IHp^^V-^ — : -^ tQl> *• THE WM. S. HE Memorial Collection of Southern History Presented to TRINITY COLLEGE LIBRARY DATE By Mr. W. S. Lee, Jr. r us 3 , / S'. 8£his tuorh IB iMOST RESPECTFULLY AND AFFECTIONATELY DEDICATED. PREFACE. Much experience in Field and Hospital, has convinced mo of the necessity for the publication of a work on Surgery, more elementary, practical and concise in its character than has hitherto appeared. I have therefore, devoted myself to the preparation of this volume, as a vade mecum for tin geons of the Confederate service, with the view of supplying the desideratum which exists in this regard. .Little claim to originality, either as to principles or details, is advanced in these pages; but I have mainly endeavored to glean from fields of experience far richer and broader than ray own, such views, facts, and deductions as are most worthy of diligent study, and faifjhful preservation. The ablesl authors ou the various Bubjecta discussed, have been freely consulted, and the intelligent reader will have no difficulty in discovering to what extent I am indebted to them for the substance matter of this volume. Wherever an issue has been made with standard authorities, it has been from an honest conviction of the absolute necessity for such a course, and from an earnest desire to advance the best inten Surgical science. So far as the typographical execution of this book i- con- cerned, I must urge in extenuation of its imperfections, thai the best printers are in the service, and that thoee who re- main behind are too young and inexperienced to do proper justice to any author. For this reason many errors will he found in this etfition which ahall he corrected in a subsequent one. For the invaluable statistical information contained in thu Appendix, I am indebted to the courtesy of Surgeon Samuel Preston Moore, Surgeon General of the Confederate St under whose intelligent scrutiny and able direction it was carefully collected by Surgeon Francis Sorrell, tn Hospitals for the City of Riohmond. Vi PBBFACS. Whatever the raeritg or defects of this unpretending work, ii has been undertaken in a spirit of loyalty and humanity >. and it is now issued with the hope of contributing something te a cause in which every sentiment of my bosom is moat warmly enlisted. Should it be the means of saving a single life, of alleviating a pang of pain, or of inspiring one professional brother with a braver heart and a steadier hand in the hour of trial, my proudest aspiration will be more than realized. INDEX PAOZ. Abscesses, ........ is Accidents after Amputations, 116 Acupressure, - - '22£ Alteratives, ..--.--_ 78 Amputation, varieties of 81 " primary, - < - - - - 81 seco»dary, 87 " modes ol, ..-..- 104 of great toe, - 137 of metatarsal joint ----- 138 of metatarsal bones, - - - - 138 tbrougb tarsus, 139 at ankle joint. ----- 140 " of leg, 14'J " at kmee joint, 144 '• of thigh, L46 at hie joint. ----- 152 ot fing?ra, ...... 155 " at wrist joint, 158 of fore arm, ------ 159 at elbow joint, ----- 160 " of upper arm. .... - 161 at shoulder joint. ... - 102 Anremia ti-om loss of blood. ----- -JO^ Antiplogistic regimen, ------- 62 Applications, cold and warm. 73 Arteries, structure of, 239 compression of, - - - - - - 218 ligation of. 235 Vlll INDEX. "page. Arteria innominata, 266 Anterial sedatives, - " - . - - - . - 57 Axillary artery, ---.__. 268 Barton's fracture, :}7G Blisters, -'__'. 71 Blood, changes in, ------- 13 " condition of, 4 213 Blood letting, - - - - - - . - 54 Bones, exoisio» of, - - - - - - - .101 " reproduction of, 203 fractures of, - - 340 Brachial artery, - - - - - - - -...27 Brainard's perforator, ------ 348 Carreer. -_-._-_-- 43 Causes of Hemorrhage, - - - - - - 211 Carpal bones, dislocation of, ----- 323 " " fractures of, - 379 Carotid artery, -■-'.- 247 Circular method of amputation. - 104 Colle'p fracture. - 376 Comminuted fractures, 342 Complicated fractures, - - '■'^- Compound fractures, ------- 342 " '■ of inferior raaxillary, - 303 " " of arm, .... - 378 of hand, - - - " '• of ribs, - 366 of pelvis, - - • " - 376 " of thigh, .---- 383 " ^ of leg. s 388 offoot, ----- 301 Compression of Arteries, - 217 " of brain, --.-*-' 351 Concussion of brain, - - °°* Corpuscles, red, .-.----" *° " white, ------- 13 Depletory remedies, ------- 54 INDEX. IX PAGE Depression of bone, - 339 I Msarticulation of fingers, ------ 157 Dislocations, --------- 295 of lower jaw. 308 Dislocations of clavicle, ----- 310 " of acromion, - 312 of shoulder joint, - - - . 313 of ulna, - - - - - 318 of radius, - - - - * 318 of wrist, ... - 322 of thumb, ----- 324 of thigh, - - - • 326 of patella, ----- ;;;;:; " of tibia, ----- 333 of fibula, - . - - • of astragalus, - . - - 336 ofcalcaneum, - - - - 337 Effects of gun-shot wound-. ■ - - 356 Erysipelas, - - « . - .123 Extension and counter extension, - - - 304 Fever, - - - - . - -26 Fissures of bone, - 369 Flaps, length of, - . - - . - - L09 Flap amputations, - - - - ■ ; 105 Flexion of bones, ----:-'- 389 Fractures, classification of. - - 328 " of pelvis. ... - 370 " of humerus, .... 370 " of ulna, - - - - 874 '' of clavicle, " of scapula. ----- 653 " of cratiial bones, - - - - 350 of radius, ----- 375 of ulna andjradius, - - - 376 of carpal boues, • - - - 379 of fingers, - - - - 378 Of feraur. - - - - .37V X INDEX. f AGE. Fractures of patella, ..... 387 of tibia, . -■- - - 380 of fibula, ----- 380 " of fibula and tibia, - 370 " of bones of foot, 300 Gangrene, ..... \gg Giiaglymoid joints, - * - - - U93 Hemorrhage, - .... 210 Hemorrhagic fever, ----- 208 Hernia cerebri, - - - - - - " 361 Hospital gangrene, ----- 120 Inclined plane, ------ 3S2 Induration, -.--.- 37 Inflammation, ----- .13-70 ligation of arteries, ... 226 " of arteria innominata. - - - 246 " of common carotid, - - - 247 " of exterior carotid, - 250 of thyroid. ----- 252 of lingual. - - • - - 252 of facial, - 253 " of subclavian, - • ... . 255 of axillary, - 268 of brachial, 271 " of radial, ----- 275 '' of ulna, - - ' - - 278 " of common iliac, - 356 " of external iliac, . 264 " of internal iliac. -."■-- 262 of femoral - - - - 280 " of popliteal, - - - 285 " of posterior tibial, - 291 " of anterior, tibial. - - - 287 " of dorsalis pedis, . 389 " of peroneal, f - - 289 Ligatures, mediate and immediate, - - - 226 Litters. ------ 346 VR D&X . xi PAGE. Litter Corpa, .--... 344 Lymph, absorption of. - - - - 36 Malar bone, fracture* of - - - - . 283 Median Baailie Vein. ... - 074 Mercury. - - - - • - 57 Morphia/ — Endermic use of - - - - 306 Nervous Sedatives, - . - -89 Opium, -*--••- 59 Organization of Lymph. .... 40 Orbicular Joint*, ----- 298 Oval method of Amputation. - 106 Palmar aroh, - - . . . 279 Point* for ligature?. ..... 235 " of stagnation. - - - - 14 Position in hemorrhage. .... 221 " inflammation. - - - - 71 Pullies compound, ..... 328 Pus, ---.--- 40 Pyaemia, . ...... 127 Pyogenic membrane., - 39 Rtdness, - - - - * - - 18 Resections in genera], . 180 Bwiection of meta: carp : phal : articulation, - . 180 " " meta: carp, bones, - - - 180 '« " wrist joint. - - - - 180 " radiui, - - 181 " " ulna, - - - 182 " elbow joint, - - - 183 " shoulder joint. . - - 185 " clavicle, - - 190 " scapula, - - - 190 " tarsus, - - 191 " ankle joint, - - 192 "knee joint, 192 " hip joint, - 199 JUaolution, ... - 36 R«vui«iv««, - - - - - 77 Xli INDEX. PA.GB. Saline elements, - . - . - 14 Seton, - . 228 Shock, - - - - - - 120 Smith's ant: splint, - -,'-..- 386 Statistics, ---... 392.400 Stumps conical, , - - - - - 119 " neuralgia of, - - - - 120 Structure of arteries, - 239 Swelling, - - - 20 Styptics, ----.. - 236 Suppuration, - - - - - 139 Tetanus, - ----- 131 Tourniquets, - - - - . 217 Transformation of tissue, - - - - 45 Trephining, ----- 169 Warm applications. - - - - - 75 Water dressings, 74 Wounds of head, - - - - • - 355 " offace, - . 862 " of lungs, - - 368 " of arteries, - - - 208 " of soft parts, generally, - - - 357 " bones, - - - 356 " entrance. ----- 353 " exit, - - 358 Wounds from round balls, - - - - 357 " " conical balls, . - - 358 " " swords. ----- 352 Ulna, ----- 313 Venesection in lung wounds, - 668 E R R A T A . Page 10, T2th line, last word", read "inflamed." " 58, 9th " next to last word, read "relieving." " 132, 18th " after principle, read " nerve." '■ 146,13th " for "60," read "50 percent." " 176, 31st " for " only," read " generally." " 252, 14th " for "antrim," read "antrum." " 285,10th " for "abductor," read "adductor/" CHAPTER J. INFLAMMATION. Definition. — Inflammation is a condition of al- tered nutrition in which a perversion of the Blood and Blood Vessels occurs, accompanied by increas- ed vascularity, augmented sensibility, change in secretion, an exudation of Liquor Sanguinis, and a modification of structure and of function. Changes which take place in the Blood. — The blood becomes //' ; , pvas first established by 1 Cewson. The J?t\l Corpuscles are increased in quantity in the early .stages of inflammation, bu1 are subse- quently decreased as the disease advances. They also have a tendency to elm ether, by the cohesion of their tlat surfaci The White Corpusci are largely increased in number, ami, by adhering to the walls of the vessel, tend to arresl the circulation. The Liquor Sa —Andra] ami ( have shown that Fibrin may he increased \ high as i! per 1000 — an augmentation whi manifestly din 1 to the more rapid ami ci met- amorphosis which takes place in the fthe part. But by far the most remarkable and impor- tant fact which man if sts itself in this r the tendency to effusion which is devi disease advances. The Liqn . 14 CHANGES IN THE BLOOD. ironi the vessel and disseminates itself through the surrounding tissues, either, to be subsequently re-absorbed, to organize, or to break down into purulent matter. This exudation, according to Virchow, is the essential element in the inflamma- tory process, giving character to it, and furnishing the most reliable index as to its pathology and treatment. The Saline Elements are somewhat below tbe normal standard, while the proportion of water is perceptibly increased. The Coagulation of i nflammatory bl ood takes place more slowly, while the coagulum is harder, and smaller, and the quantity of serum greater than under ordinary circumstances. The upper surface of the coagulum is covored with a layer of yellow fibrinous matter, known as the butty coat, and de- pressed in its centre in the form of a cup. The Buffij Coat, is regarded as an index and rep- resentative of the intensity of the inflammation, though the test is by no means infallible, in as much as the same phenomenon is manifested in Rheumatism, Pregnancy, and Plethora, in all their stages and conditions, without regard to tbe extent of the inflammatory process. Points of Stagnation may be found, upon a close examination of the inflammed tissue, at which the blood current appears to ebb and flow, until it is finally and permanently arrested. This stagna- tion usually occurs in those capillaries which are not directly located between arteries and veins, and results from adhesion of the Tied Corpuscles and the consequent blocking up of the vessels by CHANGES IN BLOOD VESSELS. 15 the masses thus formed. It is at these points also, that the drawing away or exudation of Liquor San- guinis usually commences,— 'facilitating the coal- lescence of the corpuscles, and indirectly contribut- ing to the arrest, of the blood current at the par- ticular localities in question". Wherever this re- tardation of the circulation occurs, the white cor- puscles may likewise be found in great quantities, either rolling slowly along the walls of the vessel or closely adhering to them. CHANGES MUICll TAKE PLACE IX THE BLOOD VESSELS. — The arteries, capillaries and veins are usually contracted in the first instance, but are subse- quently enlarged. The Arteries leading to the part are especially dilated, while their coats are relaxed, so that the pulsations within themare stronger and more per ceptible. The vessels, in consequence of this dilatation, actually convey more blood to the inflammed part, than under ordinary circumstances, as has been repeatedly demonstrated. In consequences of the expansion of the smal ler arteries and capillaries, red corpuscles arc more freely admitted, so that the part becomes wd, as it' from the development of new vessels. The arteries are not only dilated, but become elongated, tortuous, and waving — increasing in length as well as in circumference, while smal! brandies project from their walls, and fusiform dilatations of the whole diameter frequently pre- sent thei 16 CHANGES IN THE SYSTEM. The distention of the arteries and capillaries before the point of obstruction, induces increased effusion of serum, lymph, and pus. The veins beyond the point of obstruction are empty; and, hence, there is increased absorption with softening &c. The circulation at the point of obstruction is arrested, so that there is. a reduction or abolition of the vital properties; and consequently, either gangrene, ulceration or suppuration is developed. There is also increased circulation of the blood around the point of obstruction, causing exaltation of the vital properties; and, hence, spasm, pain, sympathetic irritations, increased secretion &c, are produced. CHANGES WHICH ARE INDUCED IN THE SYSTEM AT large. — The excitement may extend to the heart and arteries, causing inflammatory fever". The whole mass of blood may undergo altera- tions by increase of fibrin, by diminution of the secretions, and by the retention in the circulation of their elements. Exhaustion ensues after excessive excitement, the effusion of serum or the formation and escape of pus. Depression, with partial irritation, not unfre- quently supervenes in consequence of the pre- sence ot" pus in the blood. Th.ough._the pus globu- les cannot be absorbed into the blood by reason of their size, in their normal state, yet certain modifications take place in them, under some circumstances, which do admit of their being taken into the circulation,— causing the development of CAUSES. 17 peculiar and the induction of fatal consequences. causes of inflammation. — The causes of inflam- mation may be divided into predisposing and exci' ling. **• Predisposing causes act both locally mid generally. The general or constitutional predisposing cause.-, are plethora ; excess in food, or bodily exertion; exposure to miasmatic influences; disorders of the liver, skin and kidneys; great mental emotion; over stimulation ; vascular and nervous depression &C. The local predisposing causes are, excessive use of the part ; previous injury or disease ; deli- cacy of organization &c. The exciting causes are, mechanical injury; chem- ical agencies; morbid poisons; and certain impon- derable agencies, as beat, cold, galvanism &c. The causes of inflammation may produce their legitimate results either directly — that is to by irritating and inflamming the part with which they are in contact — or indirectly through the icy or instrumentality of nervous reflex action^ as when cold applied to the feet causes inflamma- tion o\' the lungs, bowels, or peritoneum. The causes of inflammation are common or specific,- the former being of constant occurrence, and a -iitutions equally, — the ! . being pctai liar in their origin, action and effects upon the human economy. mmation. — The symptoms or • by which inflammation is distinguished are • lend.— that is to say, connect -them- 18 SYMPTOMS. selves both with the part aftected and with the system at large. Local Symptoms. — The symptoms of inflamma- tion which connect themselves with the part afiect- ed, are reclifrss, pain, heat, swelling, alteration of structure and changes in function. Redness — This is owing to the primary production of a greater number of red corpuscles than usual; to the enlargement of the vessel, permittiug red corpuscles to circulate more extensively through them; and to the presence in the part of an unu- sual amount of blood. Pain. — This is due to the tension of the nervous ii laments directly involved; to the greater irrita- bility of the whole nervous mass; and to the aug- mented susceptibilities of the sensorium. There are different varieties of pain. Thus, it is dull obtuse, heavy or aching in congestions, and chronic inflammations, or in acute inflammations of pa- renchymatous, organs: it is gnawing or lacerating in rheumatism, gout, and periostitis : it is lanci- nating in scirrhus or in inflammations of the nerves : it is twisting, griping or spasmodic in dysentery, ileus, gastralgia, and obstruction of the intestines: it is burning as in cutitis, and erysipelas: it is sharp and cutting in inflammations of serous membranes : and it is oppressing in inflammations of the stomach, testicles, liver, and kidneys. Pain is riot an invariable concomitant of inflam- mation. Thus it is absent when inflammation only ends in adhesion ; — when the inflammatory action is indolent, as in scrofula ; when both the mental and physical susceptibilities have been SYMPTOM?. 1 9 destroyed, as by the abuse of spirituous liquors, opium and tobacco, — the exhibition of chloroform, or the existence of that peculiar morbid condition which is denominated insanity; when the nervous centres have lost their normal irritability or re- sponsive power, in consequence of the absorption of some "blood poison," or the retention of the elements of the bile, urine, &c; and, when the connexion between the brain and the affected part is destroyed, as by the destruction of the nervous filaments serving as their bond of union. Heat. — The amount of heat in an inflammed part, is never so great as the patient supposes, though it has been established by the experiments of Becquerel, and Breschet, that Celsus and Hunter were correct in regarding elevation of temperature as a characteristic of the inflammatory process. The temperatura,of the foci of inflammation is to be regarded as the expression of several distinct sources of heat, viz : 1. From the blood which accumulates in an unusual quantity about the centre of irritation. 2. From the increased metamorphosis of tissue which tal;.'- place in consequence of this accumu- lation of blood, and the attendant superabundance of those elements whereby the structures ar< ne wed. '■'•. From thr more active metamorphosis of tissue which is induced by specific changes in the nervous status of the part. The blood is warmer than the subjacent tissues, and hence, there must bo more Jieat al those points where this fluid accumulates. Again, as i' is now tfPTQMS. placed beyond question, that the source of the normal animal temperature is to be found in the chemical development of heat attendant on nutri- ent changes continually occurring in the tissues, it follows that, where there is an elevation of tem- perature, there must also be increased metamor- phosis. 3STow, this increased metamorphosis be- comes a matter of necessity when an unusual supply of pabulum is presented, as is the case where blood accumulates in tissues which have at once an appetite for it, and the power of appropriating it according to their necessities. And lastly, the experiments of Bernard and Sequard, have clearly established, that this ap- petite of the tissues, or in other words, their forma- tive power, or metamorphic capability, can be in- creased or diminished according to the amount of nervous influence supplied to them. It follows therefore, that when there is an excess of pabul um — i as must occur when the circulation is more rapid than usual, or there is an increase of blood in the part from any cause, and such a concurrent change in its nervous condition takes place as tends to stimulate its nutritrivu power, — there must be a more rapid and complete metamor- phosis, and a corresponding elevation of tempera- ture. oiling.— This is caused at first by the increas- ed quantity of blood, and subsequently by the effusion of lymph, the pouring out of serum, or the formation of pus. The more dense the texture, the less there is of swelling, and vice versa. Alteration of Function. — Each tissue and every SYMPTOMS. 2 1 organ has a certain part to perform in the econo- my, which is its contribution to the completeness and perfection of the organism. This is known as the function of the part. Thus the function of muscular tissue is to contract, and of glands to se- crete. Now, a given tissue requires two things par- ticularly, in order to secure the proper perform of its appropriate function, viz : the distribution to it of a certain amount — neither too much nor too little — of nervous influence; and the preservation of its structure- in their normal condition, [n- flammation, as previously shown, not only changes the n* of the part, hut constitutes per se such a veritable perversion of its nutrition, as speedily induces a positive modification of its structure. It thus becomes plain, that inflammation, must, as a matter of necessity, materially interfered with the function of the part in which it has been pro- duced, while all experience confirms the truth of this deduction. It is in this way that alteration of secretion ensues. Thus, secretion is usually diminished at the commencement of inflammation, susp< when it is at its acme, and increased at H health be. the termination. In the same manner, •lions may change their character.- chemically, or become mixed with the produqts of inflamma- tion, as pithelial cells, tube cast. lymph and pus. Alterations in Structure.- -These take t p]ace in consequence of the alteration in the nutrition of the part. The various tissues of the body are differ- 22 SYMPTOMS. ently affected by the inflammatory process, as will be shown hereafter, but there are certain changes common to all of them, which ma} r be mentioned here. The weight is usually increased, unless apo- plexy be produced : hardness is diminished, — that is, there is less of cohesion in the part, because of the effusions which infiltrate its tissues. In chronic inflammations the opposite of this is frequently the case, inasmuch as the effused lymph organizes, or the whole limb may become shrunken : Trans- parency is destroyed . Polish is impaired mate- rially: and alterations may take place in all the physical properties pertaining to the tissue. General or Constitutional Symptoms. — The most promenent and important of these is fever. Fever and inflammation are processes that many con- found with each other, though they are really dis- tinct. They may alternate or be intercurrent; and on the other hand, their characters and pheno- mena may be so blended as to render it a matter of impossibility to draw a line of demarcation be- tween them, and even to necessitate the use of a mixed term to define the resulting condition. It is in this way that the expression Inflammatory Fever has obtained a place in the vocabulary of medicine; and yet, whatever may be the analogy between them, or however undoubted the fact of their simultaneous existance at certain times, it is impossible to deny that they differ in their essen- tial nature, and that they are totally distinct pro- cesses. vm PTO Points of Resemblan and Inflam- mation. — The following characteristics distinguish both of them: 1. An elevation of the animal temperature, such as can be distinguished and measured by the thermometer. 2. An acceleration of tissue metamorphosis of a decided and appreciable character. 3. An increased rapidity of the circulation and definite changes in the nervous system, as have al- ready been referred to, and as will be more tally explained hereafter. Points of Different betw nd Inflamma- tion. 1. Inflammation is usually of local origin, jvhilst fever irally of systemic origin, and in its course involves the whole organism. 2. In Inflammation, the 'attending heat, acceler- ation of metamorphosis, excitement of circulation and change of nervous status is localized : while in fever these conditions are produced generally and simultaneously throughout the system. 3. Tn Enflamation metamorphosis is induced in the tissues even to the extent of their disorganiza- tion. In Fever, the nutrient local changes, t hough accompanied by interstitial absorption, progress, both in tissues and organs, without material inter- ference with their functions. I. [nflammation usually results as the effect of some mechanical, or chemical cause, acting upon the animal structures, and i an be produced at will. Fever, on the other hand, is produced by causey which can be neither explained nor controlled. tfPTOMS. 5. The Inflammatory process can be checked, controlled or modified by the employment of pro- per therapeutical agents; while, of most fevers, it mavbe asserted, that they are self-limited, and that any attempt to cut them short must fesult in failure as a matter of necessity. In this connexion, Lyons,* uses the following appropriate and significant language: " While I believe it may be said with truth that we can cure many Inflammations by the intervention of art, the same cannot be affirmed of Fevers. In Fevers the highest efforts of our art, the most delicate can.'. the most refined skill, the most nice appreciation and adaptation of means to ends which we can comjnand, must be all directed to watching, sup- porting, maintaining, and it may be stimulating the system till the fever-storm shall have passed over it." Circumstances under which fever is not readily produced. 1. "When the Inflammatory process limits itself ;y to the repair of tissues, Fever is not one of its attending phenomena. 2. When it is circumscribed, that is, when. but. a small portion of the animal structure is involved, Fever is not ordinarily developed. 3. When it occurs in tissues of an inferior de- • of vital organization, the svstem does not respond to the local impression, and that reaction, *A Treatise on Feyer &c, by Robert D. Lyons, K. C. C. D. D. Blanchard k Lea, Philadelphia, 1861. To this admirable :':■:, we are indebted to many i'or the above views. SYMPTOMS. 25 which we denominate febrile excitement, is not produced. Thus, an inflammation of the skin, cellular tissue fee., docs not. produce fever so readily as inflammation of the parenchyma of the lungs, of the pleura, or of the synovial membranes. 4. When it occurs in persons whose constitu- tions are neither above the standard of health, nor below — neither plethoriq nor ancemic — , fever is not readily produced. ( ircumstances u,nderwliich Ferry is readily produced. 1. When the Inflammatory process assumes a greater degree of violence than is necessary for the repair of tissues, and threatens the disorganization of the part. 2. When it involves a considerable portion of the animal structures. !!. When it affects tissues which possess a high degree of Organization. Instances in explanation of this point were given under the last head, though if additional proof be wanting, reference can be made to the facility with which Fever is developed in connexion with Inflammation of the delicate coat- of the eve, of the nerves and of the internal tunics of the blood vessels. 4. When it attacks parts which have, numerous and important nervous connexions with the system al large. In this way fever is developed either directly, or indirectly by what is known as nervous reflex action. Thus [nflammatioria of the brain spinal cord, and stomach readily and rapidly pro- duce an impression upon the whole system, which expresses itself in fehrile-exoitmeat 26 SYMPTOMS. 5. When it occurs in persons whose constitu- tions possess an unusual degree of susceptibility to local impressions and general influences of a morbid character. 6. When it is developed in those whose nervous systems are particularly irritable because of the existence of plethora, or of ancemia, though in the one instance the fever assumes a sthenic character whilst in the other, it is of a low grade. 7. When it exists in connexion with an epide- mic of fever, the development of malarial poison, or those debilitating influences which are the pro- lific sources of typhoids, and typhus, such as infest crowded camps, ill-ventilated Hospitals, and the confined Burden Cars in which soldiers are so fre- quently transported. Definition of Fever. -Lt is a matter of the first importance to understand the exact meaning of the word Fever, to comprehend the precise pa- thological conditions which are included in and expressed by that most significant term. From the days of Celsusto the present time, the Profession has sought eagerly tor a proper defini- tion of Fever; but it is generally agreed, that Cul- lin's description embodies the most correct en umer- ation of its essential phenomena. It is as follows : " after a preliminary stage of languor, weakness, and defective appetite, there occur acceleration of the pulse, increased heat, great debility of the limbs, and disturbance of most of the functions, without primary local disease." Phenomena of Fever. — EssentialP henomena. — Galen long since declared that the essence of fever kfPTOM • 27 consists in a color prceter naturam, and the most recondite researches and scientific analyses have succeeded in discovering no element thai is more characteristic, constant and important than the vation of tranperahm which invariably accom- panies the febrile paroxysm. That there is such an elevation has been decided by the experiments of'De ffaen, who found, that even in the algid here was, in the internal parts, a manifest increase of temperature, in some cases to the extenl of 2 ., 3' and even 1 ', and that the slightest febrile conditions are attended with an increase of heat, which is likewise in some in- te only observable phenomenon what- ever. The chief source of the increased tempera- ture in Fever is to be sought in an exaggeration of those causes which operate in the production of heat in the normal stale of the system. It is now universally admitted, that the source of the normal temperature is to be found in the chemical de- velopment of heat, which results from the nutrient processes invariably occurring in the various structures of the organism. It follows therefore, that th< '.of tern which characterizes the febrile condition, is the result and the exponent of 'Hi ■ d metamorplwsis in tf . It must 1)'- remarked, in this connexion, that there is not "ids an increased nption *A' the natural pabulum which the blood supplies to tissues, but that the actual constituent elements of the. body themselves are appropriated and removed by the increased metamorphic activity indued in the 28 SYMPTOMS. structures generally. Thus the fluids, the muscles, the adipose tissue, the glands and even the bones themselves waste away during the progress of a febrile attack, particularly if it be of long duration, or of great intensity. As the normal nutrition of the tissues bears a direct ratio to the amount of blood distributed to them, — since it is the source of their pabulum, it follows that the accelerated metamorphosis which characterizes the Febrile paroxysm, must be accompanied by an increased activity of the circu- lation. It is well known that however induced, an augmentation of the force and the rapidity of the circulation presents itself among the earliest concomitants of a large majority of febrile at- tacks. So invariable is this association, in fact, that alterations in the Pulse are universally re- garded as an essential element of that peculiar condition which we denominate fever. Metamorphosis, though depending to a great degree upon the amount of pabulum supplied by an increased .circulation, or an accumulation of blood from any cause, is also, to a certain extent, influenced and controlled by the nervous system, since, as before remarked, it has the power of in- creasing the appetite of the ultimate elements, and of thus inducing a larger consumption of those materials upon which they feed. It has been shown by Bernard, Sequard, — Weber, Virchow and others, that the nervous system exercises a direct and most potent control over the circulation. Thus, Bernard has demon- strated that the section of the sympathetic nerve SYMPTOM.-. 29 in the neck is followed by a rapid increase of tem- perature in the corresponding side. Brown Se- quard has cut the sympathetic filaments dis- tributed to the oar of a Rabbit, and found, that there was not only an increase o\' temperature in it, but that the blood was Avarmcr on leaving, than when it entered the part. Weber lias shown, that irritation of the Vagi nerves causes an arrest of the heart's action; and it has been known for a long period, that after section of these nerves, an im- mediate and decided acceleration of the pulse takes place. Similar experiments have been made by Ludwig, Valkman, Fowelin, and Traube, and with like results ; whilst Virchow has investigated the. subject still farther, and with such success as to induce him to build upon the facts eliminated, the whole superstructure of his febrile pathology. For these reasons, it is now regarded as an es- tablished fact, that certain parts of the nervous system preside over the general and local circula- tions, and that all changes in them, depend upon andrepresentcertain complimentary and precedent alterations in the nervous status of the organism. Virchow, who may be regarded as the great pathological pioneer ot the 19th century, believes that these alterations affect primarily the regulator or moderator functions of the nerves, and that the nerves which play this important part in the economy are the Vagi and Sympathetic, having, in all probability, their centre, especially the former, in the Medulla Oblongata. 30 SYMPTOMS. The essential phenomena of Fever may therefore be thus summed up : 1. Increased heat, produced by — 2. Increased metamorphosis, produced by — 3. Acceleration of circulation, produced by — 4. An irritation of the regulator nerves, especial- ly the Sympathetic and Vagi, whose centres are in the Medulla Oblongata. Non essential phenomena of Fever. — Fever may be accompanied by pain especially of the the head and loins ; a sense of heaviness or general lassitude ; deficiency of either secretion, or of all of them; dryness of skin; thirst; nansia; scanty and high colored urine; delirium; constipation; jactation ; &c. Some one of these symptoms is always present in connexion with inflammatory action, but they constantly vary, and, on that account may be re- garded as non essential phenomena. Varieties of Fever. — Fevers may be divided, with reference to the causes producing them, into two great varieties, viz : Idiopathic and Symptomatic. 1. Idiopathic Fevers. — These are produced by causes of an inappreciable character, either developed within or without the organism, and act- ing upon the nervous system directly or indirectly through the agency of the blood. Typhoid, and Typhus are types of this class of Fever. 2. Symptomatic Fevers are produced by some injury or disease of a particular portion of the organism. They are, in fact, nothing more or less than the system's response to an impression made by a disturbing agency, upon some one of its parts — the general manifestation of a special SYMPTOMS. 