89.
operation of tying the, described, 88.
tied in false aneurism, 91.
case in which -hemorrhage followed
ligature of, 92.
Brachial cords, inferior of the three, inclu-
ded in a ligature accidentally, 48.
Brain, softening of the, after ligature of
subclavian artery, 48.

* Bronchocele.

GENERAL INDEX.

Braspor’s operation for aneurism re-
ferred to, 74.

Brescuet’s researches in developmental
anatomy, 163.

treatment of varicocele, case of, 103.

Bronchitis, consequent on “tracheotomy,
194.

See Goitre.

Cancerous tumour of the neck, case of
tracheotomy in, 209.
Carotid and jugular, varicose aneurism of,
85.
Carotid artery, ligature of, in aneurism by
anastomosis, 50.
operation of tying the, 52.
case of aneurism of the internal, 54.
ligature of, followed by hemiplegia,
56.
causes of death after ligature of the,
57.
CuEseLvEN’s notice of fibro-cellular
encysted tumours, referred to,
362.
Clavicle displaced by axillary aneurism,
45. :
Coldness of part about to mortify, re-
markable, 23.
Colon, distension of sigmoid flexure of,
a cause of varicose veins, 96.
ulceration of, in iliac abscess, 305.
Compression, as applicable to aneurism,
30.

in false aneurism, use of, 90.
Compressor used for the femoral artery,
33.
Congenital hydrocele, treatment of, 360.
Coorsr’s, Sir A., case of Brasdor’s ope-
ration referred to, 75.
remarks on contracted fingers and
toes, 220.
Coronary arteries, ossification of the, 20.
Croup, remarks on operative interference
in, 206
statistics of tracheotomy in, 207.
Cyst may be mistaken for aneurism, 34.

Delirium, nervous, causes of, 280.

consequent on operation for sarco-
cele, 281.

following fracture of a rib, 282.

after attempted suicide, case of,
283.

after operation for cataract, 284.

following fracture of the leg, cases
‘of, 285, 286.

diagnosis of, 287.

persons most usually affected with,
289, “Ne
GENERAL INDEX.

Delirium, predisposing causes to, 290.
post-mortem appearances in, 291.
value of opium in the treatment of,

292.
Delirium tremens, allied to nervous deli-
rium, 291,

Dexrecn, his case of ligature of femoral gx.

artery in wounded tibial, with
fracture, 10.

Depletion, employment of, in aneurism,
29.

Descuampes, Brasdor’s operation first
performed by, 74.

Development, remarks on arrested, 161.

Diagnosis of aneurism, source of embar-
rassment in, 34.

Emphysema, on traumatic, 267.
case of, consequent on fractured
ribs, 268.
death following, 270.
complicated by wound of heart, 273.
affecting the eyelids, 275; cases of,
275—277.
of the temporal region, from frac-
ture of frontal sinus, 277.
from the bite of insects, 279.
from voluntary puncture of cheek,
279.
Encysted tumour, on a particular sort of
. fibro-cellular, 361.
the various forms of, 361.
supposed tobe connected with
nerves, 362.
case of, on the thigh, 363. .
cases of, connected with the fifth
nerve, 364, 365.
cases of, on the fore-arm and finger
and, great, toe, 365, 366.
mode and period of development of,
366. .
character of pain in, 367.
confused with. ganglions, rheuma-
- tism, &c., 367, 368. '
extirpation necessary in this form
of, 369. ee
case of, mistaken for rheumatism,
369. : ‘
Epigastric and mammary arteries, anas-
tomosis between, 62. :
Excision of hemorrhoids, on the, 121.
Eyelids, emphysema of the, 275.

Femoral artery, tied in wounded tibial,

with fracture, 9, 10.

ligature of, in a gun-shot wound,
12.

case of false aneurism: of, 65. .

pressure tried in a case of aneurism

v of the; 66. :

operation of tying the, 66.

373

Femoral artery, gangrene following liga-
ture of the, 68.
case of ligature of the, 73.
Femoral vessels, gangrene consequent on
obstruction of the, 22.

Fibro-cellular encysted tumour, on a

particular sort of, 361.