31 pathological disturbance. It is with Fevers of tin discription that the Surgeon lias specially to deal, and the}- must therefore lie particularly considered in this connexion. The essential elements ot'al I feversare identical, while their non-essential phenomena constantly va- ry. Heat: in ceased metamorphosis; acceleration of the circulation; and nervous disturbance are the in- variable phenomena which distinguish and charac- terize febrile action. Fever, then , regarded as a pa- thological entity— a distinct unit, made up of the peculiar morbid conditions just mentioned — is always the same so far as its essential nature is concerned. It is true that the degree of heat, the extent of the metamorphosis, the rapidity of the circulation, and the amount of nervous disturbance arc exceedingly variable; but it is equally certain that the mode, order and history of their develop- ment are. precisely the same under every variety of circumstances. Tt is therefore a misnomer to denominate fever per se as inflammatory, irritative, &c. j and, hence, Hie usual classification adopted by writers on this subject, is manifestly unphiloso- phical because it has no foundation in positive pathological fact. Fever, however, may associate itself with the In- flammation ofa healthy system, orwith the [nflam- mation of a debilitated, impoverished each" system. The first is known ns Pyrexia, or true Sur- gical fev< r. and character. Jt> symptom are a li"t and dry skin; a full, bound ing and frequent pulse; the diminution or a 32 , SYMPTOMS. the secretions; acidity and high color of the urine; constipation of the bowels; coating of the tongue with a white fur; thirst; languor., heat and pain of head. A disposition is always manifested in this connexion, to remit or intermit, or in other words, the fever is not of a continuous character. Its abatement is followed hy the subsidence of all the symptoms mentioned above: — by a free per- spiration; — by abundant discharge of urine a- bounding in Uthates ; — by a natural movement of the bowels, or it maybe diarrhoea; — by cleansing of the tongue, abatement in the frequency and force of the pulse ; — by subsidence of thirst and a general feeling of relief on the part of the patient. The second which is of a decided asthenic charac- ter, presents itself under three forms, viz: Typhoid Fever, Irritative or Nervous Fever, and Hectic Fever. The true Asthenic or Typhoid Fever occurs prin- cipally in persons whose constitutions are enervated by exposure, privation, irregularity, of life, grief, or long residence in a vitiated atmosphere. Symptoms. — The period of depression is marked and much prolonged. The reaction is not of a very active character ; there is a disposition to heaviness, stupor, and delirium ; the pulse is feeble but quick and frequent; the skin is sometimes moderately hot, then again is particularly dry and burning, and occasionally covered with an abundant perspiration ; the cheeks are flushed, and the eye< bright and starring, while the tongue is red, dry and sometimes cracked in its centre. The abatement of the fever is characterized by a gradual disappearance of all the symptoms ; BfMPTOMS 33 the patient remains weak and debilitated for nd the return to health is invariably alow and uncertain. Should the disease lake an unfavorable turn, the pulse grows more feebleand frequent, the tongue dryer and more cracked, the skin eoWand mottled ; while hiccup, subsultus, dyspnoea or coma comes on and death closes the scene by claiming its victim. There is always a tendency to visceral compli- cations in connexion with this affection, which not unfrequently decide the fate of the pa- tient. The fever is usually continuous and pa- thologists locate the especial seat of the disease in the Sympathetic system. Irritative Fever is a variety of the asthenic form though not of so specific a tyj>e as the last. The rvous system is especially concerned ; and the , action presents itself in connexion with the those whoso mental powers have been over taxed, or whose vital energies have been destroyed by excessive venery, indulgence in drink. ul intellectual Labor, &c. The symptoms which distinguish Irritative fever areadry and red tongue; a sharp, small, but frequ- entpulse; subsi and delirium, which rive place to sigus of debility, with coma and rebral irritation, sudden exacerbations, unequal and irregular remissions; rapid and important iqueut concomitauts of this form of disease. Bectic Fever, is also a variety o{ the asthenia form and generally present* iUelf in conjunctiou with ►rganic, ieriousdi ive dischargeol 34 TERMINATIONS. any secretion, but more particularly with the for* mation of abcesses and the production of pus. Emaciation; debilit} 7 ; clear and red tongue? disposition to diarrhoea and profuse perspiration; a frequent and small pulse; slight chills follow- ed by burning of the hands and feet, with a cir- cumscribed flush upon the cheek, indicating de- rangement of the capillary circulation, are the symptoms which characterize this form of fever. Hectic is but too frequently the harbinger of a speedy death ; and yet, it is really astonishing to observe with what rapidity and completeness many patients recover even after the development of its most characteristic and unfavorable symp- tomps. It not unfrequently has the effect also of pro- ducing an exhileration of the spirits, — elevating them to such an extent as to preclude all fear of the fatal catastrophy of which it is the sad pre- cursor. Terminations of Inflammation. — Inflamma- tion may terminate either in the repair of the part; in its return to health ; in the modification of its function and struct arc; or in its death. Repair of the part. — A part whose continuity has been broken or destroyed may be repaired, after the development of ruflammation, either by the immediate organization of the Effused Lymph, or by its more slow and gradual conversion into a structure identical with that of the subjacent tissues or similar to it. When the repair is immediate, it is called union by the " First Intention," and when more tardy — TERMINATION- o5 being accompanied by the formation of healthy pus, granulation, &c„, it is denominated union by the " Second Intention." Restoration of the Part to health. — Inflammation may be developed in a part, which has suffered no solution of continuity, under the influence either of some Loeal or General cause, and, after the manifestation of all the characteristic symptoms, of that process, leave it in its original condition. This is accomplished by the reabsorption of the effused Plasma, either in its nascent stale, <>r after it has been changed into blastema and fibro-cellu- lar tissue. The absorption of the Lymph in its liquid state is denominated Resolution, and is the most favorable termination or effect of Inflamma- tion. Nature, in many cases, labors to make way with effused Lymph in such a manner as will prove least injurious to the surrounding parts as well as to the organism ; and, hence, the work of reab- sorption is commenced, under its watchful and in- telligent guidance, to be perfected or not accor- ding to the circumstances of the ease. Each petholigical step is then carefully and successfully retraced. The attraction between the Q-lohules and the walls of the vessel, loses its intensity ; the stasis of Blood disappears; the Heat, Pain and Swelling abate; and the part assumes its normal status, both as regards function and organization. Et sometimes happens, however, that all of these steps are taken suddenly and simultaneously, or occur, so rapidly as to be inappreciable. This is i \ led DeUtesa n Metastasis is the sudden translation of Intiainma- 35 TERMINATIONS. tion from one "point to another. This, in a ma- jority of cases, may be regarded as a phenomenon of Nervous Reflex Action — a principle which plays a most important role both in the Physiological and Pathological processes of the organism. Resolution is the natural, legitimate and most favorable conclusion of the Inflammatory process — a result towards which the efforts of the Practi- tioner should be invariably directed as the most effectual method of preventing disastrous conse- quences. The Absorption of Lymph after its conversion into blastema and fibro- cellular tissue, does not occur to any considerable extent during the height of the inflammation by which it has been produ- ced. There must always be a marked reduction of the morbid action before the absorbent vessels can be forced to take hold of it ; but when this point has been once reached the process often goes on with great rapidity. When the Lymph has become completely organized, absorption is, of course, still more difficult, and not unfrequently impossible. It is more than probable that Lymph even in a liquid state, is not absorbed until it has been dis- solved in the fluids of the affected parts, when it is brought more readily under the influence of the absorbent vessels. Modification of the structure and functions of the Part. Inflammation may also leave the Part mod- ified both as regards function and structure. This modification is due to the influence of certain pro- ducts* oi the Inflammatory Process, which should TERMINATIONS. 37 be briefly considered, in connexion with this mode of development, and the nature of the effects pro- duced by them. The effects or products of Inflammatory Action, which play this important part in the economy are : Induration, Hypertrophy, Atrophy, Effusion of Serum, Formation of Pus, Organization of the effused Lymph, or Transformation of Tissue. Induration. When the effused lymph is not absorbed it organizes, either forming a sort of in- ternal cicatrix which is harder than the surrounding tissues or increasing the density of the part by aug- menting the amount of plastic material within it. Softening. This results either from the infiltra- tion of effused liquids, or disintegration of the substance of the textures themselves, by which their consistence is diminished. Hypertrophy. It has been previously shown that the Inflammatory Process not only increases the amount of Blood — the pabulum sent to a given tissue — but also stimulates the appetite of the part, so as to render its nutrition more active and com- plete. It thus happens, not unfrequently, that tissues, and whole organs are permanently enlarg- ed, asa consequence of Inflammation. — Hypertro- phy is essentially a local disease. Atrophy. Though atrophy is the opposite of Hypertrophy it is not an unusal effect of Inflamma- tion. Nutrition is made up of two elements, which though entirely distinct, the one from the other, are absolutely essential to the perfection of the process. Cell destruction as well as Cell elabora- tion—the breaking down and the building up of 38 TERMINATIONS. ;, occur simultainously throughout the whole organism. The term metamorphosis includes both of these processes ; and in the normal condi- tion of the system presupposes a perfect equili- brium between them. Under the influence of In- flammation this equilibrium is lost, so that cells may be too readily produced, or too rapidly destroyed. In the one instance Hypertrophy is produced and in the other Atrophy is the result. Effusion of Serum. — Congestion or the accu- mulation of Blood in the part affected, consti- tutes one of the distinguishing features of Inflam- mation. It is, in fact, an essential element of that process. The vessels thus become filled with an unusual quantity of the circulatory fluid, which distends their coats, and «facilitates the pouring out, or the exosmosis of the watery portion of the Blood into subjacent cavities or neighbouring tissues. It is in this way that fluxes are produced and dropsies occur, materially altering the struc- ture of tissues and organs, and interfering with their peculiar functions. All the tissues do not present the same tendency to the effusion of serum in connexion with Inflammatory action. The structures which supply it in greatest abundance are the cellular and serous, the secernent vessels of which are extremely active even when the disease itself is comparatively mild. The mucous mem- brane of the alimentary canal, particularly that of the Colon and Rectum is frequently the source of large effusions of serum, as is seen in diarrhoea and Cholera Infantum. The appearance of the serum is usually limpid, TERMINATIONS. 39 though it may be changed by admixture with the secretions, Lymph or Pus. The effusion of Serum is always a phenomenon of Osmosis, while it is con- trolled by the laws which govern that process, and is dependent upon that principle alike for its production and its cure. Suppuration or the formation of Pus. The idea was long entertained that Pus was a veritable secretion, poured out from the vessels under cer- tain abnormal circumstances, and subject to all the laws which control the products of secerning organs general ly. The researches and arguments or Gulliver, Mandt and Addison have demonstra- ted the incorrectness of this opinion ; and it is now generally agreed among Pathologists, that Tus Corpuscles are modifications of the Exudation Cells, and that suppuration is nothing more nor less than the breaking down or degeneration of the Lymph poured out in connexion with the inflam- matory process. When Lymph is not converted into tissue, or false membranes — because of the blight impressed upon the formative power of the contiguous struc- tures by the Inflammatory action — or fails to or- ganize even into cacoplastic products, a peculiar depreciation takes place in it whereby the corpus-' cles of the Plastic mass are transformed into Pus Cells, the Blastema degenerates into liquor puris, and Purulent matter takes the place of the more highly organized effusion. When Pus is formed upon a free surface, it is styled a Purulent secretion; and when elaborated within the structure of a part, it is called an Abscess. 40 TERMINATIONS. Nature usually makes an effort to retain the Pus thus formed within limited bounds, by depositing around it an external boundary of consolidated Lymph, known as the Pyogenic Membrane. This does not secrete Pus as was supposed by Delpech and many others, but is simply the boundary line between the abnormal product and the intact tissues. When this Membrane is absent, it may be regarded as indicative of a want of tone in the system, and as such furnishes a valuable hint to the Surgeon as regards prognosis and treatment. In the above remarks concerning this Pyogenic Mem- brane, the production of Pus in connexion with abscesses, is only referred to. This fluid is elabo- rated aloug the track of wounds extending through tissues of all grades and varieties, with so much rapidity and in such large quanties, as to preclude, even in the most vigorous constitutions, the for- mation of a protecting membrane, and is, hence, found diffused, in many instances, throughout the subjacent structures. When Pus is opaque, thick, smooth, slightly glutinous, of a yellowish white color, with a green- ish tiuge, a faint odour and a alkaline reaction, it is said to be healthy or laudable ; when mixed and tinged with blood it is sanious ; when thin watery and acrid, ichorous ; when it contains cheesy looking flakes, curdy, and when diluted with mucus or serum, muco-pus or suto-jms. It consists, when laudable, of corpuscles, floating in a homogeneous fluid, styled " liquor puris." These corpuscles are modifications of the exuda- tion-cells, and are composed of a semi-transparent TERMINATIONS. 41 cell-wall, with two or three nuclei, of large quan- tities of granular matter., of particles of fibrin, and of disintegrated exudation cells. A multi- tude of changes, however, may occur in it, altering its composition, and changing its character, which can be detected by the microscope. When the suppurative process has once been set up, it may continue for an indefinite period, becoming, as it were, the fixed secretion of the part. From mucous membranes particularly, it has been known to last for years. The symptoms which indicate that Pus is about to be formed, are ; a more throbbing pain, a greater swelling and tension of the part, and a red, glazed and shining appearance of the skin, though it is sometimes elaborated without the development of any antecedent local sign. The symptoms which indicate that Pus has been formed are : the disappearance of the ordinary signs of inflammation ; the occurrence of chills or rigors ; alternations of heat and cold; abatement of the intensity of the fever, and its assumption, in some instances, of an intermittent character; softening and perhaps qnickening of the pulse ; and fluctuation in the part, with enlargement also when the fluid is diffused throughout its tissues. The symptoms which indicate that Pus is esca- ping from the system in too great a quantity, arc : emaciation and loss of strength, a quick, small and compressible pulse ; a coated and dry tongue with red tips and edges; flushed cheeks; dilated pupils; profuse sweating; copious purging; large 42 TERMINATIONS. discharges of urine, filled with red deposits ; great debility ; hypocratic countenance ; husky voice ; insomnia, &c. There is usually an exacerbation towards evening, and the actions upon the bowels, skin and kidue}^s alternate with each other, until the patient dies from sheer exhaustion. The tendency to suppuration is increased by the following circumstances, viz : 1. Peculiar conditions of the Patient's system. Thus, in conditions of debility from any cause which diminishes the vital powers, as bad food, impure air, cachectic states of the organism, scro- fula, &c. 2. Specific character of the Inflammatory pro- cess. Thus, in Gonorrhoea and Purulent Opthal- mia, Pus is more readily eliminated than under ordinary circumstances. 3. Locality of the Inflammation. Mucous mem- branes more readily suppurate than serons, &c; cellular tissues more rapidly than muscular, &c. ; Iuflammatory surfaces when exposed to atmos- pheric air supurate more readily and freely than others. 4. The state of the part affected. All parts of the system are not invariably in the same condition of health. Thus the nerves running to a particu- lar part may have been divided by some previous accident, or some affection peculiar or confined to it may have lowered the tone of its vital powers, &c. In this way Inflammations which some portions of the body would readily resist, terminate else- where in suppuration. The Plastic matter thus destroyed is the food of TERMINATIONS. the tissues involved in the Infla on— the pabulum upon which they depend for the pre- servation of such properties as arc essential to the integrity of their structure and the perfection of their functions. Again, the purulent fluid by desseminating itself throughout the tissues, or by pressing upon them, so changes the normal status of the. part as to disqualify it, cither partially or completely, for the performance of its proper offices. Of the fatal consequences which connect them- selves with the presence of Pus in the blood, it is unnecessary to speak in detail here, in as much as they will be more fully discussed in another con- nexion. It is sufficient to say that the Purulent elements, when thus absorbed or developed, so paralyze the nervous centres and blight the tissues of the organs generally, as to interfere with the action of all the component parts of the organism — suspending nutrition, aborting or altering secre- tion, robbing the muscles of their tone and power, destroying "nervous influence," and inducing a complete revolution in the whole system. Organization. The Plastic Lymph effused in connexion with the Inflammatory process may cither Organize or breaJc down into Pus. The term organization includes the n of the into tissue, taking racter from the subj; structures; the development of fals and the formation ■ in hcteromorphou ducts, as Tubercle, I Plastic Lymph an inhere!) iity for organization, oon as ii is effused, this tendency mai 44 TERMINATIONS. itself by the formation of cells and nuclei in great numbers, which connect themselves with each other, and gradually spread out into fibres lying for the most part in parallel lines, and profusely in- laid with granules. Vessels soon show themselves, which are the result either of a new epigenesis, or the contributions of the neighboring structures, the latter being the more common source of sup- ply. Nerves and absorbents, finally appear, but whether they are supplied by the surrounding tissues, or are spontaneously developed from the effused matter, has not been determined by Pa- thologists. In this manner the effused Lymph either assumes the characters and functions of the tissues with which it is in contact, or forms false membranes. "When, however, there is a deficiency of nervous influence in the part or system, a want of plasticity in the effusion itself, or a deficiency of vital power in contiguous tissues, the same at- tempt at organization is made, but the issue is an aborption, and a product results, of an inferior de- gree of organization, and lower in the scale of vital endowment, to which the term heteromorphus has been applied. It is m this way that Tubercle and other similar growths are developed, as the effects of Inflammation, complicating the termina- tion of that process, and inducing eventually the most serious consequences to the system. Inflammation may terminate, leaving behind the liigher products thus formed in a state of complete organization, and materially modifying the structure and functions of the part in which they have been developed. An organ, as the Liver or Spleen, TERMINATIONS. 45 tvhich has been hypertrophied, by the organization of Lymph cftused into its structure, does not pre- serve its original statics either physically or func- tionally, and is, hence, modified to an appreciable extent by the precedent morbid action. iSo like- wise, False Membranes, by agglutinating the Intes- tines, binding together the Costal and Pulmonary Pleura, constricting or contracting the Urethra, &c., &c., materially interfere with the legitimate functions of these parts, and produce disastrous consequences in the economy. Transformation of Tissues. Each tissue posses the power of appropriating certain elements suppli- ed by the Blood, and of converting them into its own substance. In order that this " formative 'power'" may be legitimate!) exercised, it is neces- sary that the structures remain in a condition ot health, that the ordinary supply of nervous influ- ence and of proper pabulum be supplied them, and that their normal Ph}-siological status continue intact. The Inflammatory Process interferes with the supply of nervous influence, and destroys the responsive power of the tissues without necessarily depriving them of the elements which constitute their proper food. Instead of converting plastic Lymph into their own substance, they simply impress it with a sufficiency of vital force to insure Its organization into tissues of a lower grade, and, hence a spcies of degenerati2 TEfcftlNATIO creases in consequence of tbe effusion of Sangui- nolent Serum. When Gangrene terminates in Sphacelus the hue of part becomes dark and dirty — the tissues grow flaccid and cold, while crepitation man- ifests itself on pressure, and a most offensive odour is evolved. When the progress of the Gangrenous process is arrested, healthy circulation is developed up to the margin of the diseased portion, while a bright red line — the line of demarcation — indicates the es- tablishment of adhesive Inflammation, and shows that the living parts are to be separated from the dead by a spontaneous effort of nature. This line of demarcation extends to the entire depth of the Gangrene, totally and completely surrounds it, and by a process of interstitial ulceration, removes the dead part, without hemorrhage or other serious inconvenience, leaving a granulating and healthy surface behind, which undergoes cicatriza- tion without much difficulty or delay. In some instances however, as when Patients have been subjected for a protracted period to the influence of debilitating agencies, the blood does not coagulate in the vessels and hemorrhage of a fatal character occurs. treatment or INFLAMMATION. — As the pheno- mena of Inflammation connect themselves both with the Part affected and with the System at large\ it is plain, that tbe remedies employed in its treat- ment ninst.be of a Local and a General character. This constitutes the first and most important classi- fication of the remedial agents at the command of TREATMENT. 53 the Surgeon in his contest with this dangerous, and often defiant malady, though more minute sub- divisions may be necessitated by an accurate and elaborate investigation of the subject. From the account which has been given, of the symptoms, products and terminations of Inflammation, in the preceding pages of this work, it is plain, that the Remedies employed in its management, should be used with reference to the following Indica- tions : 1. To control the response made by the system at large to the local disturbance — i. e. to control the adventitious, — non-essential phenomena of In- flammation. 2. To control the Heat, Pain, congestion, &c. — the essential phenomena of Inflammation. 3. To limit the effusions incident to the Pro- cess — i. e. to confine the Inflammatory Action within Physiological grounds by securing simply the repair of tissues. 4. To promote the re-absorption of the effusion and to restore the tissues to health — i. e. to insure Resolution. 5. To prevent modifications in the structure and functions of tissues and organs — 6. To prevent the death of the part affected, either molecularly, by ulceration, or entirely by Gangrene. All General and Local Remedies, used in tin- treatment of Inflammation, act either by controlling the phenomena, limiting the effects, or modifying the terminations of the Inflammatory process. General Remedies, — Inflammation may be asso- 54 TREATMENT. ciated with a system in a condition of vigor, or of debility, and is sthenic or asthenic according to the circumstances of the case. When connected with a healthy and vigorous system, it is usually characterized by such symptoms of Inflammatory Fever, — as were referred to under the head of Sthenic Fever, and when developed in connexion with an impoverished and debilitated system, the resulting Febrile action is of a Typhoid character. These facts, necessitate a division of the constitu- tional agents employed in the treatment of In- flammation into Depletory and Stimulant Reme- dies. Depletory Remedies. — Among the most promin- ent agents which belong to this class are Blood- Letting, Mercury, Depressants, Cathartics, Emet- ics, Diuretics, and Diaphoretics, Nervous Sedatives, Agents which control the Capillary circulation and the Anti-philogistic Regimen. Blood-Letting. — Without entering into the merits of the great Blood Letting controversy, which has so divided the Medical world, it will be sufficient for present purposes, to mention the cir- cumstances, &c, under which, according to the instructions of the ablest masters, and the teach* ings of a sound therapy, the Lancet may be em- ployed in the treatment of Inflammations. 1. Blood Letting should never be resorted to save in Inflammation which connects itself with a constitution which is strong and healthy, — that for instance of a vigorous, athletic man. 2. When T ■ nation, is associated with Pie- TREATMENT. 55 thora — a full habit, and an unusual supply of red blood. 3. In Inflammations which produce an excessive disturbance in the system at large, accompanied by a full pulse, hot skin, flushed face, and the usual evidences of Inflammatory Fever. 4. In Inflammations of some internal organ, •which manifests itself by symptoms of great de- pression such as small pulse, cool skin, clammy perspiration — in a constitution healthy and vigor- ous up to the moment of the attack. 5. In all Inflammations of a high grade, when no tendency to Typhoidism exists, and the Patient can be subjected subsequently to proper treatment The cuds which may be accomplished by Blood- letting are: 1. To lessen the amount of blood when it is too great, and to reduce its quality when abnormally rich or stimulant, and thus, to relieve Irritation ami Inflammation. "2. To lessen the action, of the Heart and Ar- teries, to restrain the momentum of the circulat- ing fluid, and consequently to diminish Heat, to abate Tain, to prevent effusion, to equalize the circulation, to obviate local determinations, to relieve spasm and nervous irritation, and to arouse usceptibility of the various organs, rendered insensible by the congestion of the Nervous pent To promote absorption, and to increase the action of other remedies. l. To arrest Hemorhage by inducing scyncope, and favoring the formation clots, by which the 56 TREATMENT. Vessels are blocked up, and the escape of Blood prevented. It cannot be denied however that there are multitudes of cases, particularly in connexion with the Surgery of Camps, and Hospitals, in which Blood-letting would not be beneficial, but positive- ly inj urious. But as a pure anti-phlogistic when the grade of the Inflammation is high and the attend- ant conditions are such as to admit of its proper application, the Lancet has no rival, particularly if employed before the exudation of Plastic Lymph, or the development of those phenomena which indicate that the acme of the disease has been passed. This can be readily understood, when it is remembered, that in Inflammation, with each pulsation of the Heart an unusual amount of Blood is sent to the affected part, which serves to keep up and to increase the already excited irrita- tion ; that the Blood itself is far more stimulant than in health; that the momentum of the circu- lating fluid, is greatly increased ; and that nervous irritation exists far beyond the natural limit, — morbid conditions which Blood-letting ameliorates and removes upon the principles already enunciat ed. The employment of the Lancet is based upon the supposition, that, though the nervous centres possess the inherent power of generating a suffi- ciency of vitality or nervous force, they are pre- vented from so doing by the presence and pressure of an unusual quantity of depraved Blood, and that the proper performance of their functions can be facilitated by the removal of this pressure, and TREATMENT. 57 the supply of a better material for their consump- tion'. Arterial Sedatives. — Veratrum Veride, Digitalis, Aconite, Tartar-Emetic, &c, produce the same effects as Blood-letting, though in a less marked degree, by the impression which they make upon the circulation. Under their action, the skin re- lazes, the pulse softens, the tongue grows moist, Becretions are restored, nervous irritation abates, and everything indicates the restoration of the circulation to its normal equilibrium, and the abate- ment of the Inflammatory symptoms. Their em- ployment is particularly adapted to the cure of Inflammations of an acute character, in young and robust subjects, whose systems require to be rapid- ly impressed in order to stay the march of the se. In Inflammations of the Respiratory Organs their beneficial effects are so particularly marked thai they have almost entirely supersed- ed the use of the Lancet. These agents are not spolialive. They do not deprive the system of its blood, and thus rob the [issues of their food. Their depressing effects are feqnsequently far more transient than those pro- fituccd by tin- Lancet : and, hence there is not the suiii" ■ difficulties to be apprehended in building the system up — in giving it tone and recuperative r -attendant upon their administration, as upon the employment of Blood-letting— a mos( important circumstance in these times of Typhoid tend em ies, and low grades ol Fever generally. Mercury. — This Drug not only controls the 58 TREATMENT. symptoms of Inflammation, but limits its effects, and modifies its terminations. It controls Inflammation by rendering the Blood less irritable ; by diminishing the momentum of the circulation ; and by promoting the secretions, and by acting as a depletant and a deobstruant. It limits the effects of Inflammation by robbing the Blood of its Plasticity, and thus precludes extensive effusions; and, by releaving local con- gestion, accomplishes the same end. It modifies the terminations of Inflammation by liquifying the effused lymph and facilitating its absorption— thus promoting resolution, or "ten mination in health;" by promoting absorption and obviating induration; by destroying false mem branes, "— thus preventing modifications in th "structure and functions of tissues ; " and con-, trolling ulceration by altering the condition of granulating surfaces. D Rules for the administration of Mercury : 1. Administer it in the form of Calomel, Blue Mass, or Mercury with Chalk. 2. When from the violence of the Inflammation a prompt and powerful impression is required Calomel should be given in large and frequently repeated doses. S. When the Disease is less violent, and the or-' gan not important to life, Blue Mass or Mercur| with Chalk may be given in smaller doses. 4. To make Mercury more Purgative combine with it finely powdered White Sugar, and give upon the Tongue. 5. To prevent it from running off the Bowel TREATMENT. 59 combine with cadi dose a small quantity of Opium. ii\ Repeat- ed doses, is the best remedy for ►Salivation. Cathartics, Diaphoretics and Diuretics are ad- ministered for their depleting, dcrivitive or revul- sive effects. Nervous Sedatives. Although the part played by the Nerves in Inflammation is not thoroughly understood, yet the following facts may be re- garded as established : 1. The primary morbid impression is made up- on the nerves, from which it is reflected to the Capillary Vessels, and hence irritation and subse- quently congestion arc the primary phenomena of the process. 2. The nervous cenfm, responding to the per- turbation, thus induced in the economy, participate in the irritation, ami licnce, the circulation and the secretions, together with the nutritive process an- disturbed. 60 TREATMENT. 3. Inflammation is as much a product or con- comitant of nervous irritation, as of vascular dis- turbance. It has been shown, that when the Opthalmic branch of the fifth pair is divided in the Cranial Cavity of a Rabbit at the Varolian bridge, Inflam- mation is developed in the surface of the eye, and that, when the nerve is cut in such a way as to di- vide the Ganglion of Gasser, the Inflammation is more violent and deeply seated. It has also been demonstrated that when the Pneumogastic Nerves are cut high up in the neck, the Lungs become engorged with Blood and present many of the phenomena of Acute Inflammation, while the stomach becomes also envolvedto the extent of an arrest of its secretion. So likewise when the Bra- chial Plexus is tied, the integuments and finally the deep structures of the Limb become inflamed in a very high degree. These and a multitude of kindred facts which modern Physiology has established, demonstrate that the role performed by the nerves in the development and continuance of the Inflammatory Process is one of the greatest inportance. The Therapeutical action of Sedatives is to di- minish the injection of the nervous centres, to relieve the irritability of the whole nervous mass, and thus, indirectly to restrain the action of the Heart, to disgorge the Capillaries, and to regulate the action of the secreting organs. From this plain statement in regard to the con- dition of the nerves in Inflammation, and the therapeutical action of Sedatives, it is made TREATMENT. 61 apparent that this class of remedies is peculiarly indicated in the treatment of that morbid process. The agent which stands at the head of this list is Opium, with its different preparations, as the Salts of Morphia, Laudanum, and Dover's Pow- der, though Stramonium, Hyosciamus, Indian Hemp, &c, may also be employed. This remedy is particularly indicated when the Inflammatory Pro- cess is accompanied by violent pain, a symptom which may complicate the morbid action to a con- siderable degree, even to endangering the patient's life. Rules for the administration of Opium. 1. Precede the exhibition of the Opiate, by Bleeding or Purgation, particularly when there is Plethora, Fcecal distention, Disorder of Secretion, &c, 2. Administer it in large doses — say from two to four grains of Opium within every twelve or twenty-four hours. 3. Give the Opiato at night, so that rest and quiet may be secured to the patient. 4. Remember, that under the influence of Pain the System acquires a greater tolerance for the Opiate. 5. If the skin be dry, combine with the Drug some Diaphoretic or use Hover's Powder. (>. When Inflammation occurs in structures which are likely to be pu1 in motion by the nor- mal processes of the economy, as the Peritoneum, the Pleura, the Alimentary Canal, &c, Opium may be freely used, not only for the purpose of controll- ing the Enflammation already existing, butto keep the part at rest and thus indirectly to prevent the 62 TREATMENT. farther development of it, — by serving as a verita- ble splint to the affected structure. Agents which contract the Capillaries. In those cases where the local disturbance is excessive, ac- companied by great Heat, Pain Congestion, and Swelling, it becomes a matter of importance to act upon the Capillaries in such a manner as to limit the amount of Blood in them. The remedies by which this end can be most readily attained are Ergot, Belladonna, and the Muriated Tincture of Iron, — agents which by diminishing the calibre of the Vessels, reduce the local hyperemia, and relieve the unfavorable symptoms incident to it. Theore- ically these Remedies, from their known thera- putical properties, would seem to be particularly indicated in the treatment of that variety of In- flammation refered to ; but as yet the utility of their administration has not been subjected to that practical test which the Profession demands as the essential condition of its faith and confi- dence. It must not be supposed however, that these agents act particularly upon the diseased part, for it is only by the impression made upon the organ- ism in its totality that the engorged Capillaries are incidentally contracted, and the congestion re- lieved. They are certainly worthy of a thorough and impartial trial, and as such are recommended to the Profession. Antiphlogistic Regimen. Under this head are included the diet of the Patient, and certain other circumstances and conditions by which he may be TREATMENT. 63 surrounded. During the height of the Inflamma- tion, when the functions arc interrupted, the se- cretions deranged, and the Blood filled with sti- mulating elements, great care should be observed in the regulation of the diet. Food is usually loathed, under these circumstances, and when injested in solid form, serves only as an additional source of irritation to the system. When the acme of the affection has passed, mild and easily digested food should be administered in a liquid form, beginning with gruel, arrow root, &c, and gradually and cautiously advancing to other more nutritive articles. The drink should be cooling and demulcent. The question of diet in connexion with the Inflammatory Process, is an important and delicate one. Care should be taken to run neither into the extreme of over stimulation nor of too great abstinence ; but the Surgeon should remember that there is danger to be apprehended alike from an excessive supply of pabulum to the already infected Blood, and from the debility which necessarily and in some instances, rapidly ensues from the destructive metamorphosis inci- dent to Inflammatory action. It is also a matter of the first importance to se- cure perfect tranquility of mind and repose of body, as well as a proper amount of healthful sleep. So, also, recovery and comfort are both promot- ed by a regular temperature, free ventilation, cleanliness of body, words of encouragement 'and kindness, clean and comfortable bedding, the presence of friends and relatives, the assurance of 64 TREATMENT. victory, confidence in the skill and humanity of the Surgeon, and a multitude of similar circumstances which will readily suggest themselves to the Physician. Stimulants. — This class of remedies is indi- cated : 1. When the morbid action has been originally developed in connexion with a depraved and de- bilitated system. 2. When the strength of the system has been exhausted by the Inflammation itself or some of its products, as when Hectic is developed in con- sequence of the excessive discharge of Pus, &c. The principle upon which stimulants are exhi- bited, in this connexion, may be thus explained. The Nervous Centres, which are the great foun- tains of vitality, — the sources from which flow out the influences which give tone to the muscles, action to the secerning organs, life and power to the whole organism, become debilitated from the absence of those conditions which are essential to the health of the system, such, for instance, as pure and proper food, cleanliness of person, ap- propriate clothing, contentment of mind, and other similar circumstances. The Blood, at the same time, is impoverished, losing its red globules, augmenting in watery elements, and becoming more irritable and less stimulant to the tissues through which it circulates. The development of Inflammation, finds a system in which these changes have occurred, in but a poor condition to resist its invasion, and to prevent the induction of its most TREATMENT. 65 unfavorable consequences. The great centres, from their preternatural irritability, respond im- mediately and violently to the local impression,-— so excessively in fact, as speedily to exhaust them- selves, and to lose the power of supplying that in- fluence upon which the integrity of the Organism so much depends. The tissues generally being thus deprived of the stimulus from the Nervous System, are incapable of appropriating their necessary pabulum. The secerning Organs having lost their guiding and controlling principle fail in the performance of their legitimate functions. The chief motive power of the circulation being weak- ened or destroyed the Heart beats wildly, the ar- teries contract irregularly, the Capillaries en- gorge themselves with blood, and the circulating fluid is vitiated to a still greater 'degree under the constantly increasing demands for its vitalizing principles, the retention of the checked Secretions, the development of Inflammatory products, the waste of exhausted tissue, and the expenditure of its Carbo-IIygronous elements in the work of Ca- lorification. In this emergency, the only means of preventing speedy disorganization, — the com- plete overwhelming of the system by the violence of the disease, is to supply it with strength. The exhausted fountains must be replenished, the wasted stream restored, the motive power of the paralyzed machinery supplied anew, or the Patient surrendered to the embrace of death. Stimulants, therefore become a necessity, so absolute and im- perative, that to fail in their employment is to ume the responsibility of a fatal result. 66 TREATMENT. A simple illustration will elucidate the whole subject. The system may be likened to a Fortress, the Inflammation to the attacking Party, — the first resisting the assault, the latter striving to re- duce the Work. Now, it is plain that a successful resistance can be ensured in two ways : — either by weakening the attacking Party, or by strengthen- ing the Fortress. By Depletants, we diminish the number and power of the assailants, and thus en- sure the safety of the Garrison. By stimulants, we strengthen the weakened Work, victual and encourage its defenders, and secure the repulse of the attacking Party. The one plan prevents fatal consequences by abating the force and intensity of the Inflammation, while the other accomplishes the same end by strengthening the sinking and overpowered system. A large majority of^army Patients present symptoms of debility in connexion with the pro- gress of all Inflammatory affections, and the ex- hibition of stimulants and tonics is consequently demanded as a general thing in the treatment of their diseases. This is the general rule, but it must be borne in mind that it has its exceptions, and is not of universal application, as some teach and many believe. Many affections which assume a Typhoid type during their progress and thus necessitate a resort to sustaining remedies, may bo "cut short" by the timely employment of active measures ; while it is possible to stimulate too ex- cessively even in diseases which primarily and unequivocally demand that plan of treatment. It should never be forgotten that debility is as surely TREATMENT. 67 and speedily produced by surfeiting the Nervous Centres with too great an abundance of the rich food which alcoholic Preparations supply, and by over taxing their generating properties by ex- cessive aud protracted stimulation, as by any other possible means, and that Carbon and Hydro- gen, whilst subserving valuable purposes in the economy, are not the elements from which the most important structures of the organism gather their vitality or power. In exemplification of the truth of these observa- tions, it is only necessary to refer to the recorded experience of Dr. Gualla, Surgeon in chief of the military Hospitals at Brescia, in regard to the treat- ment of the wounded after the battle of Solferino. He declares that the Italian soldiers who fought up- on their own soil, in their native climate, in their full vigor and health, and not exhausted by long marches, or injured by unusual food, recovered rapidly from their wounds, though subjected uni- versally to an Antiphlogistic treatment; w r hile the French soldiers, who were weakened by the dan- gerous and protracted march over Mount Cenis, Buffered greatly and died in large numbers, though treated on opposite principles. The greater sufrer- ing and mortality of the latter, he ascribes to the fact that they were allowed too rich a diet, and stimulated to an unreasonable extent, notwithstand- ing their previous debility. It is much to be ap- prehended, that under the extravagant teaching* oi'Tod.l, Ben net, and others of their School, the death blow of many an unfortunate victim has been given in the excessive potations administered 68 TREATMENT. for his comfort or relief. The Surgeon should enter upon the discharge of his most responsible task with an honest determination to discard all bias and prejudice in regard to particular 'modes of treatment, and with "in 'medio tutissimus ibis" as his rule, should only depart from it after a thorough individualization of each particular case, and an accurate knowledge of all the surrounding circum- stances. Stimulants and tonics have been spoken of in- discriminately, for the reason that the one is so administered as to secure 'permanency of impression and the other employed in such a manner as to ensure rapidity of action, thus approximating them therapeutically, and making them subserve the same ends in the economy. The Remedies of this class in general use, are Alcoholic Liquors of all kinds, Wines, preparations of Ammonia, Sulphate of Quinia, and Tinctura Muriatici Ferri, &c. The alcoholic liquors stand at the head of the list, in as much as they can be more conveniently obtained and administered; as their effects upon the system are prompt and decided; as they are better borne by the stomachs of most men; and as they are more palitable and agreeable to a large majority of Patients. Rules for the administration of alcoholic stimulants — 1. Examine well into the present condition and previous habits of the Patient before administering them. 2. Commence with small quantities — say half an ounce, and gradually increase the dose accord- ing to the necessities of the case. TREATMENT. 69 3. Administer at such intervals as will ensure a prompt, continuous and equable impression up- on the system. 4. Watch the condition of the stomach, care- fully, lest an initiation of that organ be develop- ed, thereby interfering with the absorption of the stimulant and adding to the burdens of the labor- ing system. 5. Examine the Pupil frequently, noticing whether it be contracted or dilated abnormally and discontinuing the Remedy from the fear of cerebral Inflammation in the one instance or a ex- cessive congestion in the other. 6. Attend strictly to the circulation, continuing the medicine, if the Heart beats more slowly un- der its influence, or continues at its original rate, and rejecting the stimulant when its pulsations are excessively increased in frequency and force. 7. If Coma be produced, Delirium increased, or sleep prevented, change the treatment. 8. If the Tongue grow red and cracked, the month dry, deglutition difficult, and the voice husky, stimulants are contra-indicated and should be abandoned. 9. [f the Kidneys or Skin — particularly the lat- ter — be too much acted on, thereby debilitating the Patient, stimulate carefully. 10. If the Heat, Pain, and congestion of the part increase, or the wound looks redder, fails to suppurate, or discharges Pus too freely, the reme- dy should be discontinued. 11. On the other hand, when noue of the acci 3b 70 TREATMENT. dents just mentioned present themselves, and the attendant phenomena assume an opposite charac- ter, the Surgeon should not be alarmed at the quantity of the stimulant employed, but being guided alone by its effects, and observing the pro- gress of the case with the most intelligent scru- tiny, he should push his advantage until the sys- tem has secured an entire mastery of the Disease. In regard to the particular preparation of Alco- hol which should be employed, the fancy of the •Patient, or the convenience of the Surgeon may be consulted when good Liquors are within reach. Whiskey is usually preferred, because when pure (?) it is more acceptable and less irritating to the stom- ach ; while French Brandy also has its champions. In the present condition of the Country, Apple Brandy is the purest, most palatable, and least dif- ficult to procure, since distillation from grain has been prohibited ; while experience has convinced the Author, that as a pure stimulant it stands un- equaled. The manner in which the other Remedies refer- red to under this head, are employed will be more fully considered in various connexions. Local Remedies. — These are either \weiicntwe or curative, according to the end for which they are employed. The most prominent and important among them are Rest, Position, Local Depletion, Revulsives, Cold and Warm Applications, Topi- cal Alteratives, and Compression. Rest. — The importance of steady and persis- tent rest, can readily be understood, when it is re- membered that the least exercise of the part ne-^ TREATMENT. 71 cessitatcs the flow to it of a large amount of blood and nervous influence "VThere Best cannot be secured by the Patient's own efforts, Splints may- be employed, or Opium used for the purpose of temporarily paralyzing the muscular fibres of the affected structures. It is well not to continue this treatment long, lest anchylosis, permanent immo- bility, &c., be the consequence. Position. — In Inflammation the vessels are filled with an unusual amount of Blood, which is still controlled by the laws of gravity, — accumulating in a dependent part, and vice versa. This is true for the other fluids as Serum, Lymph and Pus which are developed in connexion with the pro- cess of the morbid action. So likewise position may increase the pain of the affected part, by causing muscular pressure upon it. For these reasons, the part should bo kept in an elevated position, and so arranged as to relax its muscles, while the comfort of the Patient should likewise be consulted as far as practicable. Local Depletion. — This is accomplished by means of Scarifications, Punctures, Leeches, Cups, and Drainage. The Blood may be taken di- rectly from the part by local bleedings, or rob- bed of its serum by Blisters. These remedies al- ercise an indirect control through the agency of nervous reflex action, or by their general se- dative e fleets upon the system at large. Blisters should always be employed with caution particu- larly in the earlier Btages of Inflammation, lest they add to the irritation of the diseased structure, and thus prove an injury rather than a benefit to 72 TKEATMENT. the Patient. Punctures are employed for the pur- pose of relieving the suffering tissues of the Se- rum or Pus which may have been poured out in them. The artificial evacuation of Pus may be accomplished either directly by the Knife, by Caustic — though the latter is seldom attempted — or, by what is known as Drainage. Bides for opening Abscesses. — 1. Take care in in- troducing the Bistoury not to interfere with any important nerve, to open a large vessel, or to pen- etrate one of the large cavities of the Body. 2. Make the opening great enough to ensure a free vent of the pent up fluid. It is far better that the opening should be too large than too small. 3. Assist the evacuation if necessary, by the hand or linger, used however, with the greatest gentleness. 4. Prevent the incision from healing by " First Intention," by inserting a small tent made of old linen, well oiled, and interposed between the edg- es of the wound. 5. Employ the "warm water dressi-ng" or an E moll ientCataplasm(?)for the purpose of promoting the discharge of the fluid, after the bleeding has ceased, but be careful not to continue it for too long a period lest too much relaxation ensue. 6. Approximate the sides of large abscesses by means of compresses. 7. Make the opening, if possible, so that gravi- tation will promote the escape of the purulent matter, but if this cannot be effected, try a counter- opening. A current of water passed from one open- ing to the other is frequently of great advantage. TREATMENT. 73 8. If arteries be divided in the operation, ligate them. Chaissaignac has proposed to relieve abscesses of their coutents by a system of "Drainage," which is, in fact, but a revival of the old doctrine of the Seton. He plunges a Trocar lined with a Canula through the abscess and out again through the in- tegument ;then withdrawing the Trocar, he passes through the Canula, which remains behind, a tube of India Rubber, perforated with holes for the es- cape of the matter, and ties the two ends togeth- er. In this way the escape of Pus and Serum is facilitated, and a collapse of the parts secured, while the introduction of atmosphenc air — an agent which promotes suppuration while it de- composes Pus — is entirely prevented. Cold and "Warm Applications. — This class em- braces everything from the "Cold water dre* sin-" to the "Medicated Poultice." Though Cold "Water has been used in the treatment of Inflammation from the earliest times, the experience of Ambrose Pare has mainly contributed to the elevation of the remedy to its proper position in the estimation of Military Surgeons. It has perhaps boon more universally employed, in the War which is now being waged by the Confederacy than in any oth- er previous struggle, and with results, which when properly tabulated, will astonish the world. To Sur- geon J. J. Chisolm, Professor of Surgery in the Medical College ot South-Carolina, and Author of the best "Manual of Military Surgery" that has been published in any language, we are in- debted for the just appreciation in which this in- 74 TREATMENT. valuable mode of treatment is held, at the present time. If- he had done nothing more than incul- cate, in that able work, his most scientific and ra- tional views in regard to the Cold Water treat- ment of wounds, he would deserve the lasting gratitude of the Profession and of the Public. Truly it may be said, the days of Cerates, Oint- ments, and Cataplasm has passed, — having been swept to oblivion by the copious streams of Cold Water, with which an enlightened Surgery has comforted and relieved the mutilated victims of a thousand Battle Fields. The advantages of " Cold Water Dressings" in all stages of Inflammation, as local applications, may be thus summed up : 1. Cold Water is clean, cheap, simple and gen- erally agreeable to the feelings of the Patient. 2. It enables the Patient himself, or the most ignorant assistant, to dress the wound. 3. It keeps down the temperature of the parts, constrains the Capillaries, and relieves Hyperse- mia. 4. By forcing the Blood out of the Capillaries and preventing its passage into them, the source from which Pus is developed, is thus cut oft, and the suppurative process arrested. It has been conclu- sively demonstrated that the process of suppura- tion, so far from being necessary to the healing of wounds, or the arrest of Inflammation, retards the one and seriously complicates the other. The im- portance, therefore, of Cold Water Dressings, even in the most advanced stages of Inflammation is thus made apparent. TREATMENT. t5 6. It relieves nervous irritation, and thus, both directly and indirectly controls the Inflammatory process. Cold Water may be applied in various ways, as by saturating Linen, Cotton Cloths, Sponge, &c, and frequently squeezing them over or constantly applying them to the part ; by suspending a Buck- et and then by means of a narrow strip of Cloth, on a lamp wick, conducting a stream of Cold Wa- ter to it; by elevating a funnel above the part af- fected, filling its nozzle with lint and permitting the Water to percolate through it from above; by means ot Bladders tilled with pounded Ice; and by many other contrivances which the circumstances of the case will suggest to the Surgeon. Care should always be taken to prevent the bed cloth- ing, and the clothes of the Patient from becoming saturated, lest he be chilled or inconvenienced thereby. In some instauces, though they are rare, Cold Water cannot be borne at first, when Tepid Water should be substituted for it temporarily, taking pains, however, to lower the temperature of the application, gradually but decidedly, until that degree has been reached at which "' sedation and astringency" manifest themselves. Warm Applications. — The circumstances under which Warm applications are demanded, may be thus stated : 1. When the Blond lias .-<> completely stagnated at certain points, as i" become insensible to the visatergo warm applications may l>c sometimes employed, lor the purpose of adding to the volume and force of the Blood current flowing towards 76 TREATMENT. the part, and of thus indirectly relieving the Ca- pillary congestion. 2. When an unusual amount of irritability ex- ists in the nerves of the affected tissues, manifest- ing itself in great pain, tenderness, sensations of cold, spasm, &c, warm applications are indica. ted, in as much as the resulting Hypersemia though inevitable is the lesser of the two evils. 3. When, from the extreme delicacy of the Pa- tient's organization, his tendency to pulmonary irritation, the existence of . bronchial affections, or the impossibility of making cold applications with that regularity and system requisite for the preser- vation at an equable temperature, the " Cold Wa- ter" treatment is countra-indicated. 4. When the part affected assumes a glazed? red, dry and angry appearance, manifesting no disposition to heal by the "First Intention," re- sisting the application of Cold Water, and pro- gressing but slowly towards any termination, warm applications may be employed with advan- tage. 5. When a wound which has suppurated freely suddenly ceases to do so, without indicating a ten- dency to heal, either with a total abolition of the sensibility of the part, or an extraordinary aug- mentation of it, Warm Water may take the place of Cold. The instances, however, in which Warm water is required to the entire exclusion of Cold appli- cation, are of comparatively rare occurrence ; and the Surgeon should hesitate and most carefully consider the indications before concluding to make Treatment. 77 tlie substitution. If there Jbe any doubt in regard to the matter, give the Patient the benefit of it, and continue the Gold Watei* It should not bo forgotten, that the exposure of wounds in which Inflammatory action has been developed, to vicissitudes of temperature is the prolific source of Tetanus; and hence, whether Cold or Warm AVater be selected, use it freely and persistently — in such a manner as will main- tain an equable temperature in the part. Should it become necessary to employ a poultice, a soft wet Compress, covered with oil silk, and Secured by a flannel roller or outer Compress, will fulfill any possible indication. The proper thermal status is preserved by the absorption of animal heat, the application is light and comfortable, medication can be readily effected, the materials are always attainable, cleanliness can be invariably insured, and, in fact, so many advantages present themselves in connexion with it as to "preclude all substitutes." Either cold or warm water can be medicated, with Sugar of Lead, Sulphate of Zinc, Tannin, Spirits of Camphor, Preparations of Opium, Tinc- ture of Arnica, and according to the presenting indications. The temperature of the Water can be lowered by the addition of Alcohol, common Salt, or a strong solution of Nypcrchlorate ot Ammonia and Nitrate of Potassa. Revulsives. — U(ri irritatio ibi affluxus est is a pathological axiom, and upon it the whole problem of (he revellent action of Medicines is based. The system possesses but a definite amount of Blood and 78 TREATMENT. " Nervous force, and by securing their accumulation at one point, all other parts are relieved of them to a certain extent. *Counter irritants are employ- ed in the treatment of Inflammation for the pur- pose of creating a new disease, which, by attracting the Blood, &c, to itself may serve as a diverticulum for the part originally affected. Great judgment is required in determining ivhere and ivhcn to apply them, since if not wisely employed they increase rather than abate the morbid action. As a general rule they should not be used until after some pre- liminary depletion has been practised, while care should be taken not to apply them too near a*" delicately organized structure, or too far from one of a different character. To this class belong Rubefaciants, Blisters, and Suppurants. Local Alteratives. — The most prominent of these are Nitrate of Silver, and Iodine. The first named is used extensively in acute Inflammations as a topical antiphlogistic agent, while the other is more particularly employed to promote the re- absorption of Lymph, as in dissipating a gathering abcess, andsoftening an indurated tissue. Nitrate of Silver is not only a powerful vesi- cant or destructive, but by substituting a new and more controllable action of its own for the one existing in the part, it serves as a valuable auxiliary in the treatment of Inflammation. Its action may be thus stated — 1. As a vesicant, producing counter irritation, and controlling Inflammatory action, as explained . above. TREATMENT. 79 2. Destroying tissue and thus assisting nature in her work of elimination, as in Gangrene. 3. Neutralizing certain causes of Inflammation, as virus of the serpent, the poison of the cadaver, and thus indirectly restraining that morbid pro- cess. 4. Producing certain changes in animal struc- tures, such as prevent the progress of Inflamma- tion ; and hence used in Erysipelas and Hospital Gangrene. 5. Substituting a new and more manageable action of its own for the existing Inflammation, — as in Gonorrhoea, &c. Iodine acts upon the absorbent vessels, and sti- mulates them to a more vigorous discharge of their duties; and like all other alteratives, controls the great work of cell-development, and cell-destruc- tive, — the metamorphosis^ and nutrition of the tissues. ^Compression.— The afllux of Blood to an in- flamed part may be prevented by mechanical means, and that local congestion prevented from which effusion ensues with its attendant conse- quences. Nor is this all, spasm may be controlled in this way, the absorbent vessels stimulated, the affected structures supported, and effusions pre- vented, — results of the most vital importance to the individual parts and to the whole organism. The means of Compression are the common band- age and adhesive plaster, so applied as to make : le and agreeable pressure over the whole of the affected struetui 80 TREATMENT. In all that has heen said as regards the pheno- mena, pathology and treatment of Inflammation, a direct reference has heen had to the acute form "of that affection, as it is with that variety particu- larly that the military Surgeon has to contend alike in Camp, Field and Hospital. CHAPTER II. AMPUTATIONS IN GENERAL. Varieties op Amputation. — Amputations arc Primary or Secondary, according to the period at which they are performed. Primary Amputations are those undertaken for direct injury, and are performed either immediate- ly after the wound has been received, or after re- covery from the Shock and before the develop- ment of Inflammation. By the term Shock is meant that condition of the nervous system which sooner or later en- sues upon particular injuries in certain persons. It is characterized by coldness of the surface, pal- lor, tremors, an anxious expression of the coun- tenance, small, irregular and feeble pulse, sighing respiration, partial or complete paralysis of the bladder, mental disturbance and Incoherence of speech. This condition may continue for a long- er or shorter period, but usually disappears in a few hours ; while the intensity of the shock is not al- ia direct proportion to the extent or severity of the wound, as it is sometimes very greal even where the injury is trivial. It it persist however, whether the injury be seemingly great or small, 82 PRIMARY AMPUTATIONS. there is always danger to be apprehended, and the Surgeon should prepare himself to meet it. The evidence of the English Naval Surgeons, as summed up by Hutchison, when taken in connex- ion with that supplied by Macleod from his Cri- mean experience, clearly establishes the fact that the condition which is known as Shock is not ne- cessarily established immediately upon the re- ceipt of the injury, but that an interval ensues which differs in duration according to the severity of the wound, the agency producing the injury, or the constitutional status of the sufferer. The Circumstances under which immediate Ampu- tations are demanded are : 1. "When the Shock is delayed. The importance of seizing upon the moments of comparative tran- quility which frequently elapse between the re- ceipt of the injury and the development of Shock, was first recognized by Ambrose Pare and Rich- ard Wiseman, and is now growing into favor with the Profession. 2. "When the Nervous Depression is slight, or is not developed at all, as sometimes occurs. — Larrey declared that he had lost a great number of Soldiers by delaying the operation too long, with- in the first twenty-four hours, and recommended Amputation as one of the surest means of reliev- ing the "commotion," and of diminishing its dan- gers. When the Shock is slight it certainly should constitute no centra-indication to the use of the knife. 3. When a limb is either nearly or completely PRIMARY AMPUTATIONS. 83 torn off, and a dangerous hemorrhage is occurr- ing which cannot be arrested. 4. When the smaller members, as the fingers or toes are seriously injured. 5. When Broken Bones, Fragments of Shell, splinters, clothing, or other foreign substances are lying in the track of the wound in such a man- ner as to preclude their extraction, and to induce such anjamountof pain and nervous commotion gen- erally as threatens the immediate destruction of life. In eases like these, even the teachings of Larrey may be followed and the operation perform- ed whether the shock exist or not. In deciding upon the practicability of this oper- ation, it is important to take into consideration the moral condition of the Patient. All Army Surgeons know that men are brought from the field of battle, either enthused by the combat, in- different "to all save the " fate of the day,'.' and willing to submit to any thing which gives a pro- mise of future revenge, and the prospect of a parti- cipation in the triumph of their comrades, or dis- pirited, disheartened, and depressed, both physically and mentally by the appearance or the pains of their wounds and the idea of permanent mutila- tion. The meanest coward, under the strange in- fatuation of the Battle Field, — the roar of Cannon, the flashing of the deadly Bayonet, the deeds of daring done round him, the stirring notes of com- mand, the presence of his comrades and all the wild excitement of the stirring scene may forget his own mortality and be transformed into a hero, who, while the fit is on him, will despise the steel 84 PRIMARY AMPUTATIONS. of the Surgeon as thoroughly as the Bullets of the foe. On the other hand, the Soldier who has marched to the cannon's mouth, insensible to fear, and dreaming only of revenge or triumph, is par- alyzed by the flowing of his own blood, and is borne to the rear in mortal terror of an operation by which additional pain is to be inflicted or de- formity entailed upon him. In the one case, the Surgeon could perform the operation with impu- nity, while in the other still greater depression would follow each stroke of the knife, and per- haps speedily terminate his existence. Upon general principles, it might be supposed that the soldier would bear an amputation better when "heated and in mettle" — when excited by the combat and within sound of the cannon, pro- vided he be not completely prostrated by the shock — than when opportunity had been offered for tne abatement of his excitement, and calm re- flection upon the dangers and inconvenience of the loss he is to sustain ; and hence, if it be not contra-indicated by other circumstances, an imme- diate operation may be resorted to. The circumstances which demand the performance of amputations — subsequent to the abatement of the shock and prior to the development of Inflamma- tion, are : 1. The tearing off or crushing of an entire limb, without the accompaniment of an uncontrollable Hemorrhage, and with the complication of nervous shock. 2. Compound or multiple fractures, especially of the lower extremities, accompanied by great PRIMARY AMPUTATIONS. 5 laceration of the soft parts, such as amounts to their purification. 5. Complicated Fractures, involving the section both of the chief Vessel and Nerve of the member. 6. Simple Fracture complicated by the opening of one of the large articulations, and the tearing of its ligaments. 7. Great injury of soft parts unaccompanied by fracture, with the division of their main arterial trunks or nervous filaments. 8. Extcusive destruction of the integuments, such as precludes the possibility of cicatrization within a reasonable time. 9. Fractures accompanied with extensive con- tusion, generally demand Amputation. Exten- sive contusion necessitates amputation more than open laceration, even of great extent. A complete revolution has taken place within the present century, in regard to the advanti of Primary when compared with Secondary oper- ations. The opinions of Faure have been en- tirely overturned by the more philosophical v of Boucher, dispite the decisi* Academy: and the mostcnligji! has indicated the wisdom and humanity ing to early Amputations, especially in mili surgery. When the circumstances of the case do not lily an immediate operation, tin hould administer a cup of cool yater, (hen vine, bran- dy or food if possible, ancrdrcss the wounds tem- porarily, wailing for the establishment of reac- tion before proceeding to take tho proper steps 86 PRIMARY AMPUTATIONS. for the performance of the later Amputation. — Words of encouragement and kindness, whether the sufferer be friend or foe, should never be neg- lected by the medical officer, as the moral condi- tion of the patient plays a most important part in relieving the nervous depression incident to his physical mutilation. Reaction should occur within 48 hours after the receipt of the injury, even in the worst cases, and Primary Amputations are supposed to be perform- ed within that time. JRulcs for performing Primary Amjmtaiions. — 1. Operate within forty-eight hours after the re- ceipt of the injury. 