Fingers, case of gangrene of the, 20.

on the causes of permanent contrac-
tion of the, 220.
occupations usually causing contrac-
tion. of the, 221.
history of contraction of the, 221.
Various: explanations concerning
contraction of the, 222,
dissection in a case of contraction
of the, 223. ° .
failure of usual methods of treating
contraction of the, 224.
case of contraction of the, cured by
division of palmar fascia, 225.
section of the palmar fascia in con-
traction of the, 228.
cases of contraction of. the, from
_ various causes, 230, 231.
case of contraction of, from wound,
232.
case of contraction of, from burn,
cured by operation, 233.
case of contraction of, from defor-
mity of joints, 234.
case of contraction of, from injury
. of flexor tendons, 235.
operation in a case of contraction of
the, 236.
Fissure of the anus, characteristics and
causes of, 148.
local applications in the cure of, 150.
external to the sphincter, 151.
different forms of, 151.
case of, cured by incision, 152.
with hemorrhoids, case of, 152. '
Fracture of. leg, with arterial lacera-
tion, 3.
with wounded artery, amputation
in a case of, 4.
Fractures complicated by aneurism, 1.
Frontal sinus, emphysema from fracture
of, 277.

Gangrene, possible occurrence of, in liga-
’ ture of femoral artery, 14.
symptomatic of -arteritis, 16.
consequent on ossification of arte-
ries, 18.
of the leg, with disease of heart,
case of, 18. <
consequent on arteritis, case of, 20.
of nose and fingers, case of, 20.
‘case of symptomatic, following
phlegmon, 23.
374

Gangrene, symptomatic, more common
in summer than winter, 24.
cases of symptomatic, cured by
bleeding, 25, 26.
sometimes follows ligature of fe-
moral artery, 67.

following ligature of femoral ar- ag.

tery, cases of, 68, 73.
following ligature of axillary ar-
tery, 76.
Genital organs, mutilation of, referred
to, 114
Glands, ranula may occur in either sub-
maxillary or sublingual, 178.
polypus causing closure of
the, 200
death caused by a piece of meat
blocking the, 201.
tracheotomy in oedema of the, 202.
Goitre, on the treatment of, by the
seton, 215.
prevalence of, in Savoy and the
Valois, #15.
case of large, cured by the seton, 215.
the usual methods of treating, 216.
different forms of, 216.
mode in which the seton acts in, 216.
unsuccessful. case of, treated by
seton, iodine, &c., 217.
Gun-shot wound, with arterial lesion, 12.

Glottis,

Hare-lip, on congenital, 161.
proper period for operating on, 164.
how to treat double, 165.
case of double, 167.
case of double, with projecting in-
cisor teeth, 168.
- case of double, hemorrhage follow-
ing operation on, 169.
mode of treating fissured palate
in, 170.
ease of simple, with fissure of
palate and velum, 172.
case of recent, from accident, 174.
Heart, chronic disease of, a cause of
symptomatic gangrene, 17.
hypertrophy of the, followed by
gangrene, 18.
wounds of, their causes, &c., 105.
wounds of, recorded cases of, 105.
wound of the right auricle of
the, 106.
various forms of wound of the, 110.
symptoms of wounds of the, 117.
diagnosis of wounds of the, 118.
treatment of wounds of tht, 118.
Heat, loss of, in approaching gangrene, 23.
Hemiplegia following ligature of carotid
artery, case of, 56.
Hemorrhage following ligature of ex-
ternal iliac artery, 61.

GENERAL INDEX.

following ligature of the femoral
artery, 73.
in case of ligature of brachial
artery, 92.
risk of, in operating on hemor-
rhoids, 127. .
following excision of hemorrhoids,
133.
Hemorrhoids, on the excision of, 121.
treatment of, by the ancients, 121.
various opinions regarding the na-
ture of, 122.

nature of internal, 122.

nature of external, 122.

how are they to be treated, 123.

common in pregnant women, 123.

symptoms of, 124.

mode of operating on, 125.

risk of hemorrhage in, 126.

use of leeches in, 128.

case of internal, accompanied by
hemorrhage, 132.

case of excision of, followed by
bleeding, 133.

hereditary nature of, 133.

case of excision of large and old, 134.

case of internal, treated by ex-
cision, 136.

case of external and internal, treated
by excision, 137.

Petit’s treatment after excision
of, 138.

case of excision of, 139.

constriction of anus after excision
of, 139.

Henrt IV, cause of the death of, referred

to, 109

Hereditary nature of hemorrhoids, 133.

HunTer’s mode of treating aneurism, 34.