2. Operate as far from the trunk as possible, as every inch saved diminishes the risk of the patient's life. 3. Operate as soon after recovery from Nervous Shock, and as much before the development of In- ftamatpry reaction as possible. 4. Operate at a joint rather than go beyond it. 5. Keep the patient underthc influence of Chlo- roform no longer than is absolutely necessary. 0. Cut rapidly, tie qnickly, dress slowly, and bandage lightly. 7. Guard against the development of nervous depression, or of excessive vascular reaction, and stimulate or deplete according to the necessities of the case. 8. Let the knife JoMow the condemnation of the limb as speedily as practicable. 9.- Operate upon the lower limbs for injuries ONDARY AMPUTATIONS. which would nol demand the condemnation of the superior extremities. There are various oilier principles which should guide the Surgeon in the performance of these operations, but as they apply with equal force to all Amputations, they will he considered under a different head. Second ub i A.mputations. — Secondary Amputa- tions as distinguished from. Primary, are those performed after the Inflammation which super- venes upon the injury, has been developed. There arc two varieties of Secondary Amputa^ tion, viz : — those which are performed be/on the Inflammatory action has abated — during the In- flammatory Fever: and those which are perform- ed after the subsidence, partial or complete, oi the Inflammatory action, and in connexion with some of its products, particularly Pus. The Circumstances which justify Amputations du- ring the existence of Inflammatory F< ver, are : I. Excessive and uncontrollable lieinorrl. occurring al that period. •J. Tetanic symptoms manifesting themselves in connexion with the wound, and resisting all remedii :!. Indications ofa tendency to debility rapidh and unexpectedly showing themselvi 4. A sudden necessity demanding the immedi- ate removal of the patient, when it is manifest Unit th«- dangers incident to transportation are iter than those of the operation. 88 SECONDARY AMPUTATIONS. The Impropriety of operating as a general rule, before the subsidence of the Inflammatory pro- cess — when a great amount of perturbation exists both in the Nervous and Vascular systems — is too plain to require demonstration. Cases, however, do present themselves when the risk must be ta- ken, and the Amputation perfoimed without re- gard to the principles which ordinarily control tbe Surgeon in this connexion. It is impossible to establish any definite and universal law in this regard; and the Surgeon can only be enjoined to individualize each parti- cular case, weighing the danger of delay, thor- oughly comprehending the risk of the operation, and duly estimating the nature, extent and poten- cy of the emegrency before him. These operations sometimes do astonishingly well, surprising both operator and patient by pro- gressing speedily and surely to a favorable termi- nation. The Circumstances which necessitate Secondary op- erations proper, or those undertaken after the abater ment of the Inflammatory process, and tin: forma- tion of its products, are : 1. Secondary Hemorrhage, occurring at a late period in the history of the case. 2. Rapid and excessive formation of Pus, jeop- ardizing the life of the patient. 3. Mortification rapidly developing itself. 4. Rapidly decreasing strength of the patient. 5. Necrosis and malignant diseases of bone, or extensive and exhausting ulceration of the Soft Parts, defying other remedies. > \'.;\ \miti vno-NS. 89 6* Diseases oi the Joints, especially those oJ o malignant character. 7. The appearance of Tetanic symptoms. These contingencies and various others of a similar character, which will readily suggest them selves to the mind of the Surgeon, will justify him in resorting to Secondary operations. Rules for th performarii condary Amputa- tions. — 1. Operate as far from (ahove) the seal of injury as practicable. 2. ( Operate above a joint rather than at it. :'>. Operate before the strength ot the patient i too much exhausted, and before Pus has been ab sorbed, if practicable. 4. Operate, as a general rule, after the su dence of Inflammatory Fever, the developmenl oi a free and healthy suppuration, and the restora- tion of the skin to its normal functions, particular- ly in the affected limb. 5. Operate in rases of traumatic gangrene — save in frost-bites and burns — just SO soon as the first symptoms show themselves : but in constitu- tional oridiopathic gangrene, wait lor the line of demarcation. ;_\ 272 Primary Amputations — fur- nishing 190 recoveries and 82 deaths, and 308 Secondary amputations, giving 145 recoveries and 163 deaths. For fuller information in regard to this subject the reader is referred to the tallies which constitute the Appendix to this work. — These tables were prepared with great care by Surgeon F. Sorrell, Inspector of Hospitals for the City of Richmond, Ya., under the immediate su- pervision of Surgeon General S. P. Moore, ('. 8. A., and constitute an invaluable contribution to Surgical science. In thus collecting and perpetu- ating these important facts, they have stamped their names in indelible characters upon the pro- fessional history of the times. The term " Intermediate " is employed in these tables evidently to designate operations which were performed neither immediatel}- subsequent to the shook, nor after the development of suppura- tion ; and.it consequently corresponds with what has been treated of in these pages as a Secondary Am- putation made in the first period — during the exis- tence of [nflamramatory reaction. It is true that these views in regard to Primary Amputations, are opposed by many Surgeons of great ability, such as Faure, Hunter, Percy, Blan- din and Mause, but they are mainly of the last century, and the weight of authority preponder- 02 OBSERVATIONS. ' ates greatly upon the side of Primary Amputations in military surgery. Dr. John Stone, after a most careful and elabo- rate investigation of this subject, both in its mili- tary and civil practice, thus sums up his conclu- sions: 1. Primary Amputations of the upper extremi- ties are more successful!, and to be preferred both in military and civil surgery. 2. That in military surgery, Primary Amputa- tions of the lower extremeties arc twice as success- ful as Secondary. 8. That in civil Surgery it is immaterial wheth- er Primary or Secondary Amputations of the low- er extremeties arc resorted to. 4. That Secondary Amputations of the upper extremities in civil surgery are 8 per cent, less fa- tal than in military surgery. o. That Secondary 7 Amputation in civil surgery are 12 per cent, less fatal than in military sur- gery. There is another view of this subject which should not be overlooked. The number who sur- vive after a given number of Primary and Secon- dary Amputations does not afford a proper index of the relative value of the two operations. The most severely injured have their limbs removed early ; while the milder cases are reserved for Se- . condary Amputation. In estimating, therefore, the value of the two operations, an account must be taken of the more unfavorable circumstances which practically surround early operations, ren- 98 tiering death inevitable in many cases, or materi ally retarding recovery in others. So likewise thequestion is not whether a hun dred men freshly wounded and requiring Amputa lion are more likely to survive than ahuudredwho bave gone through the dangerous ordeal of a llos pital; but whether the first hundred would live to thai period — the probability being that they would not. In view of all the tacts of the case, the conclu- sion is inevitable, that Primary A.ruputations tire tar more successful than Secondary, and that hu- manity and science unite in demanding their per forniance whenever practicable. Instruments. — If possible the Surgeon should have always on baud and ready {'or use, Knives, Saws, Forceps, Tenaculre, Bone Nippers, Sponges, a lietraetor, Threaded Needles, Adhesive or [sin- glass, Plaster, a Tourniquet, Cold Water, Brandy, and Chloroform. Amputations, however, have been performed with no other instruments than a well- sharpend Carving or Bowie Knife, a common Saw, and a Fork bent in such a manner as to serve as a Tenaculum; and no Surgeon will ever permit his patient to die from an exhausting and uncontroll- able Hemorrhage or any sirumilar accident, for the want of an operation, when these implements can be procured. It has become fashion able to decry the Tourni- quet, and many repudiate it altogether. The abuse of a thing is no argument against it when properly used; am!, though there arc, many and serious objections t<» this Enstrumenl asordiuarily li. ' 04 TOURNIQUET. employed it .may be made to subserve moat important purposes in the hands of a judicious operator. It is true that it only controls the bleeding when tight" ly applied, and that when so applied it acts as a gen- eral ligature around the member, and can be used but for a short time without injury to the limb, and, yet, within the brief period in which it can be used, the fate of the patient may be decided. The experience of every practical Surgeon will confirm the assertion, that, in multitudes of in- stances, either from the ignorance, fright or fa- tigue of the assistant engaged in controlling the Artery, or from some sudden spasmodic motion of the patient himself, the Vessel slips from beneath the compr&ssing finger and permits the escape of that precious "fluid, whose every drop is required by the necessities of the weakened system. To find a new assistant may be difficult, to search again for the Artery in the midst of the patient's struggles requires time, while but a few turns of the Screw, if the Tourniquet has been previously adjusted, will obviate all occasion for delay, and by arresting the flow, snatch the patient from the hands of death. Again, it frequently happens, that in consequence of some abnormal develop- ment of the Vascular System either congenital or the product of morbid action, sufficient digital compression cannot be made to prevent the flow of Blood, and the Tourniquet comes in as a most valuable auxiliary in the arrest of the inevitable and most destructive Hemorrhage which follows the Knife. It is therefore best not to discard the Tourniquet TOURNIQUET. 95 entirely but to adjust it upon the Limb loosely and yet in such a manner as to enable the Operator to command the artery in an emergency, so that in the event of the accident referred to, the screw may be turned and the Hemorrhage arrested. — This plan is entirely practicable, and, while it ob- viates the objection to the instrument, fulfills a most important and preponderating indication. ( Horofprm. — The discovery of the anaesthetic ef- fects of Chloroform is the great surgical achieve- ment of the age. Under its soothing influence operations have been performed -which otherwise would have been impossible, while the amount of suffering obviated cannot be estimated in words. It has thus extended the domain of Surgery, crowned the noble science with fresher and proud- er laurels, and proved a source of incalculable'com. fort and security to the human race. That acci- dents of a serious character have attended its ad- ministration, and that it docs occasionally produce fatal consequences cannot be doubted. • And vet, when the immense advantages which it secures, both to the operator and the patient, togeth- er with the comparative in-fi'equency of these unfor- tunate results, arc taken into the account, theargu- nients so speciously urged against its employment; are rendered utterly nugatory and abortive. Thus Velpeau declares that he has emplovcd Chloroform more than five thousand times with- out a single accident. Baudens affirms that the French Surgeons in the Liussian war, '-had no fa- tal accident to deplore from its. use, although it was employed thirty thousand times or more." OG CHLOROFORM. Macleod states that though almost universally employed by the English Surgeons in the Crimean Campaign, but one fatal result could, with any show of fairness be attributed to it. At. Guy's Hospital, Chloroform was used 12,000 times before there was any' serious accident. Dr. Gross says that he has given Chloroform for more than ten years without an unfavorable result in any case. In a word, it has been demonstrated by the stern logic of facts that this invaluable agent is far less dangerous than was supposed in the earlier days of its history — less dangerous than many other reme- dies which are daily used without stint or lim- itation by those who most bitterly and pertinaci- ously oppose the administration of Chloroform. The advantages which attend its administration are : 1. The abolition of all pain — a fact which im- proves the moral condition both of Operator and Pa- tient, with reference to the operation. 2. The induction of a condition of tranquility, in which the muscles are passive, all motion sus- pended, and the patient is entirely under the con- trol of the Surgeon, so that more difficult, pro- tracted, and nicer operations can be performed. 3. The suspension of sensibility permitting the more thorough examination of wounds. 4. The arrest of Hemorrhage, during the oper- ation. M. Chassaignac has particularly called the attention of Surgeons to this important fact. Ac- cording to the observations of this distinguished operator, both the Arterial and Venous circula- tions are materially controlled by this agent — a CHLOROFOJRM. 97 conclusion which must be sustained by the expe- rience oT medical men generally whose opportuni- for an investigation of this subject have been sufficiently extensive. In order to give a rational account of the forces, in virtue of which these phe- nomena take place, it is only sufficient to compare the condition of a patient operated on in the ordi- nary state, with that of one under the anesthetic influence of Chloroform. In the one the appre- hension of the operation about to take place in- creases the number of pulsations, and augments the cardiac impulse; while the disturbance Oi the respiration, and the efforts made by the pa- tient, when restrained by the Assistants, retards the free return of Venous Blood. An increase in the force and frequency of the pulsations of tho Heart, and a retardation of the Venous flow are the circulatory conditions of those who are submit- ted to operations without the employment of ai thetics. When Chloroform is administered there ensues a diminution in the frequency and force of the pulse, together with an establishment of the normal condition of the respiration, and the in- duction.of a state of perfect tranquility and quie- tude. This fact should be remembered by the Surgeon in connexion with the application of dressings, as the chances of ulterior hemorrhage art." greater in proportion as less Blood has been lost during the operation. RuUs i th Administration of CJrforoform. — 1. Place the Patienl in a recumbent position, to maintain a proper circulation in the Brain, and 98 CHLOROFORM. as a means of avoiding *tlie disadvantages of great muscular relaxation. 2. Remove all causes which arc likely to inter- fere with the Respiratory Function by controlling the Diaphragm — such as tight clothing, heavy cov- ering, sword, belts, &c. Upon the same principle, avoid the administration of Chloroform on a full stomach. 3. See to the introduction of an abundant sup- ply of Atmospheric Air with the vapor of the an- esthetic. This is absolutely^ dispensable to the safety of the Patient, both as a means of prevent- ing too great an accumulation of Carbonic Acid in the Blood, and the possible development of Car- bonic Oxide. All the Inhalers which have been invented are objectionable on account of their in- convenience and the difficulty of obtaining a prop- er supply of Atmospheric Air. The best mode of administering Chloroform is by means of a cloth, folded in the form of a cone, in the apex of which a small piece of sponge is placed. This, im- pregnated with a drachm of Chloroform, should be held over the mouth and nose, at a distance of about two inches, being gradually approximated until within one inch of the face, beyond which it should not be carried. Great care should be taken not to force the cloth down upon the face of the patient, lest respiration be interfered with and suf- focation ensue. -1. In Primary Amputations particularly, and in those undertaken after the development of Pus, precede the anaesthetic by an ounce of brandy or CHLOROFORM 99 'whiskey, and repeat, thedoso if the pulse becomes very weak. 5. See thai complete anajsthesia be induced and kept up until the operation is completed, but watch the pulse and breathing carefully lest it be carried too far. This should be made the special business of the assistant to whom the In- halation is confided, taking care to select an expe- rienced man for this purpose. 6. Discontinue the remedy temporarily when the breathing becomes toisy, when the insensibility of the skin is lost, and when muscular power is abol- ished- -as is shown by the falling ofthe arm or leg when raised from the bed, the dropping oftheeyelid when opened, &c. If, in connexion with these phe- nomena, the pulse does not become too feeble, anaesthesia is perfect and the operation may be performed without the fear of fatal consequences. Much discussion lias taken place in regard to the quantity o\' Chloroform which should be ad- ministered; but, as the strength of the article ma- terially varies, and as the susceptibilities of pa- tients differ widely, it is plain that nospecific quan- tity can be fixed upon in this connexion. Let it be freely but cautiously administered without re- gard to the quantity consumed, and with an eye single to i he effects produced. When much blood has been lost, absorption is more rapid, and a smaller quantity is required. A consideration oi the modus operandi of Chlo- roform doe- not legitimately pertain to a work of this description ; and it is therefore only nec< ry to remark thai its ultimate effects are those of a 100 CHLOROFORM. powerful sedative to the ETervous System — a fact which should never be forgotten or disregarded. Notwithstanding that sedation is induced by it in the system and the dangers which attend its ad- ministration on that account, its usefulness is par- ticularly apparent in connexion with operations performed immediately a iipon the receipt of inju- ries. Under these circumstances, it seems to ward off that commotion of the nervous system which we denominate Shock, and to prevent the fatal con- sequences incident to that condition, by taking possession of the great centres and appropriating them exclusively to its own purposes. Disastrous Effects. — Though (Jkloroform has proved an inestimable boon to the human race, it is potent for evil also. Effects sometimes follow its administration which all the skill of the Sur- geon cannot restrain, and which necessitate the speedy sacrifice of the patient's life. The modes in which these unfortunate results are produced are : 1. By an interference with the functions of the brain — either from the congestion of that orga n or the presence in it of too much impure blood. 2. By an interference with the respiratory func- tion. This results from the sedative impression made upon the nervous centres which preside over that important function, and the interruption of the process of pulmonary osmosis upon which its integrity depends. 3. By inducing certain alterations in the blood. The changes in the blood which attend the inha- lation of Chloroform are the accumulation in it of CHLOROFORM. 101 an unusual amount of Carbonic Acid, the absence ol a proper amount of Oxygen, and the develop- ment of Carbonic Oxide. The accumulation ol Carbonic Acid, and tha absenceof Oxygen, which is the vitalizing element of the tissues, can be read- ily understood when it is remembered to what an extent (lie respiratory function is interfered with ; while the development of Carbonic Oxide, can like- wise be readily explained. The tissues, through which this altered blood circulates, have a natural affinity for Oxygen — an affinity which increases in intensity just in proportion as there is a deficiency of it. So imperative^ does their demand be- come, that the Carbonic Acid gas parts with one of its elements of Oxygen, and is thus converted into Carbonic Oxide — a most deleterious com- pound according to universal experience. I Bernard has shown that Carbonic Oxide has a greater affin- ity for the blood corpuscles than Oxygen itself, and that it forces them to surrender all of this vitaliz- ing principle, only to become inert and effete mat- ter themselves, incapable alike of stimulating the centres, of supplying the tissues, and ofperform- ing their appropriate part in the economy. I. By interfering with the action of the heart, Dalton has shown by a scries of interesting arid conclusive experiments-thai Chloroform kills in a majority of instances by an instantaneous and di- rect paralysis of the heart — a conclusion which has been verified by other able Physiologists. This demonstrates the Importance of watching the pulse as well as the respiration,- and of carefully noting all the change.- which take place in its 102 CI1LOK0FO11M. rhythm, rate and volume, during the performance of an operation. From the foregoing facts it becomes plain that Chloroform is contra-indicated when organic dis- ease of the heart or lungs, and a tendency to apo- plexy exist in a marked degree. Means for resuscitating a Patient ivhen over dosed by Chloroform. — 1. Desist from farther administra- tion of the drug. 2. Give the patient an abundance of pure air, by throwing open the Avindows, using the fan, and sending off as many assistants as can be spared. 3. Dash cold water with some violence upon the body, or pour it from a heigth of several feet. 4. Stimulate the surface, especially over the spine and heart, with hot mustard water, dilute Spirits of Ammonia, mustard plaster saturated with Chloroform. 5. Institute artificial respiration by the Marshall Hall method. 6. Administer injections of turpentine, or pour Chlorofo.im over the scrotum. 7. Apply galvanism in such a way as to stimulate the heart and diaphragm. 8. As soon as the patient can swallow, adminis- ter stimulants, commencing with a small quantity and increasing it. 9. Should the patient vomit turn him upon his side and not upon his abdomen — so as not to inter- fere with the diaphragm — with the head inclining downwards. Assistants.— When 'practicable there should be 1 I \NTS. L03 four assistants} viz: One to administer Chloroform andwatch thepulse;'a second to compress the artery and apply the Tourniquet it' necessary ; a third to hold the Limb, and retract the muscles; and a fourth to lieate the arteries. If it be difficult to obtain this number, the third assistant can be made to re- t ract and ligate also. It is better to have too many assistants than too lew. and the Surgeon should always bear this in mind when making his detail. In field infirmaries, Surgeons will find their duties much lightened by a division ol labor, each Jop- erating and assisting in turn — the ono us-' ing the knife having nothing to do with the dress- ing of the stumps, save to exercise a general super- vision over it. These directions are, of course, to apply only when there is a lull complement of med- ical officers present — a rare circumstance in the Confederate service, and a most unfortunate one, as the history of every camp and field attests. — When will wisdom be learned or justice doue in connexion with the medical department ol the army? Modes of. Operating. -The*methods of Ampu- tating are known as the Circular, the Dovble Flap, the Single Flap, the Oval y and the Diaclastic. Of these various methods, tin' ( Hrcular and Double Flap are most in vogue at the present day. The special ends sought to he attained areto re- tain enough of the Bofl parts t<> cover the hone and \o prevent its projecting; t<> eftect as speedy and firm 'a cicatrization as possible; and to so cover the stump that it may not be liable to excoriate on the 104 CIRCULAR METHOD. least friction* The consecutive treatment has as much to do with, the fulfillment of these indications as the choice of methods, and should; consequently, receive the earnest and continued attention of the Surgeon. Circular Method. — This dates its origin from the times of Celsus, but has been much modified and improved upon by Cheselden, Tetit, Bell and De- sault. It is performed in two different ways. The method of Desault. Directions: The first incis- ion is carried through the skin and cellular tissue alone, being made by one sweep of the knife, and encircles the limb ; then dissect back the skin with a Bistoury for three inches ; and turn it over in the form of a cuff (first recommended by Alanson ;) then, placing the knife upon the muscles near the fold of the skin, cut through them, by a circular incision, to the bone — taking care to have the edge of the knife slightly turned towards the patient's body. Finally, retract, saw through the bone, li- gate the arteries, and bring the wound in apposi- tion. The Method of Petit.— Directions : The skin be- ing firmly retracted, make the first incision through it and the cellular tissue, by one sweep of the knife, encircling the limb ; retract the skin still more and pass the point of the knife under it along the whole extent of its divided surface; cut through the superficial layer of muscles by another circular incision'; then retract still more, and divide the deep muscles to the bone. Use the retractor, denude the bone, saw through it, and take up the arteries. The edges of the wound should then be approxima- DOUfiLE FLAP METIIOD. 105 te»I, and the stump treated on general princi- ples. Double J i lcj> Method. — This was devised by Ver- malc, and has since been repeated with great suc- cess by other Surgeons. The Haps are formed in two ways, either from without inwards, by the meth- od of Langenheck, by drawing the sort parts off from the bone, and then carrying the knife oblique- ly from the surface and towards the bone; or from within outwards, by transfixing tbe limb with a Jong, narrow, and sharp pointed knife, at tbe point of amputation, and then bringing the edge uely outwards to form a flap. The same process is repealed for the opposite side, and in Ibis manner double flaps are formed. The flaps having been thus formed, are held hack by the assistants, and all intervening tissues divided to the bone, which is then sawed through. Then take up the arteries, bring tbe flaps together, apply sutures, and dress tbe wound. Single Flap Method. — The origin of this method may properly be referred to Loudham, an English Surgeon, who introduced it in 1679. One flap is made in -the manner described under the last head and then, the parts on the opposite side of the limb are divided down to the bone, by a semi-cii- cular incision. The flap should be long enough to cover the stump ; and, alter the arteries have been ligated, should be turned over and secured to tbe divided surface above, by means of sutures and straps. This operation is frequent!) resorted to as a mat ter of uecee ity, when the ofi parts have been 106 • OVAL METHOD. ' lacerated higher up on one side of the limb than the ' other, as frequently occurs from gunshot wounds. The Oblique or Oval method. — This v, as first em- ployed by Langenbeck, aud subsequently by Guth- rie for the shoulder joint. The incision, by this method, is carried around the Limb in a sloping direction, which is oblique with reference both to the longitudinal axis and the perpendicular diam- ter of part. The remainder of the operation is performed as in the circular method. Diaclastic Method of Maisonneuve. — M. Maison- neuve of Paris has proposed a new operation to which he has given the name of Diaclastic, or that by Rupture! According this Surgeon phlebitis or purulent absorption is the accident which most frequently follows amputations, and decides the case unfavorably. It is a matter, therefore, of the greatest possible moment, to resort to someSur gi- cal procedure by which the part can be readily removed, and this fatal symptom avoided. As the surface of a wound after amputation by the knife presents a space open to the action and pene- tration of the subsequently formed purulent mat- ter, he proposed to divide the tissues by ligatures, or by " instruments, which like scissors bruise the parts during division." By means of a peculiar contrivance, which it is unnecessary to describe here he fractures the bone and then divides the tissues with'an instrument DTACLAST1C METHOD. ' 107 similar to the Ecrasure.J M. Maisonneuvo, after many trials on the dead subject, lias at length at- tempted the operation on the living; but it can only be regarded as due of ihe curiosities of Surgical experience. The more minute manipulations in these differ- ent methods will be particularly considered when ■ individual operations are discussed. General Remarks. — Much diversity of opinion exists among Surgeons in regard, to the relative advantages of Circular and Flap operations, each having its zealous advocates, who display much energy and interest in the controversy. The advantages claimed for the Circular mode are as follows : 1. Cicatrization is more rapidly effected, or the wound heals quicker, while there is less suppura- tion and sloughing. 2. The Arteries can be more rapidly secured and firmly tied, because evenly divided; while there is no danger of transfixing the'm, as in Flap operations. :>. The wound can be more readily, efficiently and .continuously closed with sutures, so that the water dressings may be employed to greater ad. vantage than where Adhesive Piaster is exten- sively used. 4. The Vessels contract more firmly, thus to a [This is an instrument invented by M. Chaissaignac, tl part of which is a sort of blunl chain ti a crew or i>\ a rack an J by pinion. The notion of the instrument though slower than thai of the knife, is more rapid than that of the ligature, its influence is direct. Ii lir t com L then 'dividi thi with extreme reeularit v. 108 CIRCULAR AND FLAP OPERATIONS.. considerable extent obviating the danger of secon- dary Hemorrhage. 5. Patients can be more safely transported. Macleod affirms that Flaps are knocked about in such a manner as to bruise and injure them se- verely, — causiug sloughing and materially retard- ing recovery when Patients are carried a long dis- tance either by land or sea. G. Operations can be performed at a greater distance from the trunk. The advantages claimed for the Flap operation are : 1. The operation can be more readily and rap- idly performed. 2. There is less danger of having the bone uncov- ered, and of thus exposing the operator to ridi- cule, and the Patient to additional suffering. 3. The Surgeon is enabled to select a covering for the bone from some of the tissues which re- main intact. 4. The muscles can be more readily retracted, and the saw more advantagiously used. 5.. The stump is usually better covered, though the work of cicatrization may be delayed. Union by "first intention" frequently takes place in this connexion, the opinions of some to the contrary notwithstanding. With this statement of the arguments advanced upon both sides of this long mooted question, the Surgeon is left to his own judgment in regard to the the cases which may present themselves, as no specific rule can be given which will apply to each individual injury, and as the best Surgeons vary LENGTH OF FLAP. 109 their operations according to the nature of the circumstances surrounding them. As a general thing, the Double Flap operation willbe found best adapted to single bones, as the thigh and arm ; and the Circular best suited to double bones, as the leg and forearm. Length of the Flap. — Sir; C. Bell, declares that " the general rule in all cases is to save integu- ment enough to cover the muscle, and muscle enough to cover the Bone, taking care to scrape off none of the Periosteum." This is capital ad- vice and should be regarded. It should also be borne in mind that, after amputations for gun-shot wounds, there is more of tonic muscular contrac- tion than under ordinary circumstances ; and hence, greater care should be taken to see that the Bone £s properly covered. Though it is certainly possible to have the • <>l too great a I ngth, yet nothing can be more em- barrassing to the patient and annoying to the iSurgeon than to have them too short. The expo- sure and exfoliation of the Bone ibllow, as a mat- ter of necessity, and another operation has to be performed, as the only means of correcting the error. A mistake of this kind should be correct cd as soon as it is discovered, even before the stump is dressed, by sawing oil' another portion of the Bone, with an honest acknowledgment of er. ror on the part of the Surgeon. After the expi- ration of a few days only, it is exceedingly diffi- cult to denude the Bone sufficiently to apply the saw, as it immediately bccomi ted with a hard and irregular callus. — defying the knife DOUBLE FLAPS. and rendering its exposure a veritable work of ex- cavation. Let the Surgeon remember, however, that it is not so much the length of the Flaps which pre- vents the risk of protrusion of the Bone, but the height at which it (the Bone) is divided above the angle of union of the Flaps. Varieties of Double Flap Operations. — There are two varieties of this mode of Amputation — viz: When Anterior 'and Posterior flaps are made, and when covering for the Bone is sought for on either side of the Limb by cutting lateral flaps. To the latter method a serious objection can be urged, even though it is possible to save some blood by cutting the Flap which contains the artery last, the Bone is prone to rise np in the angle between the two Flaps, and, thus, to keep its lower end continually exposed. The same accident may occur when Anterior and Posterior incisions have been made, by turning the Limb upon its side instead of its posterior surface, and thus permitting the muscles to lift the lower ex- tremity of the Bone upwards in the angle between the Flaps, while the Flaps themselves are per- mitted to fall downwards by the force of their own gravity. Those evils can be avoided by proper watchfulness, and their occurrence is con- sequently a disgrace to the Surgeon. Let him guard against a protrusion of the Bone then, as he values his own reputation, not that such acci- dents necessarily imply ignorance or carelessness? "but as they are thus produced in a large majority of eases, an amount of odium attaches to them and AMPUTATING POINT. Ill which but few men have the professional status to withstand. Whether the Flap or Circular method be em- ployed, care should be taken to calculate the diameter of the Limb, and to give the skin on either side, at least half that length. The Flaps may even be a little longer on account of the de- position of the skin to retract: and the operation should not be under-taken until the length to be given them is arranged in the mind of the Surgeon, and the precise spot at which the Bone is to he sawn through, accurately determined. The Point at which Amputations should bb performed. — The French very properly distin- guish (1) the jriacc of necessity — where {here is no choice of site because of the nature of the injury — ; and (2) the place of eh ction where the most available locality can be selected. The place ofclc<'ti<>i> varies in different members, though the general rule is to save as much of the Limb as can bo done without endangering the patient's life. The facts upon which this rUle is based are, the greater futility of long slumps in general, and the dimunition of the danger in proportion to distance from the trunk in which the operation is performed. Thus, ac- cording to Malgaigne, from 26 Amputations of the smaller toes. 1 death occurred; from 46 Amputa- tions of the great toe, 7 deaths; from 38 partial Amputations of the toot, '.» deaths; from 10- Am- putations of the leg, L06 deaths; and from 201 Amputations of the thigh 120 deaths. In the 112 AMPUTATING POINT. Crimea the mortality after Amputations of the Thigh was ; for lower third fifty six per cent. for middle " sixty per cent. for upper " eighty six per cent. for Hip one hundred per cent. The mortality after Amputations of the Arm was: for the Fore-arm seven per cent. for the Upper-arm nine-teen per cent. for the Shoulder-joint thirty-Jive per cent. These facts arc significant, and should be care- fully garnered as the most reliable data upon which the Surgeon can base his judgments, both in Field and Hospital service. Many Surg-eons, and particularly those who pre- fer the Flap operation, are in the habit of Ampu- tating the Log at a point about three or four inches below the knee-joint, as the operation can be more conveniently performed there, and as the shorter stump can be more easily managed afterwards. Bockelof Strasburg has however collected the statistics furnished by various authors on this sub- ject, and shown that the mortality attending the higher operation, exceeds that of the lower — the Infra — Malleolar operation, — 100 per cent. This he attributes: 1. To the wound being farther from the Body in the lower operation. 