Hydrocele, on, and its principal varieties,

336.
different forms of, defined, 336,
forms of, in the cord, 337.
of the tunica vaginalis, signs of, 338.
cases of punctured testicle in, 338.
of the spermatic cord, cases of en-
eysted, 339—341.
with hour-glass contraction, case of,
342,
case of multilocular, 343.
characteristics of congenital, 344.
complicated with hernia, 345.
case of, complicated with sarcocele,

cases of, complicated with cartilagi-
nous degeneration of ‘tunica vagi-
nalis, 352, 353.
cured by application of a blister,
ease of, 354.
Hydrocele, mode of treating, by injection,
356.
GENERAL INDEX.

precautions requisite in injecting,

356.

extravasation of injection in a case
of, 357.

serious consequences sometimes

following injection of, 356.
treatment of, in children, 359. ;
mode of injecting in congenital, 360.

Ice in aneurism, use of, 90.
Tliac artery, aneurismal dilatation of, 56.
ligature of, compared with that of
subclavian, 57.

case of ligature of the external, 58.

aneurism of the external, case
of, 63.

Abernethy’s cases of ligature of, re-
ferred to, 64.
Iliac fossa, on abscess in the right, 294.
causes”of abscess in the right, 294.
precursory symptoms of abscess in
the, 295

predisposing causes to abscess in
the, 296.

progress and termination of abscess
in the, 297.

case of abscess in, with perforation
of cecal appendix, 297.

case of abscess in, terminating
fatally, 300.

case of abscess in, terminating by
recovery, 301.

phlegmonous tumour in the, 304.

ulceration of colon following abscess
in the, 305.

case of abscess in the, opening into
the bladder, 306.

abscess in, mistaken for hepatitis
and internal strangulation, 308.

treatment of abscess in, 309.

Inflammation of an artery productive of

gangrene, 17.

Inguinal aneurism, pressure tried in a

case of, 59. :

Injection, as a remedy in hydrocele, 356.

Intemperance a cause of senile gan-

grene, 17.
Intercostal artery sometimes wounded,
when heart is wounded, 111.

Jugular and carotid, case of varicose
aneurism of, 85.

Larynx, on the introduction of foreign
bodies into the, 192.

Leeches in hemorrhoids, use of, 128.

Leg, varicose veins of the, tied, 98.

Ligature, in hemorrhage, introduced by
Ambroise Paré, 7.

375

Ligature used in wounded artery from
fracture, 9.
of femoral artery in case of wounded
tibial from gunshot, 12.
of large arterial trunks, 28.
of the carotid artery, case of, 50.
Lip, on congenital fissure of the upper,
Lung, wound of the, complicating wound
of heart, 116.

Mammary and epigastric arteries, anasto-
mosis between, in aneurism, 62.

Mesenteric artery, aneurismal dilatation
of, 56.

Nail, definition of the word, 241.
causes of ulcers connected with the,
243. :
distortion of the, secondary, 243.
ulcers connected with in-growing of
the, confined to feet, 244.
symptoms and suffering of in-grow-
ing, 245.
case of in-growing, treated by avul-
sion, 245. é
various modes of treating in-growing,
246. *
Dupuytren’s method of treating in-
growing, 250.
extirpation ofin-growing, case of,251.
case of osseous tumour connected
with in-growing, 252.
Mr. Wardrop’s comments on in-
growing, 253.
general recapitulation concerning in-
growing, 265.
Nerve, popliteal, tied in aneurism, 73.
Nerves, permanent injury to axillary, from
: pressure of aneurism, 43.
injury to one of the brachial, in tying
the subclavian artery, 48.
Nervous delirium, 280.
Nose, case of gangrene of the, 20.
Numbness of arm following ligature of
carotid artery, 53.

(sophagus, case in which. a five-franc-
piece was fixed in the, 210.
mode of extracting a foreign body
from the, 211.
case in which a five-franc-piece
passed through the, 212.
case in which a potato was lodged
in the, 212.
different instruments used for ex-
tracting bodies from, 214.
Onglade, its definition and characters,
254

cases of, 255, 256.
is it of syphilitic origin? 257.
376

Onglade, treatment of, 259.
cases in which the matrix of the
nail was removed for, 260—262.
various modes of treatment in, 264.
Opium recommended in senile gangrene
by Pott, 24.
value of, in the treatment of nervous
delirium, 292.
Osseous concretions in aneurismal sac,
48. ‘
incrustations of an aneurismal sac,
56.
Ossification of arteries a cause of gangrene,

of vasa deferentia, case of, 19.
Osteo-calcareous degeneration of arteries,
55.. :