2. To the surface of the wound being smaller. 3. To the comparative rare occurrence of !' mia and Phlebitis. When it is possible to obtain artificial limbs of AMPUTATING POINT. 113 superior construction, much greater usefulness of the member can be secured after the supra-malleo- lar amputation has l>ccu performed; but, for the attachment of the " wooden-leg," upon which our soldiers must rely under existing circumstances, the shorter stump is for more available. The rule, enunciated above, is not however of universal application. Amputations through joints arc not more dangerous than operations made by section of the bone; and hence, a portion of a member particularly if a small one, can frequent- ly be sacrificed without detriment, to secure the advantages of a disarticulation. Thus a portion of a phalanx may he sacrificed, and the amputa- tion performed at the nearest joint, rather than wait for the saw ; and, notwithstanding all the ad- vantages of saving an inch or two of the ulna, and radius, it is better to amputate at the elbow joint than too near it, in order to avoid the disadvan- tages of the subsequent inflammation. The same remarks will apply to amputations made at a short • list a ncc from the shoulder and knee joints, J but the same rule does not hold good for the hip joint, as disarticulation there is usually fatal. Amputations made through the cancellous structures near the ends of the long bones, are less dangerous than those made through the shafts, as they are not so likely to be followed by suppuration and pyaemia. (Baud that his experience in the Crimea fissures him thai disarticulation ol the knee should always be ; of the I 114 MANAGEMENT AFTER AMPUTATION. Management after Amputation. — As was men- tioned before, the success of an Amputation de- pends as much upon the subsequent managemen- ofthe case, as upon the mariner in which the opera tion is performed. The following rules should govern the Surgeon in this regard. 1. Keep the wound open until the patient has recovered from the shock of the operation or from the effects of the Chloroform, lest Arteries which have been paralyzed thereby, may bleed, and endanger the patient's life. 2. Adjust the Flaps carefully, but not too closely, by means of sutures, and strips of adhesive or isinglass plaster. The sutures should be made of strong saddler's silk (or silver if it can be obtained,) and applied in such a manner as to embrace at least one eighth of an inch of the upper Flap, and one quarter of an inch of the lower. 3. Bring out the Ligatures at one angle of the wound and secure them by a small strip of ad- hesive Plaster, taking care to handle them lightly and to provide against the possibility of traction during subsequent manipulations. ^.4. The wound may be dressed in two ways : (1) By inserting sutures at the distance of an inch from each other, supporting them with strips of ad- hesive plaster, then using a single layer of wet cloth, covered with a waxed cloth to keep in moisture, and applying an iced bladder or water by irrigation. (2.) Applying sutures to the entire length of the wound, drawing the intermediate spaces together by means of Isinglass Plaster, leaving uncovered the angle where the ligatures escape, so AFTER TREATMENT. 115 that drainage may be kept up -, and applying the Maltese Cross by moans of a light roller, bo aa to assist in excluding the air and converting the wound into a subcutaneous one No water dread- ing is used and the stump is left undisturbed. This mode of dressing is particularly applicable to Circular Operations, where the skin alone forms the Flap. Diachylon Plaster is more irritating and less convenient than Isinglass Plaster, and should not be used in this connexion, when the latter can be obtained. 5. It is particularly important to insist upon absolute rest about the tenth or twelveth day after the Operation, for at that time the Ligature escaping from the Arteries, and ther< secondary hemorrhage, which is always a dai ous complication. 6. It should not be forgotten that a large ma of the patients who come under the care of military Surgeons have been exposed to the debilitatiug influences incident to Camp and Hospital life, am that the demand for nutritious food, stimulants. &c, is unusually great. Without attempting t( decide the much mooted question in regard to th< change of type alleged to have taken place in the diseases of the present day. it is only nec< call attention to the fact that a typhoid tendency does manifest itself in connexion wi'.b the systems of our soldiers generally, and that the denial usually for a supporting plan of treatment. 7. Apply no bandages after Amputations mil it be for temporary purposes upon the deld, or a light one to retain the proper dressings. 116 BONDAGES. Bandages have been recommended as a valuable means of arresting muscular contraction, but when it is remembered that the opposing force exerted by such appliances is nothing when compared with the power with which muscles contract when entirely severed, .the fallacy of this proposition is manifest. Again, they have been employed to prevent in- voluntary muscular twitching, causing the stump to start, &c. Experience shows and physiology demonstrates the utter impossibility of a sufficient control being exercised by bandages in this re- gard. And finally, it is asserted that they prevent purulent absorption, as well as the entrance of air into the veins. This supposes that notwithstand- ing the pressure of the atmosphere, veins remain patulous after being divided, whereas except, un- der peculiar circumstances, they immediately close without requiring the intervening agency of ban- dages applied to the stump. Besides, veins have no Such power of suction as is claimed for them under this hypothesis. But they are likewise in- jurious by complicating the dressings, concealing the stump from view, becoming offensive, and re- tarding the flow of blood to a part which requires as much of that vitalizing and recuperative fluid as its capabilities will admit. It is better there- fore, to support the limb upon a pillow and employ cold water dressings without bandages, save such as have been mentioned. Accidents following Amputation. — The accidents which supervene upon amputations are those NECROSIS OF BONE. 117 winch are peculiar to the operation and those which pertain to it in common with wounds gen- erally. The most prominent of those which are peculiar to the operation arc : Necrosis of the bone ; Conical Stump ; .Neuralgia of the Stump and Aneurismal enlargement of the Arteries. The most prominent of those which associate them- Belves with this operation in common with wounds generally, arc : Maggots in the wound, Erysipelas: Gangrene; rysemia; Tetanus; and Hemorrhage. Necrosis of the Bone. — It happens not unfre- quently that Necrosis of the .Bone takes place after; amputation. The remote causes of this accident are : Scrofula,Syphilis,and Cacectic states ofthesys. tem generally ; whilethe direct or immediate caus- es are exposure of the bone either by destruction of the periosteum during the operation or inflamma" tion of it afterwards. The signs by which it can be determined are the ordinary symptoms ot local in- flammation to which are subsequently superadded those which particularly distinguish the progress of that morbid process in bony tissue — such as great pain and swelling, red and glazed condition of the surface, the copious discharge of a very fceted pus, &c, the formation of a sequestrum, <. v :c The treatment consists in endeavoring to cover the de- nuded bone, in sustaining the strength of the pa- tient, and in exercising the affected portion. Conical Stumps. — The hone may protrude in consequence either of the carelessness of the Sur- geon iu not leaving covering enough, orof the un- avoidable retraction of the tissues. The reader is referred to what has already been said in regard 118 CONICAL STUMPS. to the length of the flaps, and the rules for cutting them. When it becomes apparent that this accident is likely to occur, the following procedure may be attempted with a reasonable hope of success : Out a long strip of adhesive plaster two inches and a half in width ; apply one end upon the inner side of the limb, beginning if possible, eight inches above the wound; apply the other end upon the other side of the limb in the same manner; make a few turns with a roller wetted or a strip of adhe- sive plaster, around the limb and over the plaster tirst applied ; to the loop ^formed by 'the tirst strip of adhesive plaster, formed below the ampu- tated surface, attach a small cord; then pass this cord over a small wheel at the foot of the bed, and tie to it a weight sufficiently heavy to bring the soft parts down over the denuded bone. Traction may be kept up in this way for weeks, without in- convenience to the patient, and with th« best re- sults. The author recalls in this connexion as il- lustrative of the advantages of this plan of treat- ment, the case of Burns of the Louisiana Battalion ot Tigers, who was wounded by a conical ball just above the ankle, in a picket tight on the Potomac. Shortly after the tirst battle of Manassas, he was brought to the General Hospital at Charlottesville, Virginia, and placed under my charge. On en- quiry 1 found that two amputations had been per-* formed on him, — one below the knee joint and the other just above it, the second being necessitated by the protrusion of the bones from the stump. Notwithstanding that the thigh operation had evi- CONICAL STUMPS. 119 dently beeu performed with care, the bo**G was protruding fur more than two inches, while the muscle* manifested ;i disposition to ooatraol farther. An effort was made to separate the aofl parts from the bone and to excise it at a propoi distance above the surface of the wound. The bone was found so completely surrounded by a hard and irregular callus, that the work of excavation could not be. accomplished, and excision was consequent- ly made on a plane with the divided tissues. The ad- hesive straps were then applied, as before described and the traction continued for several weeks, at the expiration of which period the bone had been com- pletely and beautifully covered. The principle involved in the treatment of fracture by means ox adhesive strips wassimpiy invoked in a new direc- tion and with a satisfactory result. Neuralgia of the Stump. — It sometimes hapj that a distinct tuberose enlargement bjf the nerves in the stump occurs, attaining- the size of a I cherry, and giving great pain by pressing ag the bone. Excision of this bulbous extremity ta tne proper remedy. Again, an important D may be included in one of the ligatures, pain and paralysis. The stump should be op and the end of the nerve cut off. [u the nor and hysterical, neuralgic pain frequently ocC almost defying treatment. As general r< i tonics, -cdatives and alteratives may be adlll tered ; while ae a topical application tjiesul ous injection of morphia stands unrivalled. Spasm of the stump must be treated on g principles tonics, nervous atimulanl 120 MAGGOTS IN WOUND. to the part, &c, are the most approved remedies. Aneurismal enlargements may possibly be removed by pressure; but if of a more serious character the Artery must be ligated or another amputation at- tempted. Maggots in the wound. — This is always a serious and troublesome complication — annoying to the patient and embarrassing to the Surgeon. Their tenacity of life is truly astonishing, while the celerity with which they are produced is truly wonderful. A wounded surface over which a seemingly continuous stream of cold water is flowing, will suddenly and almost miraculously teem with these active and disgusting insects, not- withstanding great care on the part of the attend- ants. Prevention, however, is every thing in this connexion. If the stream really be continuous, and the attention unremitting, the accident can- not occur. When these insects have been develop- heir destruction may be secured by either one of the following remedies: calomel, applied in powder, or suspended in water; black wash; creosote and water; an infusion of the marygold; chloroform: elder juice; an infusion of elder leav owers ; and various other applications, ■try to mention. Calomel and Elder juice are the most reliable, as well as the harmless of these various remedies. Erysipelas. — This affection is connected with some depraved and altered condition of the blood, icularly of the red corpuscles, and is essential- ly the local manifestation of a general or constitu- tional malady. It is really a disease of de- ERYSIPELAS. 121 bility in as much as the nervoui centres are not supplied with their normal and m -ar\ amount of healthy pabulum, in consequence the precedent changes in their vitalizing fluid; The pathologi cal conditions which characterize this disease may be thus expressed. 1. Changes in the blood, whereby the .Corpuscle are rendered less stimulant and nutritious to the nerve centres, &c. 2. Changes in the nerve centres resulting from the absence of the ssary food, whereby they become irritated and not duly stimulated. 3. Tn consequence of this irritation the whole system, that machinery ofwhich the Centres are the motive power — acts irregularly; and hence fever, local congestions and inflammations, disturbance of the secerning organs, &c, ensue. 4. As a result of this want of stimulation, the centres lose their tone,— their generating power abators, and the whole system becomes decidedly debilitated. The symptoms which distinguish is are so well known as scarcely to require enumeration. They are the following: a reddish flush rapidly spreading over the surface; a peculiar stinging and burning pain; considerable swelling; much tension: tenderness on pressure ; great heat ; and. tendency to effusion, together with a full, tent, hut weak pulse; a dirty and coated tongue; and deranged ^astro-intestinal secretion. There wo principal varieties, viz: the simple Cutane- ous and the Cellulo-Cutaueons or Phlegmonous. The former limits itsell to the skin, while the latter extends to the cellular tissue which separates that 122 EKYSIPELAS tissue from the muscles and the muscles from each other. The phlegmonous is far the more serious and fatal affection. Its symtoms are more violent ah initio, while a tendency to rapid and ex- tensive suppuration is one of its most serious characteristics. Beneath its hurried and fearful footsteps muscles are uncovered, blood vessels ex- posed, bones robbed of their covering, joints opened, and whole members terribly and complete- ly devasted. In its train comes Hectic with all its frightful retainers, the ghastly herald of an early death. When suppuration has been established, and pus is evacuated externally, openings are formed bounded by edges of mortified cellular tissue, and cicatrization takes place most tardily if at all. In many instances sloughs of great extent are pro- duced, while the fever continues, the general dis- turbance augments, an intestinal .inflammation is excited, prostration ensues, and a fatal diarrhcea is developed. Occasionally Erysipelas is primari- ly and essentially gangrenous, marching with rap- id strides to a fatal termination, and utterly defy- ing the skill of the Surgeon. Eesearches into the pathological anatomy of this affection clearly establish that the inflammation incident to it af- fects in different degrees the skin, the tegumenta- ry vessels, the cellular tissue and the lymphatic system, and that its fatality and violence are in proportion to the depth and number of the struc- tures involved. Without discussing ;it length the question of the contagiousness of Kresipelas, it is sufficient to ERYSIPELAS'. 123 remark that though this character has been claim- ed for it by Lawrence, Arnold, Willan and Erich- Ben, a large majority of modern potholOgists total- ly and emphatically repudiate the idea. The case referred to by Erichsen and quoted by Chisolm an illustrative of its contagiousness, is not suffi- ciently conclusive as the appearance of the dis- ease, under the circumstances alluded to, may have been a mere coincidence, and as proof equal- ly as strong can be adduced in support Oi the communicability of any disease. If the disease be strictly contagious, in the ordinary acceptance of that term, why were only the .sick attacked, while the physicians, nurses and attendants escap- ed? It may also be asked in the same connexion, why it does not ''spread" in all Hospitals alike, or communicate itsell to those who dwell in their immediate vicinity, and who arc in communica- tion with patients suffering from the disease ? The circumstances which associate themselves with the development of Erysipelas are : 1. A system which has been debilitated by pre- vious exposure, fatigue, loss of blood, indulgence inveucry and intemperance, or improper food. J. Certain special hygienic conditions, — such a- deprive the patient of those surroundings which are essential to the preservaiou of his system in its normal stain*.- -Among these are impure air, want of cleanliness, non-nutritious food, ab- normal electrical conditions of of the atmosphere, &c. These circumstances may so combiue as to de- velop the disease spontaneously, or they may fur- 124 ERYSIPELAS. nish those conditions which necessitate its dissemi- nation when the morbific elements are furnished by a case already existing, as occurred in the in- stance alluded to by Erichsen; but it cannot be pretended that without these particular conditions — this special preparation of the system for the in- vasion of the malady — erysipelas can be propagated by contract. By a " contagious disease," accord- ing to the teachings of the ablest writers, is meant an affection which under ordinary circumstances, and with the human system in its normal condi- tion, attacks a large majority of those who are brought in contact with it. Erysipelas does not thus propagate itself save under extraordinary cir- cumstances, and when the normal status of the sys- tem has been materially altered ; and hence a pri- ori, it is not a "contagious disease " according to the usual acceptation of that term. A malady which is not " contagious " cannot be " infectious,'' inasmuch as the latter term implies propagation by contact with some emanation — atrial or gaseous it may be — from an affected system. The treatment of erysipelas has become far more rational and successsful within a few years. The seeming violence of the febrile phenomena, is no longer regarded as an indication for antiphlogistic remedies ; but, regarding it as essentially and ex- clusively a disease of debility, the profession has learned to depend upon tonics and stimulants, as the agents best calculated to stay its rapid and fear- ful progress. So, likewise, the doctrines of Higginbottom, in regard to the pathology of the disease, have been ERYSIPELAS. 125 overturned by the more enlightened views of Cho- rncl, Blanche and Biett, and it is now recognized and heated an a constitutional disease which ex- presses itself in a topical inflammation. The primary indications arc to administer reme- dies which will restore the altered corpuscles to their original purity, and at the same time give tone and power to the exhausted nerve centres. Muriated Tincture of Iron and Sulphate of Quinine arc the remedies which will most successfully accomplish these results £and the following prescription will host combine them: ft Tinct: Muriatici Ferri, 5iij- Quinite Sulph : ►) ij. A«]iia, font g iv M S. — A teaspoon ful every third hour. The Muriated Tincture of Iron is not only more rapidly absorbed, but it also possesses the power of restoring the altered corpuscles and of controlling the local inflammation, byconstringingthe capilla- ries of the affected structures. The Quinine acts directly upon the the nerve centres increasing their capacity for the production of that subtle nervous influence upon which tho integrity of the whole organism depends. Stimulants should -also bo employed for the pur- pose of giving tone and strength to the exhausted system; while liquid and nutritious food consti- tute a necessary and most important addition to tho treatment. Should the progress of the disease be complica- ted with gastric disturbance, au emetic or a mild 126 ERYSIPELAS. purgative should be administered, for the purpose of removing all offending matters, and of restoring the secretions, but not with reference to its deple- tory effects. Local applications are neither to be despised nor too much relied upon. Mercurial ointment, as re- commended by Ricord, the Camphor "Water of Malgaigne, Velpeau's Ointment of Sulph: Iron, Nitrate of Silver as proposed by Iligginbottom, fo- mentations of elder flowers, poppy heads, cranber- ries, hops, &c, solutions of nitrate of potash, sugar of lead, carbonate of soda, and chlorate of potash- creosote, collodion, ice, tincture of lobelia, dilute acetic acid, white lead, muriated tincture of iron olive oil, &c, &c, have all been tried, and have their admirers. The great remedy however is Cold Water medicated according to the indication, and applied in conformity with the rules and principles enunciated in the first chapter of this work. Scai- rifications, both as a means of relieving the local hyperemia and of permitting the escape of pus are invaluable. It, of course, becomes a matter of the greatest moment to improve the sanitary condition both of the patient himself, and of those with whom he may be associated. It is well, therefore, to place the patient in a tent in the 'open air, removed from his companions, and so situated that he may get an abundant supply of fresh air. His body should at the same time be kept clean, and an abundant supply of good food furnished. The greatest care should be immediately taken to ventilate, and purify the Hospital, to see that PYEMIA. 127 wounde are frequently and properly dressed, and their products removed, to have all vessels cleans- ed as soon as they are us^d, to keep the bed linen fresh and clean, to empty the spit boxes regular- ly, to provide pure and nutritious food, to admin- ister stimulants freely, to cheer and console the patients, to segregate the sick and wounded, to till up sinks and change the location of privies, and to do such other things as the laws of health require. An Epidemic of Erysipelas is not likely to prevail if the hygienic conditions are good, and when they are so, the separation of sporadic casts no longer becomes a necessity. Pyaemia — By this term is meant that pus poison- ing which sometimes takes place in connexion with wounds produced Jby the amputating knife and other causes. It is preceded by a stage of incubation in which the patient is restless, sleep- less, uncomfortable, feverish, pale, and appre- hensive of evil. The disease proper is ushered in by violent rigors, which continue to occur at regu- lar or irregular intervals, followed by high fever' jaundiced hue of the skin and conjunctiva, a furred tongue, a frequent but feeble pulse, delirium or coma, gastric irritation, diarrhoea, sardonic coun- tenance, great thirst, copious sweats, and extreme restlessness. The patient gradually grows more feeble, the joints inflame and swell, the organs generally show greater signs of disturbance, the pulse sinks, collections of pus occur in the various tissues, and the wound frequently becomes boggy and yielding but comparatively dry, and death finally closes the scene. 128 PYEMIA. These symptoms are manifestly due to the presence of pus in the blood — poisoning that fluid and acting as an irritant to the tissues and organs generally. The purulent fluid is introduced into the circulation in two ways, which are entirely distinct from each other — viz: 1. By inflammation and finally suppuration of the internal coats of the Veins. 2. By the absorption of pus, — modified but not improved — into the blood. The Blood, as previously stated, is poisoned by the presence of this product to such an extent, that it not only fails to supply pabulum to the tissues, but becomes positively irritating to them. There are consequently developed in various parts of the body points of irritation at which the blood accu mulates until inflammation is developed, and an effusion of lymph takes place. This lymph being but poorly organized because of the blight im- pressed upon the whole mass of the blood, readily and rapidly breaks down into pus ; and hence those multiple abscesses arc formed which constitute the most prominent feature of the disease. Pyamiia being essentially a disease of debility, requires to be treated by tonics, stimulants, and a nutritious diet. The restlessness and insomnia must be controlled with opium; the diarrhoea with opium, and astringents combiued ; the inflamma- tion of the veins combatted on general principles and the purulent matter given a free vent. Macleod suggests the propriety of ligating the chief vein with the artery, as a means of cutting off the channel by which the poison is couveyed into I10SPITAL OANGHENE. 120 the system. This may prevent the absorption of pus, but it is likely to defeat its own object by in- ducimg phlebitis. Amputations after the develop- ment of Pyaemia, so far as the authors observations go, arc invariably fatal. The application of Chlori- nated washes to the surface of the wound will be found useful, in conjunction with the general treat- ment marked out. All that was said in regard to separating the patients affected with this malady, improving general and individual hygiene, &c, in connexion with Erysipelas, applies with equal force to Pyaemia. Hospital Gangrene. — This is also a disease of debility, and results from the influence of a blood in acting on an enfeebled constitution. It is both contagious and infectious. The symptoms which characterize it arc: feverishness, loss of appetite, sleeplessness, coated tongue and deranged bowels, followed by a dry and painful condition of the wound, the appearance of an ash colored — Blough, which is soft and pulpy, engorgement of the neighbouring skin, eversion and undermining of the edges of the wound — which are of a livid red color — , and finally the complete breaking down of the dying tissue, with the development of a thick and dirty fluid, and a peculiarly offensive odour. The mortification extends rapidly and the system sinks under its baneful influence. The Jireatment consist taining the system with tonic- and stimulants, and destroying the poisonous ichor, from which the local ami general poisoning results. The first indication is accomplished by the free use of Quinine, tron, and Brandy; while 130 TEtANtTS. the second is fulfilled by sue*"", remedies as the actual cautery, caustic potash, nit-ate of silver, tincture of iodine, creosote, chlon 'e o 'von, lemon juice, pyroligneous acid, nitric aciu, mutiaticacid, &c, followed by irrigation. To allay pain, calm nervous disturbance, insure sleep, &c. — Opium may be freely used. But above all things remove the patient from the infected atmosphere ; and surround him with those things which hygiene and humani- ty demand for his health and comfort. Tetanus. — Tetanus is a peculiar condition of the nerves centres, characterized by the following- phenomena; the wound is dry and painful; the patient shows signs of mental agitation and fright ; convulsive movements of the face, and of the members, particularly of the arms, take place; deglutition and mastication are rendered difficult — preceded by soreness of the throat, and followed by locking of the jaws; contraction of the muscles of the neck take place; the abdominal muscles be- come hard and knotted ; violentand repeated spasms occur, while the pulse grows feeble, the counten- ance sardonic, and the skin profusely moist. Tetan- us is said to be complete when all the muscles of animal life are equally and thoroughly contracted. Under these circumstances, the body becomes so thoroughly stiffened as to seem all of one piece, and wi 11 break rather than bend — the fingers however are an exception and still remain flexible. The face es- pecially is remarkably fixed and motionless, and wearsan expression which resembles that of death or of mortal agony. The pain of this affection is terribly severe, being similar to that produced by cramp of TETANUS. 1S1 the muscles, such as every one is familiar with. The intellectual faculties remain intact up to within a brief interval before the approach of death. The appetite is good, but the impossibility of degluti- tion frequently produces death by starvation, ac" cording to Larrey. Tetanus is a very grave malady nearly always; terminating fatal 1}', especial ly when of traumatic or- igin, and involving all the muscles of animal life. According to the muscles involved, it is styled trismus, emprosthotonos, opisthotonos and pleu- risthotonos. It is essentially a' lesion of the nerves, but as yet pathology has not ascertained its essential nature, notwithstanding the recondite researches of Bouil- laud, Begin, Andral and Magendie. The theraputi.es oi tetanus are no better settled than its pathology. Being manifestly a disease of debility, it is a matter of the first importance to sustain the patient, which has to be accomplished by means of enemata, on account of the difficulty of deglutition. Cruveilhier regarding asphyxia as the usual mode of death, in consequence of the convulsive action of the respiratory muscles, proposed to pre- ventthis fatal result by inducing violent but vol'un_ tary movement of the same muscles. He compelled his patients to make forced and profound inspira- tions until the contractions were overcome. Busse recommends friction with alcoholic tinc- ture of belladonna, particularly over those points where the convulsive rigidity is greatest. 132 TETANUS. Larrey cut short the disease in its forming stage by amputating the limb or dividing the nerve. Fournier treated the disease successfully by means of sulphurous baths, and Pare testifies to the efficiency of the same practice. Chloroform has many advocates ; extract of Can- nabis indica, opium, belladonna, woorara, and in fact nearly all the remedies in the Pharmacopea have been recommended and successfully used. No specific remedies can be relied on, but the fol- lowing is perhaps the best plan of treatment : Empty the bowels, by means of scammony, aloes, gamboge or croton oil ; divide the principal nerve of the part ; apply warm water medicated with opium to the wound ; administer chloroform freely until anaesthesia is induced ; and inject mor- phia subcutaneously, either immediately over the track of the principle or in close proximity to the nervous centres which seem most involved. If the strength of the patient can be supported there is some prospect of a favorable termination. Sleep is absolutely necessary to the comfort and salva- tion of the patient. Nothing can be more impor- tant than to remove all foreign bodies from the track of the wound, and to use such remedies as arc calculated to relieve the local inflammation. The patient should be made as comfortable as possible, quiet enjoyed, and an equable temperature preserved. The experience of all Surgeons estab- lishes the fact that changes of temperature are prolific sources of this disease — a circumstance which should be remembered botli as a means of preventing and curing tetanus. SUTURES. Tetanus is either cording to the mode of its product! Hemorrhage. — As the subje treated of at lengl !i in a i necessary to consider it here. S TURES— IN rhage has been ai cidental or arl I union between them, and ;• means of sid ether r i : ral wiles Foi he of Sutures shouh dii 1. E.uter the needle at,; distance from the margin length of the woun< 2. Have the points of perfo the amounl of tissue embraced in 1 of sufficient extent to close the p wrinkling. • : . relied : ; the wound, ;• sufficient number mu make the line of union complete, rule ter to employ r. sutures and fcli together wil 4. The knots of the Ligat upon the upp be affected by . only modera 5. £ Id be remo sion has taken pli >1 all ai once, bui pately and carefully. G 134 SUTURES. 6. In the application of sutures avoid wound- ing nerves, vessels, serous membranes or ten- dons. 7. Should union take place by " first intention," the sutures may be removed about the eighth day, but if by "second intention," not under a month. • Particular sutures. — It may be well before advancing farther, to consider briefly the differ- ent varieties of sutures employed in Surgery. 1. The Interrupted Suture. — This is formed by passing a needle and thread, through the skin and subcutaneous cellular tissue from without in- wards on one side, and from ivithin, outwards on the other, fastening the ends of the thread togeth- er, and cutting them off close to the wound. The stitches arc proportioned in number to the extent of the wound, and are usually inserted at the distance of an inch from each other. This is the form by which the margins of wounds made in performing amputations, are kept together with the assistance of adhesive straps. 2. Glover's Suture. — This differs trom the last in that the edges of the wound are brought togeth- er, and the needle and thread passed at once through both of them, then brought over to the same side, and passed, again through both edges, and so on to the end of the wound, making at each stitch a loop which is drawn tight — precisely as the edges of a glove are "whipped" together. This is not much employed at the present time. 3. The Quilled Suture. — This is applied in the same way as the interrupted Suture, only the needles TURES. 135 are armed with double threads, so that one of the extremities forms a loop. All the stitches being made on the. same line, a peice of quill is passed through the loops, and the threads on the other side of the wound are separated and tied over a similar bit of quill, with sufficient* force to bring the sides of the wound together, and to keep them there. 4. Twisted Suture. — A round, and straight nee- dle of gold or silver — or a common pin is pushed through the edges of the wound, from without in- wards on one side, and from it i thin outwards on the other. The first needle being thus introduc- ed, a thread is passed under it on either side, and sufficient force exerted to bring the edges well together; another is similarly placed, and a third, or as man;- as are wanted. Then taking the ends of the thread they are crossed in front of the first needle, and brought again under its extremities, so as to form a figure of eight, repeated four or live times. They are then passed under the se- cond, and similarly twisted, and so on for every needle introduced. When the last turn has been made, the two ends are tied together in a knot or bow. A small compress of lint should be placed under the point of each needle to prevent it from irritating the skin. Percy long since recommended lead as a good materia] for Sutures, but experience has demon- strated that silver wire is incomparably the best mail mch a purpose, in as much as it is both exceedingly ductile and particularly non irritating to the animal tissues. Physic used kid skin rolled 136 SUTURES. into small cords. Dr. Simpson of Edinburg, re- commends wire made of gold, platinum or copper as a substitute for the ordinary suture. Br. Eve has employed, with the same end, fibres from the sinews of the deer. When they are to remain in position for a long period, employ Metallic Sutures, particularly those made of silver wire, but under ordinary circumstances, it is best to use those com- posed of some organic material. Thread made of silk, flax or cotton can generally be found by Sur- geons every where, and when properly waxed, possess sufficient pliancy and strength for all practical purposes. Ihe Glover's Suture generally puckers the wound and may be replaced in many instances by the Interrupted; the Quilled Suture causes the bottom of the wound to unite while its edges remain open j and the Twisted Suture by compressing the flesh only at certain points is more liable to cut through, and disengage itself prematurely than the others. Experience has shown that Sutures made of animal tissue do not possess any decided advantages, and they have fallen into disuse. CHAPTER III. PARTICULAR AMPUTATIONS. Having given the general rules which govern Amputations, it now becomes important to describe in detail the methods of procedure in individual operations. Amputations of the Lower Extremities. — Under this head are included Amputations of the Foot, Ankle-joint, Leg, Knee, Thigh, aud Hip-Joint. Amputation of the Toes. — Directions : Seize the phalanx firmly and bend it so as to give promin- ence to the joint; make an incison across the joint, cutting well into it ; divide the ligaments carefully on either side; and then cany the knife through the joint and cut a flap from the under surface of the toe. The flap should then be brought over the surface of the disarticulated joint and secured by ligatures or adhesive plaster. The toes may be amputated at the second joint in precisely the same manner. Amputation of ihc Great Toe at the Meta-tarsal Articulation. — Directions : Pass a narrow bistoury up oh one side of the proximal phalanx as high as the articulation; carry it then across the joint t turning the point so as to cut the ligaments and open the articulation ; lay the blade flat against 138 AMPUTATIONS OF THE TOES. the toe and cut out a flap on the opposite side. The joint really lies much deeper than one un- acquainted with the Anatomy of the part would suppose, — a fact which should be remembered in introducing the knife. It is important to preserve the distal end of the meta-tarsal bone so as to strengthen the foot and prevent lameness. The Meta-tarsal bone can be removed by an operation similar to the last, — the first cut being extended to the tarso — meta-tarso articulation. Avoid the anterior tibial artery in opening the joint, for it dips near this point between the meta-tarsal bones. There is always danger of lameness and the oper- ation should be avoided, if possible. Amputation of all the Toes at their Meta-tarsal joints. — Directions: Make a transverse incision along the dorsal aspect of the meta-tarsal bones; divide the tendons and lateral ligaments of each joint in succession ; dislocate the phalanges up- wards ; and then, placing the knife between the meta-tarsal extremities, cut a flap from the skin on the plantar surface, sufficient to cover the heads of the exposed bones. Tie the arteries; bring the flap in position ; and lay the foot on its outer side so as to facilitate the discharge of pus. Amputation of all the Meta-tarsal Bones. — Direc- tions: Find the point at which the great toe arti- culates with the inner cuneiform bone ; make a semilunar incision beginning at the projection of the scaphoid and terminating at the outer side of the tuberosity of the fifth meta-tarsal bone ; turn the small flap thus formed backward, pass the knife around and behind the projection of the fifth meta- AMPUTATIONS 01 OT. tarsal bone, so as to divide the ligaments which connect it with the cuboid : a and cut the remaining ligaments; disarticulate the third and fourth meta-tarsal bones; then a the first meta-tarsal and finally the second, which being locked between the three « uneiform bones is difficult to dislodge and should in some instances. All live bones being cl cany the knife behind them, and cut a flap from the sole of the foot of sufficient length to cover tb posed surfaces of the disarticulated bones. Li the Arteries; bring the flaps in position, and keep the foot slightly elevated. This is known as Lisfranc's Operation. Instead of disarticulating, the bones may bo sawn across, a little in advance of the articulation as proposed by Hey and Cloquet, facilitating the operation, and giving results equally a Amputation through the larsus. — Directions. — Find the the joint at which the cuboid articulates with, the os-caleis, and the point v the scaphoid articulates with the astragalus ; make a semilunar incision acr< >ss the front of the foot con- necting these two points; turn hack the anterior flap, and divide the ligaments which connect the four bones mentioned above ; then pass the n through the joint, and cut a long f \ the sole of the foot. Tie the dorsal and two pla arteries; round oft" the be- fore bringing it into position : and care during the cure, to have tl muscles completely relaxed, by I foot 140 STATION OP THE I h i fcs outer surface over a pillow; This is known ''j opart's operation. i at the Anlde Join'. — To Syme "be- long-; the credit of having elevated this operation to its proper position in the Surgery of the pres- ent day. Being! Lgerous than amputation of the leg, and particularly successful as to its i*e- 6th in America and Europe, it is now re- eled with great favor by the 'profession. ections. — Make a curved incision across tke ep, from one malleolus to the other; make a id across the sole of the foot; dissect up the id expose the joint; disarticulate the os- galaswith the rest of the foot; and \ 3 the projections of l\c malleolar pro- ber with ihe. saw or forceps. Should the joint it involved, a slice of the louver end -.(1 iibrula may also be removed. • It to dis »'<•! the flap at the heel; hoiilcl be taken not to cut ; ; it, o to wound the posterior tibial ^re- operation is a great improvement on the older methods of disarticulating at the ankle int. The operation of Syme has been modified by Tyrogoft, by retaining a portion of the Calcanc- um, and thus imparting greater length and rotun- dity to the Stump. Directions. — Make a curvi- linef! ion around the foot in iront; make a sond incisipn under the sole, extending from the front, of one malleolus to the other; dissect up the flap, divide the different ligaments and detach AMPUTATIONS OF THE FOOT. 141 the astragalus ; apply the saw just behind the as- tragalus and divide the anterior portion of the caloaneum ; remove the malleolar projections to- gether with a thin layer of the extremity of the tibia ; tie the vessels and bring the flaps aceurate- ly together. The advantages of this operation are that a larger and better stump is secured, there is less danger of wounding the posterior tibial arte. ry, and the posterior flap is not so liable to form a pouch for the accumulation of pus. Remarks. — These operations are undertaken with a view of saving as much of the foot as pos- sible, in order that greater support and a more convenient stump may be secured; and though in proper hands they constitute the most valuable and scientific of Surgical measures, they should never be undertaken without a knowledge of the anato. my of the parts, and an acquaintance with the rules which have jurat been enunciated. Either Lisfranc's or Iley's operation is preferable to Cho- part's or Syme's, when admissible, in consequence of affording a greater length of Foot and securing a less tender stump, Pancoast's proposition to sev- er the Tendo Achillis, is a goodpne. Syme's op- eration does better for chronic diseases of the foot than when made lor traumatic lesions. PyrogofFa modification is liable to the same criticism, though a beautiful operation in itself. Malgaigne in his statistics of amputations in the Hospitals of Paris found the mortality after the removal of the great toe one to six; and after the removal of the .-mail- er toes one to twenty-six ; while in amputations of the foot the proportion of deaths was twenty- 6b 142 AMPUTATIONS OP THE LEG. five per cent. For the statistics of the operations performed upon the foot in Richmond the reader ia referred to Table "A" of the appendix. Amputation of the Leg. — Directions for the Cir- cular Operation : Administer Chloroform ; bring the Patient down upon the Table; command the Artery either by applying the Tourniquet to the Femoral Artery or compressing that vessel against the Pubes; have the limb well supported and the skin drawn upwards ; make an incision through the integuments entirely around the Leg; dissect up the integuments for about two inches or tw3 inches and a half and turn the cuff back; and then divide the muscles clown to the Bone. This being done, pass a double catline between the Bones, so as to divide the interosseous membrane ; and then having drawn the muscles back by means of a three tailed Re- +racter, saw through the tibia and fibula — engag- ing it in the larger Bone firmly but completing the section of the smaller one in advance of the other. Smooth off the bony surfaces with the nippers ; lig-ate the Anterior and Posterior Tibial Arteries, and such branches as may require it; and dress the stump according to the directions previously given. Directions for the Flap Operation. — Place the Patient in position ; administer chloroform ; bring the limb down until it projects well over the lower edge of the table; ascertain the exact locality of the bones and transfix the limb by passing the knife horizontally behind them, and not between them ; cut a flap from the posterior muscles about five inches in length ; and, then, make a semilunar AMPUTATIONS OF THE LE 143 incision across the anterior face of the Leg, con. necting the two points at which tl i e point of the knife was made to enter and to leave the Limb. After this, dissect back the anterior Flap slightly; divide the interosseous muscle and ligament with a double edged catline ; use the retractor ; and saw through the bones, as previously directed. Mr. Furgusson directs that the Anterior Flap be made first, by placing the Heel of the Knife on the side of the Limb most remote from the Surgeon, and then drawing it aeross in front of the Limb. As soon as the point of the Knife arrives a.t the opposite side, the limb must be transfixed and the posterior Flap made as above described. See that the bones arc of equal length and that their edges are smoothed off; bring the edges accurately and evenly to^etser ; and re- move the spine of tho tibia, if it project too much. Remarks. — The Flap Operation may be performed at any point above the Aukle Joint, where a pos- terior flap can be obtained, though the rules men- tioned above, should always be "borne in mind. Great care should be taken not to push the knife be- tween the bones or transfix the main artery; never operate above the tuberosity of the tibia le^ joint be opened or injured by the subsequent in- flammation ; and do not forget to shorten the r t Achillis when the operation i med near the Ankle. 144 AMPUTATIONS AT THE KN1B JOINT. STATISTICS. Pennsylvania Hospital 69 operations, mortality 42 percent. New Yoak " 102 ' " " 84 " " Massachusetts " 23 " " 21.7 " " Reported by Malgaigne " 192 " " 56 " " University College 14 " " 14 " " Reported by Mucleod lol " " SO.S " " " by Sorrell 123 " " 43. 9 " " The reader is referred to Table "B" of the Appendix tor fuller information on this subject. Amputations at the Knee Joint. — Amputations at this joint may be performed in two ways : 1. By making a large anterior fiap of skin and a short posterior one of muscle. 2. By making a short flap of skin in front and relying upon the gastrocnemius behind for a flap of sufficient length to cover the joint. Directions for process jNo 1. — Make an elipti- cal incision upon the anterior and lateral surface of fhe limb, from the centre of one condyle of the femur to the same point on the other condyle* This incision must have its convexity downwards, and should embrace surface enough to cover the joint after it has been exposed. Dissect up the flap of skin just made; divide anterior ligaments and open the joint; then divide the lateral and posterior ligaments ; and, finally, carry the knife behind the joint and cut downwards and back- wards, making a short flap from the muscular tis- sue on the posterior aspect of the leg. This being done, retractand saw off a portion of the condyles of the femur, so as to secure a smooth surface over which to adjust the flaps, &c. The patella should not be removed in the operation. Directions for process No. 2. — Between the same points, i. e., the centre of the condyles make an elip- IMPUTATIONS OP TIIK KNEE JOINT. 145 tical incision embracing but a short flap, upon the anterior and lateral surfaces of the limb; divide the ligaments as before ; and ^finally pass tho knife behind the disarticulated extremities, and cut downwards and backwards, making a suffi- cient l' tp of the muscular tissue behind to cover the exposed surface. Then retract, and saw off condylesas before. ThePopliteal with itsbranches, the inferior articular, middle articular, and gamel- lar, is cut in this operation, and should be imme- diately tied. The wound is closed and treated in the usual manner. There are other methods of performing this op- eration, but the plans proposed above, will be found to answer sufficiently well for all practical purposes. Remarks. — The propriety of amputating at this joint has been much questioned by Surgeons, yet Velpeau, Baudens, Pancoast, Malgaigne and Macleod have all declared in favor of it; and it may be resorted to in connexion both with prima- ry and secondary operations. It can be perform- ed very expeditiously, but, there, is danger of sub- sequent inflammation, and perhaps of atardy con- valescence. The advantages which this amputa- tion | over that of the femur may be thus summed up : 1- The shock to the system is h 2. A larger and more available sfump is secur- ed, while it is less liable 1" ulceration. 3. A false leg can be more readily attached, and later power is obtained \'<>v progression. 4. The Medullary ( 'anal is not interfered with, and 146 AMPUTATIONS OF TUB KNEE JOINT. the extremity of the femur being well supplied with Blood Vessels, there is less danger of exfoliation. 5. The Artery being in the centre of the Flap and but few ligations being required in the opera- tion, there is less danger of hemorrhage. 6. The operation is not so fatal 'as that fpr the fermur. STATISTICS. Reported fey Macleod, Operations 8 mortality 50.. t>er cent. Reported by Smith, P 86 " 43 ~ 11 41 Reported fey Malgaigne, 9 " 77.* " 40 (i u Reported by Pager, Reported fey Sorrell. (( 37 CI It .( 2 " op' ii it Mr. Baudens affirms that his experience in the Crimea convinces him that disarticulation of the Knee ought always to be preferred to amputation of the thigh, raid in this opinion he is sustained by Macleod and Malgaigne, as well as many other Surgeons of the highest character and widest ex- perience. Amputation of the Thigh. — Directions for the Cir- cular Operation. — Place the patient upon the ampu- tating table; administer chloroform, and bring him down upon the tab-fe until the wounded leg projects well beyond its l^wer margin — being sup- ported at the knee by an assistant. Compress the femoral artery either by tourniquet or digital com. pression against ramus of pabes ; direct the assistant to seize the limb with both hands just above the point selected for amputation, and to draw the skin forcibly back; grasp the limb with left hand so as to steady it ; carry the hand under the thigh, and make an incision at one sweep completely round the limb through the fat down to the fascia, dissect up the skin, &c, about two inches and a AMPUTATIONS OF TIIE THIGH. 147 half; and having turned the cuff back, with one circular sweep of the knife, divide the muscles down to the bone. This being done, separate the muscles from the bone for the space of about an inch ; divide the periosteum ; retract the flaps • and saw through the bone. In cutting through the muscles, it is a matter of importance to turn the edge of the knife towards the body of the patient so as to make a more conical flap. Instead ot dissecting up the skin, and turning it back, some Surgeons simply retiact forcibly after the first in- cision has been made, and, then, with the edge of the knife turned towards the patient's body, and the retraction continued, cut through each succes- sive layer of muscular tissue until the bone is reached, when the periosteum is divided and the bone sawed through, as described above. The arteries should then be ligated, — the femoral first, and the profunda next, if it be cut, and all pres- sure suddenly removed, so as to encourage hemor- rhage from any vessel that may have boon over- looked. After all this has been done bring the cut edges together after the manner already point- ed out, and dress the stump according to the cir- cumstances of the case, upon the plans already discussed. Directions for Double Flap Operation. — Ad- minister Chloroform ; arrange the patient upon the table; compress the main artery as directed in the last operation ; and, then, having transfixed the limb, by passing the knife in front of the bone, and as near to it as p issible, cut a flap, of about five inches in length, from the anterior portion of 148 AMPUTATIONS OF THE THIGH. the thigh. This being accomplished, insert the knife in the upper portion of the wound depress it and transfix the limb, by passing the instrument behind the bone, and, then cut a flap from the muscles which cover the posterior portion of the thigh, a little longer than the anterior flap. Turn these flaps back ; and, having cut through all in- tervening tissue, divide the Periosteum, use the retractor, and then saw through the bone. Ligate the Arteries, bring the flaps together, and dress the wound. The patient should then be removed to bed, and the stump supported on a pillow, — if he has been brought to the Hospital. Should the operation be peformed at afield infirmary, see that he has re- covered thoroughly from the shock of the opera- tion, and the effects of the chloroform, and then, move him to some comfortable position, supporting the stump with a knapsack, or whatever may be convenient. As before remarked, flaps may be made from the inner and outer side of the limb, by transfixing it from above downwards; but this operation is ob- jectionable for the reason that the bone tilts into the upper angle if the wound remains uncovered. Remarks. — There are some general rules which should be remembered in this connexion. 1. Stand on the outer side for the left leg, and on the inner for the right — always be prepared to grasp the limb with the left hand, above the amputating point. 2. Arrest hemorrhage from large veins by elevat- ing the stump, and compressing with the finger ; AMPUTATIONS OF THE THIGH. 149 but should this fail, they must be ligated. Ooziug From the I on ma.3 be invested by holding a com- press firmly against it for some time. istinate oozing from small vessels. 4. Divide the bone evenly, and use the bone nip- 10 render its surface smooth and less- irnta- I ul not to include nerves in the liga- arteries. 6. Do noi pull al the ligatures until about the 12th flav, le,< Lary hemorrhage ensue. 7. Tbe l - ' should remember, as a cardinal prinei] wer an operation is performed upon the thigh, the g\ re the chances for the patient's recovery, and via versa. He should, in fact, lot only :y rg inch, but, every line, sav- ed, a tg ;no rial advantage, — an advantage' wh.ch cannot be denied to the object of ", jeopardizing, to a still of the patient. onstrates the advantage ns of the thigh; and the ab- ianees, proper means of • ■.. upon the battie Held, should inducement to postpone the 'ank or claims of the suffer- iidiciouslyj and operate speedily, ifyou wish ife of llio patient. Delay is deatl ii may be, but often inevitable. 150 AMPUTATIONS 0¥ TUE THIGH. STATISTICS. Reported from University College, Operations 19 mortality 58 pr. ct. " by Malgaigue, " . 40 " 75 '• " ' r Soath, " 24 " 100 '• " " Buel, " 34 " 59.16" " " Norris, " 4 " 00 " " " Maeleod, " 161 " 64 " " " Mounicr, " 46 " 82.6 " " " Sorrel 1, " 172 " 59.8 " " " Sedillott, " '" 87.5 " '.' " Esmarch, " " 60 " " l i Baundens, l \ " 51 " " " Alcock. " " CO " Maeleod after giving a very large number of cases calculates that the average mortality of Primary Amputations for gunshot wounds alone, is 65.5 per cent; and for secondary operations the mortality is 79.0 per cent. In civil Hospitals, the mortality, according to the tables furnished by that author, is for Primary Amputations 69.6, and for secondary 75.4. The per centage of mortality for secondary Amputations after the first battle of Manassas, — and but few Primary operations were performed — greatly exceeded this ; while the rela- tive success of the two varieties of Amputation as indicated by operations performed in connexion with the Richmond Battles is much more decidedly in favor of the Primary than is established by the records of other fields. From the statistics on file in the Surgeon Gen- eral's office, it appears that there were performed in and around Richmond, from June lstto August 1st, 1862, 70 Primary Amputations upon the thigh, of which 16 were circular and 10 flap, and 44 not stated, with a mortality of 36.9 per cent, — or 56.2 for the circular operations, 30 for the flap, and 31.8 for those not stated ; 61 intermediate amputations, of which 9 were circular, 6 flap, and 46 not stated, AMPUTATIONS OF THE THIGH. 151 with a mortality of 80 per cent, — or 66.6 for the circular, 83.3 for the flap, and 82.4 for those not stated; and 41 secondary amputations, of which 7 were circular, 2 Hap, and 32 not stated, with a mortality of 88 per cent, — or 42.2 for the circular, 50 for the flap, and 74.8 for those not stated. — These results not only clearly establish the impor- tance of early amputations, but plainly show that, as regards skill in the performance of operations, and success in subsequent treatment, the Surgeons in the Confederacy can compare most favorably with those of other countries — a fact which will become all the more patent when the statistics o* the war have been more thoroughly collected. — By referring to the appendix, table " 0," all the facts in this regard, so industriously collected and conveniently arranged by Surgeon Sorrell, maybe more accurately understood. In the Crimea, the mortality attending amputa- tions made in the various "thirds" of the thiirh was materially different. Thus, for the loirrr Hard. it was fifty six per cent; for the middle^ sixty per- cent ; and for the ighty six per cent. The facts which may be gathered from all of these figures, &c, are substantially as follows: 1. Amputation of the thigh is always a serious thing. 2. Primary Amputations, particularly in military Surgery, are more fortunate in their results, by far, than secondary. 3. That the dan a unfavorable result in- creases for every inch as the point of Amputation, approaches the. trunk, being greater for the middle 152 AMPUTATIONS OF THE THIGH. third, than for the lower third, and greater still for the upper third. Taking all things into the account however, the rule in military Snrgery is to operate at once, if the patient be in the Field, for such lesions as were indicated in chapter second, as justifying Amputation, since it is impossible to secure that tranquility of mind and body which is essential to the salvation of the limb. In Hospital practice, it is well to folio v the advice of Baudens, and to make an effort to save the limb, if the wound be in the upper third, — where to amputate is death in a large majority of cases. Amputation on the Jlip Joint. — Directions for operating after the manner of Liston. — Admin- ister chloroform ; bring the patient's buttocks to the edge of the table ; compress the antery on the ramus . of the pabes ; and, having inserted the long catline, at a point mid-way between the trochanter major, and the anterior superior spinous process of the iliUm, and transfcred the limb, cut downwards and then forwards so as to form the anterior flap. Then turning the the flap back disarticulate, by severing the capsular ligament and Ugamentiim-teres, and pass- ing the knife behind the joint, make the posterior flap by cutting downwards and backwards. This is the operation for the left joint. In amputating at the right joint, the knife must be entered on the in- ner side of the limb, just opposite the scrotum, and brought out at a point midway between the tro- chanter and the sup : spin : process of the ilium, while the flaps are made jnst as above described. Direct one of the assistants to follow the knife with AMPUTATIONS OF HIP JOINT. 158 his right hand, as the anterior flap is cut, so as to seize the femoral artery when divided. Li gate the the posterior arteries firsts and then take up the fem- oral, with such of its branches as bleed too freely> and bring the flaps together in the usu< I way. The operation is also performed by making two lateral flaps, one on (lie vrmer side, of the adductor nmscles, and the other on the outer side, by putting the knife over the trochanter and cutting down- wards and outwards. The inner flap is usually made JirsL and the femoral artery tied in advr.nce — a procedure, however, which is unnecessary if the assistant be reliable. Some Surgeons prefer ibis operation, taking care to cut the inner flap last in order to avoid severing the artery until the outer flap has been made and the joint disartic- ulated. Remarks. — This amputation can be rapidly and readily performed, though the mortality from it is very great. — so much so in fact, as almost to exclude this operation from the legitimate procedures oi'Sur- gery. When the limb i> wounded high in the wgper thirds and an operation seems indispensable, ii is better to make the amputation tihroagh 'he trochan- ters of the femur than atthe joint, ka there i danger from hemorrhage, the flaps should not bo permanently closed for soi . — not until the ef- of the chloroform and the shock have entirely 1 oil", and reacti< l hai occurred. Remember also to tie the ischiatic and gluteal arteries, in the posterior flap before ligating the femoral and pro- funda, for if the main artery is properly held by the assistant, it will. I. Though a single case is 154 AMPUTATIONS OF HIP JOINT. on record, in which the wv. ad thus made, healed by ■'' first intention," union doc not take place even in the most favorable cases nnti vfter the most profuse and exhausting discharge ot j is. Various modifi- cations of the amputation at the u .o-joint have been suggested ; but the one described is incomparably the best, and it is unnecessary therefore to describe the rest. Reported by Stephen Srditn, Operations 35, Mortality 60 per ct. "'•' STATISTICS rtcd by Stephen Smith Operations 35, Mortality GO '• " Henry .Smith, f th< four fingers at Metacarpo articulation. — Direction-.- -Proi hand, and grasp the joint with your fir thumb; make a semilunar dap on the dorsal of tin- hand, from one side to the other; dividi space betweon the finger and thumb in length ; and then divide all the do] transversely, except that of the second mi bone, remembering not to enter the joint. All I ligaments being divided, as well as the intern:' external, depress the metacarpus, and In.- bones: finish cutting the fibrous bands which r< the joint, and also the palmar ligaments; and. I gliding the knife under the pale of bono, cut a suitable flap from it. In pi this operation, it is easj to remove the thumb, ij cessary, or to retain it with either th< tie finger n li icli e\ n alon< are of g] When the operation is terminated, it.on tie the trunks of the radial and ulna arteries, a bringthe Haps together wifh adhesive str roller band:. It is a matter of the first imp* I hat the geon Bhould have an accurate knowledge of th atomy of the parte in performing ation otherwise he will be compelled to aw in oi der to complete it. 'MUe terminal points of the line which corresponds with the direction of should be ascertained before c Lng the 7 J 58 AMPUTATIONS OF THE HAND. tion, — the direction? for which are as follows:— Run your finger along the metacarpal bone of the index linger until the point is reached at which it and the second metacarpal bone approach each other, and the former unites with the trapezoides, — this is the inner termination of the line above referred to. Again, trace the metacarpal bone of the little finger upwards until a cleft is reached betweenjthe os-mag- num and pisiform — a little in advance of the hitter — this is the outer terminal point sought for. The course of this line is convex with its inclination downwards and inwards. ' Amputation at the Radio Carpal Articulation. — The first thing to be done by the Surgeon is to distinguish the exact seat of the joint, which may- be determined in this wise : Draw a straight line from the point of one styloid process to the other, and the joint will be found in the direction of a eurve, the highest point of which passes about a quarter of an inch above the middle of the straight line. Directions for performing the double flap op- eration. — Grasp the wrist so as to compress the ulna and radial Arteries and semi-pronate the hand ; ma&e a semilunar incision posteriorly, commencing half an inch below one styloid process and termina- ting ;it the same distance below the other ; — the cen- tral portion of the curve being two inches lower; dissect up this flap and let it be drawn back by an assistant ; and, then divide the extensor and radial tendons, the capsular ligament, the lateral liga- ments, and the tendon of the carpal extensor. Af- ter this is done luxate the wrist, pass the knife be- hind it and cut a dap from the anterior surface, one AMPUTATIONS OF THE KTLM. inch and a half long. fifosi Surgeons raise the had. die of the knife in the last step i avoid includ- ing the pisiform bone in the flap, but this is unne- cessary, as no inconvenience results from its being left with the skin, while the attachment of the Flex or Carpi Radialis is, in tact, preserved there- by. The radial ai d ulna arteries are now to be tied, if not too much retracted; the integuments closed by adhesive straps and a roller bandage lightly applied from the elbow downwards. The Circular Methodumy be also employed, but the above process is preferable. vputajt/in arm. — Surgically, the fore arm is divisible into three portions, viz : the in- ■/•, which is flattened and well suited to the flap operation ; the middle, which is conical and favora- ble for the flap operation, — as it is difficult to turn the cuff of skin hack ward ; and the upper third, wjiich is round and muscular and suggestiv cither the flap, circular or oral pro Circular method. Directions. — Place the patient in a chair or upon a bed — the latter if chloroform is administered : — compress the brachial artery againsl the humerus by means of a tourniquet or the fingers of an assistant ; and, then partly flex the fore arm and placeit in a position midway between pronation and supination. The Surgeon must then place him- self so a> to grasp the arm above the point of am- putation with Ins left hand, and proceed to operate according to the directions given for amputating the leg by the circular or the OVal method. Apply the upon the face of Jbotb bones, engage the ulna first but complex i more firm- 160 AMPUTATIONS OF THE ARM. ly connected with the humerus; The ulria and rad- ial arteries must then he tied, and sometimes the interosseous, and the wound closed with adhesive straps. Double Flap operation. — Directions. — Place the arm in an intermediate position between pronation and supination ;" transfix the limb, by passing the knife either from the ulna or the radial side, in front of the bone ; and then cut an anterior Hap mure than two inches in length, from the muscles on that side of the arm. Carry the knife to the opposite side, and transfix, — passing the instrument in at one an- gle of the previous wound and bringing it out at the other ; — and cut downwards and backwards so as to form the posterior flap. Have the flaps raised by ab assistant ; cut the interosseous ligament and remain- ing muscular fibres ; use the three tailed retractor ; and saw through the bones in the manner described above. Dress as before. The Single Flap operation may also be performed at any portion of the arm. Amputation at the ETbov) Joint. — The exact posi- tion of the joint may be ascertained by the following method: Find the internal condyle of the humerus, — this is three-quarters af an inch above the articulation of the humerus with the ulna; then, seek out the external condyle — this is about half an inch above the articulation of the humerus with the radius. — These tuberosities being on the same plane, it follows that the articular line is directed from within ob- liquely outwards and upwards, and that it connects two points, <>ne of winch is three-fourths of an inch "below the internaUuberosity of the humerus, and the AMPUTATIONS OF THE ARM. 161 other half an inch below the outer tuberosity. The flap, circular, and oval operations may all bo per- formed. Tlif Flap operation as proposed by Dupuytren is undoubtably the best, even though several Ligatures have i" be used, and aome of the first Surgeons pre- fer the circular method. Directions. — Supinate and partially flex the arm: ascertain the position of the inner tuberosity of the humerus ; and, having grasped the soft parts imme- diately below, pass a catline through the muscular tissue in front of the bones, entering it about one inch below the epitrochlea, and bringing it out about one-half an inch below the epicondyle : and carry the knife downwards and cut a flap at least four inches long, from the muscular tissue on the an- terior face of the fore arm. Nexl return to the base of the flap, and divide all the intermediate tissues by a semicircular sweep of the knife, down to the joint itself, which is entered between the ulna and radius. Then divide all the ligaments; dislocate the joint; and either cut oft' the olecranon process with a saw. Or pass the knife he hind it and remove it with the rest of the hone. Ampliation of tlu i>j>j"/ Arm. — The circular, oval, double flap, or single Hap operation may be made, though the circular and double flap are most popular. Directions for the Circular Operation.