Palate, mode of treating fissure of the,
170.
case of hare-lip, with fissured, .172.
Palmar fascia, description of the, 228.

case of contraction of the, treated *

by section, 228.
Parturition, laceration of perineum
during, 311.
Pe.ietan’s case of axillary aneurism, 30.
attempt to tie the axillary artery
foiled, 42.
Pericardium, case of laceration of the,
referred to, 109.
Perinzeum, on lacerating the, during
labour, 311.
scepticism: concerning laceration of
the, 311.
reference to authentic cases of lace-
rated, 312.
cases of laceration of, and birth of
child by the rent, 316, 317.
peculiar position of vulva favouring
_ laceration of, 319.
cases.of laceration of, during labour,
320—322.
how to treat laceration of the, 321.
laceration of the, may be cured with-
out operation, 323.,
Prrit’ s treatment after excision of hemor-
rhoids, 138.
mention of fibro-cellular tumours,
adverted to, 361.
Pharynx, case in which a penny-piece
was lodged in the, 213.
Phiebitis, risk of, in tying a vein, 80.
in ligature of varicose veins, remarks
on, 96.
Phlegmon. giving rise to symptomatic
gangrene, 23.
Phthisis induced by lodgment of foreign
body in trachea, 199.
Plantar fascia, alteration in the, causing
contraction of the toes, 239.

GENERAL INDEX.

Polypus causing closure of the glottis,
case of, 200.

‘Popliteal aneurism, case of, cured by

compression, 31.
pressure tried in a case of, 68.
treated by ligature, case of, 68.
treated by incision, ‘71.

-Popliteal artery, aneurism of the, 67.

Popliteal nerve tied in popliteal aneurism,

Porr’s observations on senile gangrene
referred to, 24.
Prolapse of the rectum, on the treatment
of, 141.
most common in’ infancy and old
age, 141.
best mode of reducing, 141.
scarifications recommended in, 142.
use of astringents and pressure in,
142. ©
mode of operating for, 43.
case of operation for, 144.
and uterus, treated hy operation,
145.
accompanied by hemorrhoids, case
of, 146.
Punctured wound of brachial’ artery,
aneurism following, 94.

Ranula, its nature and treatment, 176.

different opinions concerning the
true nature of, 177.

usual seat of, in submaxillary duct,
178.

may contain pus as well as saliva,
178.

calcareous matter occasionally found
in, 179.

external characters of, 179.

various modes of treating, 179.

case of, operated on by incision, 181.

mode of treating by injection and
cautery, 183.

author’s method of treating, 184.

case of, treated by the introduction
of a stud, 185.

case of double, treated in different
ways, 186.

case of multilocular, 187.

case of, consequent on inflammation,
189.

case of a tumour resembling, 190.

means of diagnosis in, 191.

Rectum, diseases of the, 121.

on prolapse of the, 141.

prolapse of the, most common in
infancy and old age, 141.

best mode of reducing prolapse of
the, 141.

employment of astringents, pressure,
&c., in prolapse of, 142.’
GENERAL INDEX.

Rectum, mode of operating for prolapse
of the, 143.
case of operation for prolapse of
the, 144.
case of prolapse of, anduterus, treated
by operation, 145.
accompanied by hemorrhoids, 146.
on fissure within the, 148,
on stricture of the, 155.
causes and symptoms of stricture of
the, 155.
syphilis complicated..with stricture
of the, 155... .
case e annular contraction. of the,
15
Retention of urine, following excision of
hemorrhoids, 131.
Ribs, different ways in which they may
be fractured, 267.
complications attending fracture of
the, 267.

Sac of internal carotid artery, description
of aneurismal, 55.
incision into an aneurismal, case of,
71.
Saphena vein, ligature of, for ulcer, 97.
Scrotum, death following gangrene of, 19.
Senile gangrene, cause of, 17.
Pott’s treatment of, 24.
Seton used in the cure of bronchocele, 215.
Spermatic cord, cases of encysted hydro-
cele of the, 339—341.
Sphincter ani, spasm of the, in fissure of
the rectum, 150.
Sphincter, fissures of the anus external
to the, 151.
Stomach, case in which a five-franc-piece
lodged near the cardiac orifice of
the, 212.
Stricture of urethra, on the treatment of,
324.
force rarely requisite in, 325.
cases of, with dysury, treated by
vital dilatation, 327, 328.
mode of employing vital dilatation
in, 330.
mode of employing mechanical dila-
tation in, 331.
utility of conoidal bougie in, 332.
cases of, treated by mechanical dila-
tation, 333.
rapid dilatation of, objectionable,
~ 3835.
liability to relapse in, 335.
Stricture of the rectum, 155.
causes and symptoms of, 155.
effect of dilatation upon, 155.
incision sometimes required in, 156.
case of, 156.
mercury in the treatment of, 157.