-— Raise the arm almosl at a righl angle; divide the skin by a circular incision ; retract forcibly and divide the su* periiciai fibres of- the muscles: retract again forcibly and divide the deeper fibre- down to the bone: de- 162 AMPUTATIONS AT SHOULDER JOINT. nude the bone for a short distance upwards ; and, then, having retracted the soft parts sufficiently, saw through the bone. Or, again the integuments may be dissected up, and turned back in the form of a cuff, and the muscular fibres divided, at one sweep down to the bone as was previously described in con- nexion with the general considerations of the circu- lar mode of amputation. Tie the brachial artery, which is found at the in- ner margin of the biceps, and such of its branches as may bleed too freely ; then bring the wound to- gether with adhesive straps, and unite the integu- ments in an oblique direction. The double flap operation : Directions, — Arrange all the preliminaries as for the previous operation ; seize the limb with the left hand ; transfix it anteri- orly ; and cut a flap at least three inches in length. Carry the knife behind, and pass it through the arm at the upper angles of the previous wound ; and cut a flap slightly longer than the -first ; pull the flaps back; divide all the tissues to the bone; retract and saw through the humerus. Tie the brachial artery and its branches, and bring the flaps together with adhe- sive straps and suture-. Amputation at the Shu aide i- Joint. — There are sev- eral different procedures recommended in this con- nexion, among which that of Larrey is incompara- bly the best, though the method of Lisfranc has many admirers. Both of these methods will be described in detail, and the Surgeon left to select that one which he deems most likely to meet the presenting indications. Directions- for performing Larrey V Operation. — IMPUTATION AT SH01 LDER JOINT. 163 Compress the subclavian artery in its outer portion, just above the clavicle, by means of a key ; and then make an incision from the border of the acro- mion, to one inch below the level of the neck of the humerus — dividing the integuments and separating the deltoid into two equal parts, This being done, make two oblique cnts, from thefirst incision on either side, and terminating, the one at the anterior border <>f the axilla, and the other, at its posterior border, and both prolonged in sueh a manner as to divide the tendons of the pectoralis major, and the latissimus dorsi near ^heir insertions ; divide the tissue which retains \\w. ecuted with great celerity and neatness. Directions for performing Lisfranc's operation, — slightly modified.— Compress the artery and place the patient according to previous direction ; laj hold of the arm a little above the elbow and move it from the side and slightly backwards so as to give .•> view of the skin in the Axilla; then push a long sharp pointed_and narrow knife, through the skin in 164 AMPUTATIONS AT SBOtJLDEK JOINT. .the arm pit, ;mimediatei) in front of the ■ tendons of latissinlus, dorsi and teres major muscles, and ing it out a little in front of the extremity of the nomion process — taking care to move the elbow outwards, upwards and backwards^ as the thrust is : and with the ami in this attitude, carry the [tli a sawing motion, downwards, backwards ■■■ '\ outwards, so as to form a flap at least fourinch- n .. of the posterior portion of the deltoid, of tendons of the lattissimus, and teres, and of the ■ in. Raise the iiap ; divide the heads of the mus- irrounding the joint : carry thefelbow in front the chest and cut through the capsular ligament ; disarticulate; and then, with the knife passed in >nt of the bone, form another flap by dividing the muscles and integuments. The axillary artery is sd, and, to prevent hemorrhage, an assis- 1 ould grasp the soft parts of the axilla at this he >eration. soon as the limb is detached, ligate the main :ther with the circumflex, subscapular, and 3 as may bleed freely : then bring in apposition and confine them with the pplia tees, taking care to have the line of union • ratio]] just described, is for the left limb, is necessary to modify it for thet'ight bymak- 3 first flap from above, downwards and back- . Eiud, then, continuing, as' directed above. '•'. — in operations upon the band, it is im" ve as many finger as possible, and thumb. If the head of the metacar- hv-nt' be not removed, when a linger is amputa" ■ crsTids. 167 apparent in connexion with this operation. Tim.. Guthrie reports L9 cases of secondary amputations at the shoulder with a mortality of L9, and 10 ca es of primary amputations with only 1 death. Dr. Thompson, in giving his experience after the Battle of Waterloo, states that almost all of those recovered who had undergone primary amputation attheshoul- der joint, while fully one half died of those on whom it became necessary to operate at a later period. Le- gist, Gualla, Smith, Esmarch and Macleod all agree, thai whereas, the mortality attendant upon primary amputations at the shoulder joint was not more than 38 per rent, the mortality following se condary amputation whs at least 75 per rent. This operation admits ot no delay, and if performed at all must be done quickly in order to give the patienl a chance for his life. The experience of modern Surgery has demonstra- ted the fad that resections at the shoulder joint arc nol only safer than amputations, but may take the place of them in a large majority of cases, — thus preventing greal deformity, and securing a compar- atively useful member. This subject will be more, freely considered under another bead, and for the present, it is sufficient to say. that such operation, have been attended with wonderful success, accord- ing to the testimony of Percy, Baudens, Legoust, Esmarch, and Macleod, even when Beveral inches of the shaft of the humerus had been destroyed. Amputations at the shoulder joint have been fre quently performed by Confederate Surgeons during the present war, and with decided success, though sufficient statistical information has not vet been X'63 i tfCs. rmine the relative per ccritage of ality which has aft end eel the operations in their hands. The Shock attending amputation at this articula- tion is great, and should always be provided against by a liberal allowance of brandy or whiskey, before during the administration of the chloroform. It is earnestly to be hoped- that the Surgeons of our army wil not content themselves simply with the .; performance of amputations, bat that they p accurate records of their cases, noting er is of importance connected with them, es. • the relative per centage of mortality for i( rent operations, and contributing, of their • d varied experience, something at leasl I" e advancement and perfection of the science ■ - urge 1 rof operations performed in Rich; mdnd he battles of the "Seven Pines" and the " Se " the reader is referred to Table " F " idix to this volume. REMARKS. 165 i*po-phalangeal joint, there w ill al. be deformity, whereas, ifthu precaution is ob- served, the symmetry and usefulness of the hand can, in a great measure, be preserved. Sorrel] re- ports two successful disarticulations of the wrist joint. In amputating the lore-arm everj efforl should be made to preserve as much of the member as possible with a view to its future usefulness. Great care Bhould be taken to have the bones of equal length and exactly parallel, for otherwise they will protrude through the flaps, producing ulceration, or, it may conical stuinp. From the 1st of April to the end of the Crimean war. Macleod reports 54 opera" tions, with, only thm death.-: Dr. Lente reports 39 operations with four deaths, Dr. Haywood reports 6 with one death, and Sorrell records 45, with only (5 deaths, and 39 recoveries -all going to show that the rate of mortality attending it is very low. For far- ther particulars, consult Table " D" of the Appen- dix. All other things being equal, it would be better lo amputate just below the -'il, M \v joint rather than through it ; but, the danger to the pal tent, from sub- sequent inflammation which is likely to involve the articulation, should always be, taken into the account by the Surgeon. Amputation at the elbow-joint was firsl performed by Ambrose Pare but subse- quently sank into disrepute. It has since been re- vived by Dupuytren and Velpeau, and may be per- formed with propriety when the operator desires to avoid the danger from inflammation referred to above, or to preserve a more useful member than an U 166 STATISTICS. Operation above that point would allow. The opera- tor should never forget that the articulation proper is below the tuberosities of the humerus, and that he may be readily misled by appearaces into tranfixing too high and thus making the flaps too short to cover the head of the bone. Amputation of the upper arm can be very readily performed and is attended with great success- STATISTICS. Reported bj Macleod, Operations 102, Mortality 2-1.5 per rent. " " Norris, 32, " 6.3 " " " Lente, " 58, " 40 " •' Sorrell, " L92, " •' " ll Haywood, " -l, " 00 " The reader is referred to fable "E ,? of the appen- dix. To Barron Larrey belongs the credit of having ele- vated ampution at the shoulder joint to its proper rank in the art of Surgery; and the subsequent ex- perience particularly of military Surgeons has de- monstrated the correctness of his views in regard to it. STATISTICS. Reported Uv Macleod, ii". of operation no. of deaths 1-';. " " Buel, " 39, " 18. " " Lunte, " in, " 11. " " Gross, " 25, " 12. A s thisjoperation is general !y performed in connexion with some wound of the body of greater or less mag- nitude, whereby its result is materially controlled, statistical tables cannot afford a just estimate of its intrinsic value. This fact should be borne in mind by the military Surgeon particularly, as the question of the propriety and results of this operation must constantly present itself in field servii The value of primary amputation is particularly TREPHINING • 171 same plane with the external, a smaller instrumeir! should be introduced to cut through it, in order to avoid tearing the dura-mater at one point before another. 7. Should the sinuses be opened, hemorrhage ran be arrested by plugging. 8. 8hould the middh meningeal artery be divid. ed, the hemowhage i^ ; serious, and difficult to con- trol. Compress it with a bit o\' lint, placed inside the cranium, and retained by a thread, or with a plate of lead brut so as to embrace both surfaces of the bone; or by plugging it with sealing wax. Larrey touched the bleeding orifice with a steel probe heated to whiteness: while Dorseyand others recommended the application of a liga- ture. Operation <>n /Ac bones of the GVam'wm. — This may be divided into live different parts, viz : denuda- tion of the bone; perforation of the bone; rembr- al of the detached piece of bone: removal of the cause of compression ; dressing and after treat- ment. Denudation of the bone. — Directions. — The point of the cranium upon which the operation is to be performed, having been shaved of its hair, and the patient placed in proper position, divide l he s<.ft parts by means of n crucial or semilunar incision ; dissect up the Haps, revert them, and have them held oul of the way by an assistant. and control the hemorrhage from the severed sels, either by applications of cold water, twist them, or ligatur The first incision should reach to the bone, a 172 TREPHINING. the flaps, wrapped in fine linen to prevent injury to them. Perforation of the bone. This is to be accomplished either with the Hand Trephine, or the Trepan instrument of Hildanus, which may be made to revolve by a brace, or like a drill by means ot a bow. The former is preferable, as the Surgeon can control it better. t Directions. — In- troduce the pyramid or central bit beyond the level oi' the crown of the instrument, firmly secure it by means of the screw attached to the side for that purpose, and enter the trephine into the bone with a semicircular motion of the hand, until the teeth of the saw have reached the external table and made for themselves ;t furrow in it. Xow re- tract the pyramid, lest it injure the dura-mater: continue the rotary motion, holding the instru- ment perpendicularly to the bone, withdrawing from time to time, to clean its teeth with the brush and to enable the Surgeon to sound the depth of the groove ; — and penetrate both the diploe and the internal table. When the instrument has pene- trated at several points, introduce an elevator into {Dr. G. A. D. Gait of tlie Confederate Army has devised a new Trephine, with the object ol avoiding injury to the membranes and Bubstance of the brain. The instrument consists of a truncate* with peripheral teeth arranged in a spiral direction. crown teeth. When applied tin- peripheral teeth acl as a cutting wedge so long us the counteracting pressure acts on the crown On the removal of the pressure by the division of tin. Cranial its tendency is to act on thr principle ol a screw, but. owing to its conical form and the direction of its peripheral teeth, theacti^n and the instrument penetrates no farther. Dr. Gait says that he has operated on the dead subject twenty times, and has never succeeded in wounding the membrane, although he has endeavored tp do bo. Subsequent practical experience has demonstrated the great utility of the instrument. I fi A PTER TV. EXCISION OF BONES A.ND JOINTS. The instruments required in this connexion are the Saw—Hey's, Chain aud Circular ;— cutting for- ceps; perforator; mallet; chisel; gouge: rasp: clovator: scalpel, &< , By the circular saw is meant the trephine, an instrument potent for good or evil, according to tin- necessities of the oast- and the skill and judg- ment ofthe Surgeon. Trepliining. — The circumstances under which this operation has been recommended, are the lol- owing : fracture o\' the skull with depression of yhe bone: fracture of tin hone with penetrating wound ofthe dura matter; epilepsy, depending upon depression, or upon the existence of some point of irritation of the skull : and the presence of foreign bodies in the cerebral substance, includ- ing effused blood and pus. Locality of the operation. -Avoid the sutures; those parts *'i' the skull immediately over impor- tant arteries and vein.-: those regions of the skull where the two tables are situated at some distance from each other; the thicker portions of the bone; and th<' part immediately under the temporal mus- cle. The occipital protuberance, meningeal artery, ami the sinuses are particularly to be avoided. Mode of Applying the [ostrument. -In simple fracture apply the instrument with the pyramid 1 70 TREPHINING. resting near one margin of the fissure so the sec- tion may extend on botli sides. In fractures with depression, see that the crown of the instrument does not rest upon the loosened hone, for tear of causing laceration or irritation of the soft parts heneath. When a foreign body is wedged in a wound and the fracture is but limited, the crown of the tre- phine should embrace the whole .solution of con- tinuity. In the ease of extravasated fluids, operate imme- diately over the seat of effusion, which is frequent- ly on the opposite side fronvthe wound. Position of the Patient. — Make the patient as- sume a recumbent position, with his head resting upon a well cushioned hoard, and firmly held by an assistant. . General Hides. — 1. Do not operate simply for the injuiy, but tor the consequences produced by it. 2. Do not be hasty in resorting to the operation, but wait for nature and time to do their work. 3 If the operation be not performed before the development of inflammatory reaction, wait for its subsidence. 4. Bear in mind that in the young the skull is more yielding than in the old, and more readily depressed without fracture. 5. In caries and necrosis it is deemed mostpru> dent to permit the diseased portions to separate themselves until they can he seized with the forceps and extracted. 6. When it becomes necessary to trepan the frontal sinus, the internal table not being on the TREPHINING. 159 the groove, and seperate the circular piece from the internal table. The division of the diploe can be readily recog- nized 1 > \ the ease with which the instrument pen- etrates its substance and the bloody detritus which escapes. This structure is deficient in children and old persons, — a fact which should be remem- bered in operating upon them. When the trephine has to be applied so as to cover a small fractured portion oi' the skull, or Borne foreign body lodged in the bone, the perfo- rator can be used to start the crown; and a piece of wood, cork or sole leather with a bole in it of the proper size, and firmly held by an assistant, will serve to retain the instrument in position un- til the teeth have made a sufficient groove in the bone. Where fractures exists with depression, and the margin of one bone overlapsihe other ; where there is depression without fracture. and where an enlarge- ment of the angular tissue has to be effected, an opening may be made with 1 ley's saw. A piece of leather with aerevicecui into it. must he placed on the skull, within which the straight end of the saw plays until if sufficiently introduces itself. Removal of the detached piece of bone.— Fas- ten the bone screw into the orifice made by the central pin. and by a few lateral motions detach the piece. It is hitter to introduce the elevators on the opposite side* of the piece so as to sepa- rate and lift it out. Sometimes it is brought out with the trephine itself. If prominent points of 174 TREPHINING. bone remain, they should be carefully removed with a lenticular knife or Ilcys' saw. To remove the cause of Compression — If it be desirable to raise a portion of the bone, — as for fracture with depression — , introduce the Common Elevator between the cranium and dura mater ? without dividing the membrane, and gradually elevate the depressed portion by using the opposite margin of the bone, or the finger as a fulcrum- Loose portions of the bone arc to be picked away with the forceps and if the operation has been undertaken for the removal of a, ball or any foreign substance, it may be seized with the forceps and drawn out, unless too much effort be required to bring it away. If the operation be earty done for extravasition or effusion, the fluid, if on the outer side of the dura-mater, will come away of itself. Should it prove to be blood however, it must be broken up with the finger and then removed. If the fluid be below the dura-mater, this membrane will be found detached from the bone, and of a brownish hue with a bulging at some particular point and a feel- ing of fluctuation below. To remove this fluid the dura-mater should be punctured, by pushing a straight sharp pointed bistoury through it. Dupuytren plunged his knife deep into the ceretral substance itself, and opened an abscess more than an inch from the surface. His example has been followed by other eminent Surgeons, but it is too bold and dangerous a measure for universal imitation. TREPHINING. 175 The Dressing and after Treatment. — Ap] »1 v eold water dressings, instead of the cerate &c, re- commended by older Surgeons. Do not disturb the wound until suppuration ensues, when it may be washed and carefully dressed twice daily. Remarks. — As late as the eighteenth century Trephining was practised in almost every variety of wounds of the head, both as a curative and a preventive measure — or a means of protection be- fore dangerous symptoms were developed. The Trephine was used on all occasions and for every possible injury, realizing-, even as far as the most eminent Surgeons were concerned, the lines to Sidrophel, — "He used trephining of (he skull. As often as the moon was full. 1 " This shameful misapplication has been most energetically and successfully opposed by Dcsault, Abernethy, Langenbeck, Thy sick, Cooper and others until more rational, as well as safer views? are entertained in regard to the operation by the whole Profession. The reaction against the use of the instrument upon the cranial bones has gone so far that sonic have rejected it alto-ether as dangerous and unm under all circum- stances; but Sir A. Cooper, and Sir 15. Hrodie have very clearly demonstrated the impropriety of this conclusion so far at leas! a- some <■; see of com- pound fractures with depression arc concerned. In military Surgery, the trephine is far less used than formerly, -and flic experience of Stromyer Maeleod, iicuitt. Guthrie, Cole and Chisolm 176 TKEPHINING. clearly demonstrates not only its inutility in the treatment of cranial wounds generally, but the posi- tive detriment resulting from its employment even in many cases of fracture with depression and compound fracture, for which it has heretofore been primarily recommended. Stromyer, who was Surgeon in chief in the Schliswig — Holstein Army, and " one of the highest authorities in Gun-shot wounds of the head," positively and peremptorily affirms, " that in military Surgery, trephining is never needed." This opinion is endorsed by Loeffler? and in a great measure sustained by Chisolm, and other more modern military Surgeons. It is now well known that a depression of the ovier table does not necessarily indicate a corres- ponding depression of the inner tablet, ana that both tablets may be so depressed as materially lo compress the brain without interfering with the functions of that organ, or developing an unfavor- able symptom. Trephining is also known to be a serious operation — to be nothing ''more or less than boring a hole in a man's skull" — and as calculated? even under favorable circumstances, to produce irritation and inflammation of the delicate mem- brane it exposes, and of the sensitive cerebral sub- stance beneath. These facts, taken in con- nexion with the recorded experience of the great authorities previously referred to, should teach the military Surgeon, the vast importance of deliberat- ing well before resorting to this operation, and of only employing it when all other means have tail- ed to produce those results upon which the salva- tion of his patient's life depends. lie should avoid TREPHINING. 177 all haste in its employment, waiting for nature. assisted by oilier more rational and less violent remedies, to relieve the symptoms of cerebral compression, and to restore the patient to his nor- mal condition, [f, however, his expectations in this regard are disappointed, — if sensibility and motion fail to return, while coma and stertor in- crease, in despite of the most energetic antiphlo- measures, showing such an augmentation of congestion in the cerebral substance as immediately jeopardizes the patient's life, then, the Surgeon may resort to the trephine as a " forlorn hope" wheth- er the fracture be simple, compound, or com- minuted, or whatever the nature and limits of the injury. 11*' should neither endanger his pa- tient's life by resorting too hurriedly or indis- creetly to the Instrument, nor permit him to die for the want of it through an unbecoming timidity, or a slavish subserviency to fashion and authority. The trephine may also be applied successfully to any one of the long bones, when attacked with caries or necrosis, and for the purpose of removing foreign bodies impacted in them, such as balls, pieces of metal, &c. The operation is nearly the same in these cases us that just described, only differing according to the depth, density and form of the the bone. The experiments and observations of modern military Surgeons are decidedly favorable ton tion, particularly in those eases uherethe choice is between the removal of a joint and amputation above it. Primary resections have been found, equally as important as primary amputations. 178 RESECTIONS. Resections in General. — Resections are under- taken 1. For the removal of the articulations alone. 2. For the removal of the shafts of bones. 2. For the exterpation of certain bones entire. The circumstances which justify resection are : 1. Caries of the articular extremeties when oth- er means have failed. 2. Osteo-sarcoma, spiua-ventosa, and malignant affections generally. 3. Compound and comminuted fractures, such particularly as are caused by conical balls, imping, ing either upon the shaft or articular surfaces of bones. Also the protrusion of fragments through the skin, when they cannot be replaced, or are de- nuded of their periosteum. 4. Compound luxations, when insurmountable obstacles present themselves to reduction. 5. Necrosis of bone, when elimination is tardy. 6. Projection of the end of a bone beyond the stump in badly performed operations. 7. Exostosis, or when some foreign body has lodged in the bone and cannot be removed. Resection should never be attempted unless the patient has manifestly strength enough to bear a difficult operation and a tardy convalescence, and it is therefore, eontraindicafed when there are symptoms present of any one of the cachexias; of unusual nervous susceptibility, or of marasmus. It is also frequently exceedingly difficult, in chronic affectious of the joints to distinguish between vessels, nerves, &c. ; and. hence there is danger of tetanus, protracted suppuration, purulent absorp- tion, and erysipelas. resb noNS. 179 Rules for Resections in general. — Distinguish well the anatomical relations of the parts before commencing the operation. Know where nerves, and vessels are to he found, for it is exceedingly difficult to distinguish them during the resection. 2. In addition to the ordinary instruments, have on hand, a cutting forceps, a gouge, a mallet? and saws of different sizes and shapes. 3. Open a free way to the hone, but expose as little as possible of the muscles and tendons. 4. The nerves, the veins and the arterial trunks are never to be divided ; while the tendons, as a gen- eral thing, must he preserved. 5. Before employing the saw, ascertain to what extentthe bone ffi diseased, and see that the soft parts are well out of the way of injury. 6. Remove completely every part touched by the disease orieached by the injury. 7. Cut oil the bones connected with the articula- tions at the same distance from the joint. 8. Preserve as much of the periosteum and take away as huge a portion of synovial membrane aa practicable. !'. When a lower limb has been operated upon bring the bones together, and extend it; but when an upper, put it in a state of semiflexion, and leave the bones a little apart so as to secure, if possible an artificial joint. 1<>. Make the i on the side opposite to the main arteri< 1 1. Make the existing wound lie, if possible, in the line of one of the incisions, w hi eh should be SO arrange. I a to permit the free drainage of pus. 180 PARTICULAR RE3BCriOJT3. . Particular Resections. — Resection of the bones of the upper limb. Resection of the Metacarpo-phalangeal articula- iion. — Either the head ot the metacarpal bone or the end of the phalanx may be removed. Di- rections; commence hall' an inch from the point at which the saw is to be applied, and make a Hap with its base towards the linger; dissect up this flap; turn aside the extensor tendon and separate the muscles from the bono; open the joint care- fully, so as not to divide the flexor tendons; dis- articulate and isolate the diseased portion; and then 'slip a small peice of wood or a spatula under the bone, and saw it oft*. Extraction of the First Metacarpal Bone. — Direc- tions. — Make an incision along its radial border, extending half an inch beyond each articulation ; cautiously detach the skin and tendon from its dorsal surface and the muscles from its palmar face; have the edges held well apart and cany the knife through the upper articulation ; then luxate the bone outwards and pass the knife completely along its inner surface ; and finally carry the knife through its lower articulation. The radial artery may be avoided, but if cut it can be readily lega- ted. Close the wound, and keep the parts in their normal position. The other bones of the metacarpus may be re- moved by following the same general plan. Resection of the Wrist Joint. — Directions. — Make two longitudinal incisions, terminating on a level with the articulation, one along the outer side of the radius, and the other along the inneraide of KESECTIONS OF WRIST JOINT 181 the ulna, near their anterior edges ; unite them by a transverse incision across the back of the wrist; dissect up this quadrilateral flap, avoiding the tendons which glide in the grooves of the bone ; draw the tendons aside, as much as possible, and detach the soft parts ; and then pass a spatula un- der the bones and saw both ulna and radius at once. Bring the parts together and treat on gen- eral principles. The tendons which control the motins of the joint may be divided in an emergen- cy and the knife passed more directly into the joint, as it is not expected to preserve the move, ments of the articulation after the operation. Remarks. — In consequence of the close connex- ion of this articulation with the flexor and extensor tendons, consolidation of these and their sheaths is likely to occur, together with the consequent loss of motion in the hand. Many- cases, however, will be found in which, even with a stiff wrist, there may be some motion of the fingers; and with all the disadvantages attending this operation, it is far better to have a hand. Whatever may be its condition, as regards mobility, than no hand at alb The lower extremities of the radius and ulna maybe excised; while the -carpus remains intact if these bo, ies alone are involved in the the dis- ease or injury, by simply following the first steps of the operation, as above pointed out. irpation of the Radius. — Directions. — Semi- flex the arm ; make a longitudinal incision on the external anterior border of the radius, so as to lay it bare; dissect back the integuments; push the soft parts aside ; pass a director or scalpel umler 8 182 RESECTIONS OF ULNA. the bone and saw through it ; clear the fragments from the soft parts; and then separate them from their articulations, avoiding the nerves and arteries. Resection of the Body of the Ulna. — Directions. — Make a transverse incision down to the bone, four inches and a half below the olecranon, and extending a little more than half the diameter of the arm; make another longitudinal incision, inter- secting the lower part of the former, and along the most superficial portion of the bone down to the wrist joint ; commence at the first incision and dissect the soft parts around the bone for three inches; insert a spatula and saw through the bone transversely; continue the dissection to. the wrist joint ; and then disarticulate and remove the bone. Avoid wounding the ulna nerve, and tie the ulna and interosseous- arteries if divided. Theinferior extremity of the ulna maybe resec- ted by making a longitudinal incision along the border of the ulna ; then making another longitu- dinal incision, aross the back of the joint; dissect- ing up the flap and turning it back ; drawing- aside the tendons; and disarticulating. Remarks — Several cases are recorded of success- ful removal of the ulna and radius, and the results attending the operation are sueh as to warrant the Surgeon in resorting to it under some circum- stances. It may be more advantageously attempt ted for disease than for injury, as the soft parts are less likely to be involved in the. first instance than in the last. Resection of the radius is more likely to interfere with the mobility and symmetry RESECTIONS OF ELBOW-JOINT. 183 of the arm, than the removal of the ulna, for ob- vious reasons. Ki section of the elbow joint. — Surgeons are much divided as to the best operation for the ex- cision of this joint, some advocating the H, and others the H shaped incision; while still another class prefer Bucks modification of the latter, which consists of two longitudinal incisions, the horizon- tal cut being omitted and the sides directed so as. to expose the bone without dividing the attach- ment of the tendon of the triceps. Ordinarily the following plan will be found the most available. • lions: Place the Patient on his face, near a well lighted window, upon a table four feet high, so that his arm is supported and presents to the Surgeon the posterior and internal face of the arti- culation : then, make an II shaped incision, taking in the breadth of the articulation, exposing the heads of the bones, and dividing the skin and tendon of the triceps; dissect back these flaps carefully, taking care to remove the ulna nerve from its bed on the inner side of the arm, behind the epitrochlea; divide the posterior ligaments and expose the joint, separate the soft parts carefully, avoiding the nerves and arteries; pass the handle of a scalpel under the humerus ; saw off and detac as largo a portion of the humerus as may be ne- , ry; and finally, attack the bones of the fore, arm and such portions of these as may be . — remembering, that if either one of them is not implicated in the disease or injury, to leave it unmolested. Then close the lips of the wound by means of 184 RESECTIONS OF ELBOW-JOINT. sutures; leave the bones slightly separated; keep the limb upon pillows and rely exclusively on the cold water dressing. Remember, however, to prevent anchylosis by passive motion of the joint when the soft parts have cicatrized. It is a matter of great consequence not to remove more of the bones than is absolutely necessary. The shaft of the humerus should not be en- croached upon, if it is possible to avoid doing so, or the excision of the radius and ulna carried be- low the insertion of the brachialis anticus and triceps. The position of the parts, and the rela- tions of the bones to each other should be scrupu- lously attended to, bagging of matter prevented and exuberant granulations repressed. Remarks. — This is comparatively a modern pro- cedure, having been suggested by Park of England in 1781, and performed by Moreau in 1782. It is to Roux, Crampton and Syme, however, that the profession is indebted for the revival and vindica- tion of this operation — thus securing moveable joints and comparatively useful members to many who otherwise would have been deprived of their arms. As a proof of the utility of this operation, it is only necessary to refer to a few facts, which have been collected in regard to it. During the Schleswing-IIolstein campaign, Langenbeck and Stromyer, report that of fifty four amputations of the arm, nineteen died, whereas of forty resections? performed under identical circumstances, and with similar appliances for operating, dressing and trans- porting, only six died. Macleod records 20 opera- tions for excision of this joint, and seven deaths, — RESECTIONS OF ELBOW-JOINT. 