377

Subclavian aneurism treated by depletion,
case of, 37.

oe by ligature of axillary artery,
5

Subclavian artery, case of aneurism of,
mistaken for abscess, 35.
reasons for and against tying the, 36.
ligature of, for false axillary aneu-
rism, 38.
best position for tying the, 41.
false consecutive aneurism, treated
by ligature of, 43.
perforated in passing a. ligature
around it, 48,
Submaxillary gland the usual. seat of
ranula, 178.
Suicide, nervous delirium following at-
tempted, 283.
Symptomatic gangrene a local disease, 22.
Symptoms of arteritis, 22.

Tape-worms in the intestines, case of
aneurism in which there were, 70.
Testicle punctured in hydrocele, 338.
Toe-nail, growth of the, into the flesh,
241.
Toes, contraction of, from shortening
of plantar fascia, 239.
amputation in a case of contraction
of the, 240.
Trachea, on the introduction of foreign
bodies into the, 192.
case of operation for the removal of
a bean from the, 192.
signs of the presence of a foreign
body in the, 193—195.
modeof operating to open the, 193—
195.
case in which a half-franc-piece was
introduced into, 199.
case of an orange-pip in the, 200.
Tracheotomy, in a case of foreign body
in trachea, 192.
caseof, for the removal of a bean, 196.
in edema with inflammation of the
glottis, 202.
not to be resorted to in disease of
larynx, 205.
remarks on, in croup, 205.
does not often succeed in cedema
glottidis, the reasons why, 208.
in cancerous tumour of the neck,209.
Transfusion, varicose aneurism by, 79.
Traumatic emphysema, 267.
Tremens, observations respecting de-
lirium, 291.

Ulcer of the leg, case of varicose, in
which vein was tied, 99:

Urethra, on vital and mechanical dilata-
tion of the, 324.

25
378

Urethra, case of wound of, by a pistol-
shot, 325.

Urine, retention of, following excision
of hemorrhoids, 131.

Vausatva’s method, case of axillary
aneurism cured by, 29.
method of treating aneurism no-
ticed, 29.
method adopted in case of subcla-
vian aneurism, 37.
Varices of the lower extremity, their
causes and treatment, 95.
of the leg, with ulcer, case of, 97.
Varicocele, definition of, 99.
an hereditary affection, 100.
symptoms of, described, 100.
diagnosis of, 100.
mistaken for hernia, abscess, &c.,
101.
treatment of, by the older surgeons,
102.
case of, illustrating M. Breschet’s
treatment, 103.
Varicose aneurism, various position of, 79.
Hunter’s operation inefficient in, 80.
of the brachial artery, case of, 83.
of carotid and jugular, case of, 85.
-Varicose ulcer of leg, treated by ligature,
case of, 99.

GENERAL INDEX.

Varicose veins tied, case of, 98.
Vasa deferentia, ossification of, very
rare, 20.
Veins in varicose aneurism, altered con-
dition of, 84.
Venesection, axioms relating to, 78.
false consecutive aneurism follow-
ing, 86.
false aneurism of brachial artery
following, 89.

Ventricle and auricle of right side, most
obnoxious to injury, 111.
Ventricle, case of wound of the left, 115.

Ventricles, case of wound of both, 112.

Women less subjeet to gangrene than
men, 24.
Wound by a sword producing false axil-
lary aneurism, 39.
of brachial artery, aneurism follow-
ing punctured, 94.
of both ventricles, case of, 112.
of the left ventricle, case of, 115.
Wounds of the heart, recorded cases of,
105.
their causes, &c., 105.
the symptoms of, 117.
the diagnosis of, 118.
the treatment of, 118.

 

PRINTED BY J. E. ADLARD, BARTHOLOMEW CLOSE.
 
oe % Bee Povearhretset
. a

rien

Ee

rote
ee
ee

5

Bure rR

SNORE

SPoreatarerat heats SS
ik RES Re
CRRA an est

tH
ot
sarees
a

ee

Ne ret
Beste
ee

sya
peatboreate

 

ie
3
Bt

Wh

a