185 four following secondary resections, and not being connected with the operation. To this might be added the testimony of hundreds in civil practice, both in America and Europe: whilst if the ex- perience of Confederate Surgeons were properly collected, the value of this operation would he rendered still more apparent to the medical world. The importance of Primary resections is particu- larly conspicuous. Thus, of eleven cases excised within twenty four hours before reaction had set in, but one died ; oitioenty cases between the second and fourth day, or during the stage of irritation and ex- citement, four died; and of nine cases operated upon between the eighth and thirty seventh day, only one died. The necessity for this operation is not so great when the joint has been opened by a sabre cut, as when a ball has passed through it, grinding up the bones, annihilating the ligaments, and complete- ly destroying the articulation. Sorrell reports six operations and four deaths. AVounds of this joint may be readily recognized by the following cir- cumstances : the facility with which the interior of the joint can be reached by the probe or fin- ger; the general direction of the wound ; prefer natural mobility or entire loss of motion ; and the escape of synovia — circumstances which should always be taken into the account because of the imperative necessity for promptness in the performance of the operation if the wound has really involved the articulation. "Resection of \ l$er Joint. — The. operations of White, Lisfranc, and Syme have all their ad" 186 RESECTIONS OF SHOULDER JOINT. vocates, but the following plan, is perhaps the Lest as a general rule. Directions. — Compress the Subclavian Artery above the clavicle ; make a V shaped Flap of the deltoid muscle about three inches long, beginning at the acromion process and terminating on the upper and outer portion of the arm; dissect this up and expose the capsular ligament of the joint; ligate the circumflex arteries which are divided in the first incision; carry the arm over the chest; divide the capsular ligament and turn the head of the humerus out of the glenoid cavity; remove the long head of the biceps from its groove; place a spatula behind the bone ; and then remove with the injured portion of the humerus. This being done, return the flap to its proper position; place the patient in bed ; support the arm upon soft pillows; and apply cold water dressings. The most tedious, and perhaps embarrassing por- tion of the operation, is the removal of the tendon of the biceps from its bed. Rather than prolong the sufferings and dangers of the patient unnecessarily, it is better to sever this tendon, and to conclude the operation, as experience demonstrates, that no seri- ous inconvenience results from such a course. The deltoid is usually paralyzed after this resection even when "White's operation is performed but the other muscles surrounding the joint form new re- lations, and a very useful limb is secured to the patient — though considerably shortened, and some- what deformed. It is best to place the limb upon a pillow or a long, broad splint, without applying bandages, and to keep the patient perfectly quiet RESECTION OF SHOULDER JOINT. 187 until the inflammatory stage lias past, and suppura- tion has been established, — when, with his arm carefully placed in a sling, he may bo permitted to walkabout. If suppuration be excessive, sustain his strength by the free use of stimulants and a liberal diet. Jl< marks. — This operation is usually successful, more so perhaps than most of the Amputations, and, as it can be readily performed, it should com mend itself particularly to the attention of military Surgeons. STATISTICS. e ported by Larrey, Operations 10 deaths 4* BaudeDS, (i 14 << 1 " Si romyer, «i 1<> a 7 " Legouest, «« 6 << 4 " 'eod, <( 14 << 1 Sorrel], (C 5 << 2 Rules to be observed in Resection of the shoul- der Joint : 1. Perform primary rather than secondary opera- tions. It must not be forgotten, however, that secondary resections of this joint though inferi- or to primary, are, according to Stomeyer and Esmarch, more successful than those of other joints. 2. It" upon a proper examination only a portion of the head of the humerus is found injured, remove that and leave the remainder intact. This will at facilitate the healing of the wound, if it does not secure so useful a member. 3. The whole head and a considerable portion me wore directly attributable to the operation. Thus 2 died of Scorbutus, 1 of Hospital Fever, and 1 of Test aftei IS after recovery. 188 RESECTIONS OF SHOULDER JOINT. of the shaft may be removed, with advantage, if implicated. Thus, though Guthrie believed that the insertion of the deltoid was the lowest point at which the bone should be divided, Esmarch has shown that at least four and a half inches can be removed and yet a most useful arm remain. 4. The U incision facilitates the performance of the operation, but the straight incision of White secures a greater degree of motion, as it does less injury to the deltoid muscle. It is important, however, in gun-shot wounds to include the two openings in the incision. 6. Arrange the line of incision so as to give free exit to the pus which is produced in large quantities, so as to avoid sinuses and abscesses in the neigborhood of the joint. 6. In field practice it is not necessary to make the incision so extensive, as under other circum- stances. The muscles and tendons being thus preserved afford a better chance of restoring the action of the limb, while the healing process goes on with more rapidity and success. 7. If the head of the humerus be entirely detach- ed, and thereby increase the difficulty of disartic- ulation, it may be seized with the fingers, or a pair of strong bullet forceps, and the manipulation facilitated. 8. It is well to compress the artery above the clavicle, or to have arrangements made to do so with celerity and success in the event of too great a flow of blood. 9. Avoid wounding the nerves, vessels and the glenoid cavity during the operation. RESECTIONS OF SHOULDER JOINT. 189 10. Never operate on the field proper, unless there are facilities on hand for supporting the limb and for transporting the patient to someneighbor- i ng hospital. 11. Support the patient's system, both as a means of relieving or preventing shock, and of securing that " plasticity" of constitution upon whieh a speedy convalescence and a proper union so much depend. Stomeyer prefers a semicircular incision over the posterior surface of the articulation ; Langeu- beck favors one straight incision on the anterior aspect of the joint; Franke and Schleswic add to this a transverse cut ; Baudens makes a straight incision on the inside of the arm ; Macleod in- clines to the perpendicular cut of White immedi- ately through the deltoid ; while Chisolm advo- cates the U shaped incision described in the pre- ceding pages of the work. The daugers of cutting across the fibres ot the deltoid, are for the most part imaginary, in as much as, according to the practical experience of all who have witnessed and practised this opera- tion, the fibres of that muscle speedily form unions which give them control over the arm to a very considerable extent. Velpeau seems to have been particularly unfor- tunate with this operation. He reports thirteen deaths from it, and says that many more have occurred within his knowledge. The weight of testimony is, however, decidedly in favor of it; and when the experience of Confederate Surgeons is 8b 190 RESECTIONS OF CLAVICLE, accurately recorded the weight of testimony in its favor will be overwhelming. Reseetions of the Clavicle and Scapula. — Circum- stances occassionally demand these operations, though they are of rare occurrance. Watt has re- sected the entire clavicle by making three incisions, circumscribing a quadrilateral flap, and disarticu- lating the bone at either extremity. The Scapula has also been removed in its totality, but it is too difficult and dangerous an operation to be repeated save in the most extraordinary cases. There are no general rules for these operations, but each Surgeon, relying upon his knowledge of anatomy and his acquaintance with surgical principles generally, must proceed as his judgment dictates. Kesection of the Bones of the Lower Ex- tremity. — Resections of these bones are not so suc- cessful as of the upper extremity. Resection of the Anterior End of the first Meta- tarsal bone. — Directions : Cut a flap on the inside with its base posterior ; denude the bone to the joint at which it is to be cut; saw it perpendicidar- ly to its axis ; detach it from the soft parts ; and then separate it from the phalanx. This bone has been completely exterpated by Malgaigne. Excision and Resection of the Bones of the Tarsus. — No precise rules can be established, but the opera- tion is easy and the result satisfactory. The space left by the removal of the bone is filled up by matter which subsequently ossifies, and thus, in a measure, prevents deformity and enables the pa- feient eventually, to walk well. Caries, or necrosis of the oscalcis is a serious circumstance, since, when its inferior surface is excised, the equilibrium of the body is destroyed, and the weight thrown forward on the point of the foot; while if the tendo, Achillis is cut, great inconvenience results. But even with these disadvantages, resection is better than amputation, as the limb is saved, and the patient can walk, however, imperfectly. The astragalus may also be ^xtirpated, by lux- ating the bone through the integuments, and di- viding its attachments ; but the state of the parts must furnish the proper guide to the Surgeon. After this operation the foot is fixed to the heg and the resulting lameness great. m of the Ankle Joint. — Directions. — Make an incision three inches long, from the inferior and posterior portion of the outer malleolus ; from the lower end of this cut, make another transversely forwards and only dividing the skin ; dissect back the flap and disengage the fibula; and sep- erate the external malleolus from the other bones with the chissel and mallet, — not employing the saw, because as there is no interoseous space, nothing can be introduced behind the bones so as to protect the soft parts. Dress in the usual way. \arks. — Resection of this joint has not suc- ceeded so well as that of the others mentioned above, or even of the knee. It is recommended by the teachings of conservative Surgery; but the experience of the profession is against its practi- cal utility, and amputation is now regarded as de- cidedly preferable. 192 RESECTIONS OF FIBULA Removal of the Fibula. — This bone may be re- moved either in its entirety, or partially. Directions. — Make an incision three inches long on the inferior portion of the bone, or for its whole length ; detach the soft parts as high up as the operation is to be performed ; divide the bone ; and, then detach it from its articulation with the tibia, — taking car#to cut as close as possible to the bone so as to avoid the anterior tibial artery. The same general plan may be followed for the removal of the upper portion of the bone, or for the whole of it. Portions of the tibia may be re- moved on the same general plan. Resection of the Knee Joint. — This operation was first performed by Park in 1781, and has been va- riously modified by Moreau, Begin, and Syme. Among the various processes proposed in this connexion, the following offers the most decided advantages. Directions. — Bind the leg at a right angle to the thigh ; make a transverse incision slightly curved and with its convexity downwards, under the pa- tella cutting into the articulation ; make then, two longitudinal incisions upon either side of the limb and perpendicular to the first ; dissect up this flap, including in it the patella ; destroy first the lateral and the posterior ligaments ; carefully detach the soft parts from the femur then pass a a wooden splint or piece of thick leather under it ; and remove the injured or diseased portion with the saw. If the tibia be injured or affected, extend the perpendicular flap ; separate the soft RETECTIONS ( F KNEE JOINT. 103 parts from the tibia, and remove a portion of it with the saw. The patella may bo removed or not according to the judgment of the Surgeon. Syme advises its removal, but on the other hand, Pancoast declares that it should unquestionably be left, "as it will serve to furnish a broader basis for the subsequent union of the bones." If any small arteries are cut they should be im- mediately ligated ; — the parts brought carefully together; and a hollowed splint then applied to the posterior surface of the limb, extending from the buttocks to the heel, — while cold water dressings are applied to the wound. It is useless to expect a speedy convalescence ; and it is not improbable, that profuse suppuration, numerous abscesses, and exfoliation of bone may present themselves at some period in the history of the case ; but if the Surgeon will watch the patient closely and see that his system is kept up to its normal tone, &c., a favorable result may eventual- ly be predicted and obtained in some cases. Ba marks. — This operation is a modern one, dat- ing back only to the year 1781, when it was first performed by Park, and has not yet received the endorsement of the profession. A few remarks as to the relative value of resections of the knee joint will not be out of place in this connexion. It is well known that, when this joint is opened, what- ever the extent of the injury or the nature of the missile inflicting it, violent inflammation of the sy- novial membrane lining the articular cavity and of the tissues surrounding its exterior, speedily 194 RESECTIONS OF KNEE JOINT. follows, accompanied by great pain, excessive heat, considerable tumefaction, and violent fever. Should this primary stage be survived, then, ery- sipelas, pyeernia, and irritative fever develop them- selves, adding their baneful influence to the mul- titudinous dangers which encompass the sufferer. These facts being remembered, it becomes the du- ty of the medical man, to attempt some interfer- ence by which immediate relief may be afforded to his patient, and amputation and resection become the alternatives which present themselves to his mind. It is important, therefore, to have an ac- curate knowlodge ot the relative value of these two operations, as upon the decision of the Sur- geon, human life — the existence of a hero and a martyr — may depend. Eelief must come quickly if it come at all. There is no time for delay or investigation when the mutilated victim appeals for succor. The comparative difficulties, dangers and results of the two operations should be fully comprehended and properly appreciated in ad- vance, so that an intelligent response may be made to the demands of science and humanity, without hesitation or delay. The advantages claimed for Resection may be thus summed up : 1. In the event of a successful issue, the life and limb of the patient are both saved, — the latter an. chylosed and deformed it is true, but still not en- tirely useless. 2. But a small quantity of blood is lost during the operation, and there is no danger of seconda- OF KNEE JOINT. 195 !'v hemorrhage — an accident which seriously com- plicates and materially endangers all amputations. 3. There is Less of the substance of the limb de- stroyed, and the shock to the system is not so great as in amputation. 4. In civil practice the results of resection have been comparatively favorable. The objections urged against the excision of the knee joint, may be thus stated: 1. Even in the event of success, the limb is so completey anchylosed and deformed as to be less useful than an artificial limb of proper construc- tion. 2. Though the danger from secondary hemor- rhage is less, erysipelas, purulent infection, ex- cessive and prolonged suppuration, irritative fever, and marasmus, with their attendant evils, are more likely to occur, than after amputations. 3. The convalescence is always tedious, involv- ing a long confinement in the recumbent position, and producing the most serious inconvenience to the patient because of the absolute repose deman- ded by the necessities of the case. 4. Without the most perfect repose — the absence of all motion, and the most careful after treatment danger of destructive inflammation aud of great deformity. These constitute the necessary condition in the proper treatment of the case — the sin$ q ►fits management. This fact renders ■;ion of the knee joint in field surgery almost impracticable in view of the means of traneporta- 196 RESECTIONS OF KNEE JOINT. tion, appliances, &c, at the command of medical officers. J 5. The experience of military Surgeons does not prove this to be so reliable an operation as amputation in the lower third of the thigh. Mac leod reports only one case, and that an unsuccess- iul one in the Crimean campaign. Moreau re- ports three cases in his experience, all of which proved fatal. The former writer uses in this con. nexion the following significant language, " Ad- miring, as I do, the brave attempts which have been made in civil practice to save limbs by ex- cising the knee, I regret that it should not be ex- tended to milita practice ; but except in rare cases I fear that it cannot be accomplished, from the care- ful after treatment, and the long period of conval- escence necessary to effect a cure." The Surgical society of Paris has decided posi- tively and unanimously against this operation, in connexion with a case of resection submitted by Maisonneuve. So, likewise, Park declares that this operation indicates " more courage than judg- ment on the part of the operator;" while Vidal, " in view of the dangers, delays, and bad results " attending it, enters his formal protest against its employment. \ Erichsen warmly advocates this operation in civil practice, and gives twenty-four cases, of which seventeen were successful and eight. died. Ferguson speaks of more than one hundred cases, with a mor- tality greatly less than that for the thigh. Syme favors the operation and gives numerous instances of its successful employment. In view of these facts, it appears that resection of the knee ioint when espe- cially undertaken for chronic diseases of the articulation, or even for wounds when circumstances admit of a proper " after treatment," has been successful in the hands of civil Surgeons. BISECTIONS OF KNEE JOINT. 1 97 The conclusions to be drawn from these state- ments ami arguments seem to be plainly these : 1. When the condition of the patient is good, bis hygienic surroundings unexception- able, and the proper meaas and appliances at band for the subsequent management of the i the Surgeon is justified in resorting to it, particu- larly for disease, and even for accidents. 2. When the condition of the patient is bad, and bis hygienic surroundings exceptionable, — as when exposed to the vjtiated atmosphere of cities, ill regulated camps, and crowded hospitals — or more particularly, when the circumstances of the case preclude that absolute repose of mind and body so indispensable to its success, theSurgeonis not warranted in attempting the operation. 3. Resections of the knee joint are better suited to civil than to military practice. 4. Resection of the knee joint should not take the.place of amputation of the thigh, in the lower third, in held surgery, because of the impossibility of maintaining those conditions which are absolute- ly necessary to its surer 5. Resection of the knee joint may be resorted to in hospital (military) Service, when the tone of the system has no1 beenloweredby exposure, priva- tion, or disease, and an abundance of pure air and nutritious food can be commanded, provided that permanency ot location, constant and intelligent attention, and contentment of mind on the part of the patient, can be secured. If there be the slight- >ubt or difficulty in regard to either one of 198 RESECTION OF HIP JOINT. these prerequisites, give the patient the benefit of it, and amputate the limb. Rernember that resec- tion of the knee must be performed primarily or not at all. The drain upon the system is immense, and every possible provision should be made for sustaining and invigorating it at all periods in the history of the case. Resection of the Hip Joint. — Directions. — Make a semi-lunar incision, beginning at the anterior su- perior spine of the Ilium^ and carrying it behind the articulation to near the tuberosity of the Is- chium ; cut a large flap with its base downwards through the muscles, and raise it so as to show the capsular ligament of the joint ; divide this ligament thoroughly ; flex the thigh and carry it inwards ; divide the round ligament; carry the knife be- tween the head of the bone, and the acetabulum, and divide the soft parts behind ; and then press the head of the bone outwards and remove it, with the saw. This being done, bring the flap in posi- tion, place the limb on the double inclined plane, or in Smith's anterior splint ; and apply cold wa- ter dressings. Convalescence is necessarily slow, and is preceded by extensive inflammation, pro- fuse suppuration, and debility. Remarks. — This operation was first attempted by White, of Manchester, in 1769, and, it is said, with success. Experience has demonstrated that resection of this joint is much more successful wken performed for disease than for injuries ; and a rule has been adopted for this special operation among military RESECTIONS OF HIP JOINT. I'.'!) Surgeons, which is directly opposed to that estab- lished for all others, viz ; for hip joint, resection discard the "primary operation," and rely exclu- sively upon the " secondary." The most fatal re- sults will, in all probability ensue from haste, while * uothing»can he lost by delay. Festindte /iwfeisthe cardinal principle in regard to resections at the coxo-femoral articulation. This is a dangerous as well as difficult operation and should not he resorted to, save as the alterna- tive of an amputation in the upper third of the thigh, or at the hip joint. As regards the propriety of this operation, it is well to remark that the sentiments of Surgeons are divided. The following statistical table, taken principally from Armand, will perhaps aid in solv- ing the difficult}", with those who may he called up- on to decide this important question. PRIMARY RESECTIONS AFTER GUN-SHOT AVOUNDS. Surgeons. No. operated upon. Ceres. Deaths. Lair 6 6 ( Jooper, 2 ille, 1 1 Elutin, •> 2 Sedillott, 5 5 Sorrell, 1 1 on, 1 1 Lilli ! 1 1 Gnbiot, 3 French crim. servi< (1 9 Macleod, ;> I 4 S 1 1 2 35 200 RESECTIONS OF HIP JOINT. To this frightful record may he added a case re- corded by Seuten, in 1832, in which death followed the operation. It is plain then that primary ope- rations are to be discarded, and that these are not cases for field surgery. The statistics of operations for injury show fa-» vorable results as compared with amputation of the the thigh near the hip joint, and de- monstrate that there are circumstances under which this resection may be properly undertaken. The rule, therefore, is to attempt to save the limb, rely- ing upon a secondary operation, if the effort prove abortive. The greatest trouble is in the treatment after the operation. It is a matter of prime importance to keep the limb in a state of repose ; and yet, ar- rangements must be made to facilitate those move- ments, which, in the necessary changes of position, are essential to the patient's comfort. Violent exten- sion, then, is both unnecessary and injurious, — un- necessary because it is useless to attempt to restore a perfect limb, and injurious because it prevents those movements which are necessary to comfort and recuperation. To meet these varied indica- tions the double inclined plane, or, better still, the anterior splint of Professor Nathan E. Smith, of Baltimore, should be applied. These appliances will be more particularly described under another head but it will not be inappropriate to say in this connexion, that the latter is one of the great sur- gical improvements of the present century. "Whatever the nature or extent of the injury, or however great the seeming necessity for this oper- RESECTIONS OF HIP JOI* T. 201 atiou, it should never be performed in any Hospi- tal in which pyaemia, hospital gangrene, erysip- elas, or cholera prevails as an epidemic, or upon those whose systems arc below the standard of health. * The following principles may be regarded as es- tablished in regard to this operation : 1. This operation, though dangerous should be preferred to amputation of the thigh above the junction of the upper and middle third of the fe- mur, or at the hip joint. 2. The secondary rather than the primary oper- ation should be preferred. 3. Nothing is lost by delay, and an attempt to save the limb. 4. Statistics show a mortality after 'primary op- erations of nearly one hundred per cent, but give somewhat more favorable results for secondary. 5. It is necessary to keep the limb in -repose but to provide, at the same time, for the natural and 9sary movements of the patient. These two indications are best accomplished by the employ- ment oi' Smith's anterior splint. 6. Xever operate unless all the sanitary condi- tions are favorable, or when there are ditticulties in regard to transportation or subsequent treat- ment. 7. Sustain the strength of the patient against the immense drain upon his vital resources inei- dent to the profuse suppuration following the op- eration. Resection of the Ribs. — It may be necessary to repeat, Richerand's operation for resection oi* a 202 RESECTIONS OF RIBS. rib, though the Surgeon is seldom called upon to do so. Directions. — By a straight, a curved, or a coni- cal incision lay bare the diseased portion of the bone ; divide the intercostal muscles above aud below the rib on a director passed under them ; then detach the pleura from the bone; and saw through the bone with a chain saw. There is danger of hemorrhage from the inter- costal artery ; but the vessel is small and may be readily drawn out and ligated. Resection and removal of the Inferior and su- perior Maxillary Bones. — These operations are un- dertaken for the removal of the principal bones of the face, when attacked by malignant disease ; and hence they do not particularly concern the military Surgeon. They are bloody, tedious, and perhaps dangerous, but, both as regards deformity and mor- tality, their results are far less to be dreaded than is generally supposed, or as might reasonably be expected. Observations. — In resections art should not only seek to remove the diseased bones but to repro- duce the fragments which have been destroyed. That this is possible to a considerable extent, is established alike by clinical observation and the teachings of experimental physiology. A fresh im- petus has been given to these investigations by the recent researches of Dr. Leopold Olier, of Paris. His conclusions are of sufficient importance to justify their incorporation into the substance of this volume. The following is the substan them: REPRODUCTION OF BONE. 203 1. The reproduction of bone proceeds from the inner surface of the periosteum. 2. In transplanting portions of the periosteum, bone of various forms and dimensions can be at- tained according to the shape and position of the transplanted flap. 3. Bones thus developed are not simply shape- less concretions of calcareous matter : they con- sist of true bone with all the anatomical charac- teristics of that tissue. 4. The new bone is developed in the subperios- teal blastena, which exists normally upon the in- ner surface of the periosteum. 5. This blastema consists especially of free nu- clei — enclosed in cells floating in a semi-liquid transparent, or firmly granular material, and min- gled more or less with fibrinous elements. 6. The sub-periosteal product which is observ- ed, within the first few days following the trans- plantation, is generally cartilaginous ; but the suc- ceeding development of bone progresses without this intermediate element, ./j 7. An analagous membrane is found after a time upon the surface of the bone from which the peri- uni has been removed. S. When a bone is removed, leaving its perios- teum attached to the tissues which ordinarily cov- er its surface, at the end of a certain time, this portion of the bone is reproduced to a greater or extent. 9. Am c resection of the articular extremeties of the two contiguous bones, anew articulation is formed, if the ea, i ligamentsare left entire; 204 REPRODUCTION OF BONE, while the two long extremeties are remodeled in- dependently of each other. From these observations, it is conclusively de- monstrated, that the preservation of the periosteum is of the highest importance. As bone can be pro- duced in inferior animals, wherever periosteum is transplanted, similar results may be expected in man by retaining portions of the same membrane. Alter all resections, the excised portions of the bone should be covered with periosteum so as to ensure their speedy union. The apparent difficul- ties in the way of a practical illustration of these principles should not deter the Surgeon from a per- sistent effort to adhere to mem in as much as they open the way to the accomplishment of such im- portant results in this special branch of Surgery. These views are new, startling, and in direct op- position of the accepted dogmas of the profession ; but they certainly merit attention and considera- tion, as the land marks of a new field of physiolog- ical research, and the heralds of still prouder tri- umphs for Surgical eofcmce. Let the Surgeon inlSperating on bony tissue re- member, then, to preserve as large a portion of the periosteum as possible, in as much as no possible injury can result from such a procedure, and if the deductions just enunciated be correct, a most im- portant desideratum is supplied thereby. The ex- periment of leaving the periosteum intact, might, perhaps, he tried to some advantage in connexion with the operation of trephing the skull, — securing a bony covering for the delicate and important REPRODUCTION OF BONE. 205 parts which are exposed in this operation. For the facts in this regard, collected by my friend Sur- geon F. Sorrell, the reader is referred to table "G" of the appendix to this volume. CHAPTER V. HEMORRHAGE. Hemorrhage may be Primary or Secondary, ac- cording to the period of its development. Primary Hemorrhage. — A flow of blood may associate itself either with operations or with wounds. When it takes place during the operation, or in a short time subsequent there to, or when it occurs upon the first receipt of an injury or with- in a few hours after the accident, the hemorrhage is said to be primary. It is produced, under these circumstances, either by the direct section of the vessel by the amputa- ting knife or the missile causing the wound, and it is instantaneous or delayed according to the extent of shock sustained by the system, or the condition of the artery itself subsequent to the division o* its coats. All Surgeons have observed the fact, that in some instances a division of the large arterial trunks is followed by no immediate loss of blood, and that the flow is not only occasionally delayed, but even entirely suspended. This is observable both in amputations and in wounds, especially of a con- tused character. HEMORRHAGE^ This is due to the influence of two causes, which deserve some consideration in this connexion, viz." paralysis of the vessel, and the condition of its in- ternal coat. 1. Paralysis of the vessel. — The influence exci- ted by the nerves upon the circulation, was pointed out in another connexion. It will suffice for the present purposes to state that each vessel is accom- panied by nervous filaments, upon the integrity of which the proper performance of the circulatory function depends. "When these filaments are so affected by any disturbing cause as to become bad conductors of nervous influence, the flow of blood through the artery is interrupted to a great extent, and even suspended entirely in some instances, notwithstanding the propelling power of the heart which supplies the vis-a-tergo. AVhcn therefore an artery is severed under those circumstances, or when the vessel is divide by an agency which at the same time paralizes it, there is either no hemor- rhage from it, or the blood flows in a very small quantity. 2. The Condition oftlic Internal Coat of the Ar- tery. — If a cylinder of paper be covered internally with a coat of varnish, and then suddenly and for- cibly put upon the stretch, an examination will dis- cover an immense number of points at which this internal coating has been fractured. Thearteries are lined with a tunic equally as delicate and fria- ble, and when rudely stretched or torn, as occurs iu connexion with lacerated wounds, this internal tonic sutlers fracture ai a number of points through- out its course. At each point of fracture coagula] 208 PRIMARY HEMORRHAGE. tion and effusion takes place, tending to arrest the blood current. This taken in conj unction With the paralysis of the vessel, accounts for the fact that in some instances there is no hemorrhage, even when large arteries are severed, in connexion both with operations and wounds. Primary hemorrhage frequently relieves itself by inducing syncope — a condition in which there is such a stasis of blood in the divided part as ad- mits of the formation of clots and ensures the com- plete blocking up of its vessels. The flow of blood may take place from the ar- teries, the veins, or the capillaries, while the soft parts generally or the bony tissues exclusively may be the seat of the hemorrhage. The Blood from an artery is of a vermillion color, and flows by jets which are synchronous with the contractions of the left ventricle. It may come either from the proximal or the distal end of the vessel, but generally from the former. The blood from a vein is of a dark color and flows in a uniform stream. Usually it simply wells out, but when there is pressure as from a ligature, when the position of the part causes the fluid to gravitate towards it, or when the contrac- tion of the muscles constringes the vessel, the blood may be driven out with some force. The blood from the capillaries is neither so bright as that from the arteries nor so dark as that from the veins, and oozes out rapidly, it may ba, but with no force. Hemorrhage may arrest itself spontaneously, by inducing syncope, or it may cause the speedy death PRIMARY HEMORRHAGE. 200 of the patient by deprivingthe'great centres oi" their " life which is the blood." If tho quantity of boocl lost be very great but still not sufficient to produce death, and particu- larly if it be spread over a considerable interval of time, a state of anaemia will be induced, character- ized b}< pallor of the skin, palpitation of the heart? rushing noises in the head, muscular debility a ten- dency to syncope, oedema of the lower extremeties, and a general impairment of all the functions. From this state the patient sometimes rapidly recovers, the vital fluid being speedily reproduced, and the organism readily returning to its normal tone and standard of health. It not unfrequently happens, however that tkis state of anaemia becomes the settled habit of the system and continues for a long period, being ac- companied by great debility and disturbance of function. Hemorrhagic fever may also manifest itself aft A great loss of blood, characterized by a tendency to reaction, with extreme irritability of the heart and arteries. This is nothing more or less than fever as- sociated with anamia, as the symptoms plainly in" dicate. Hemorrhage may be delayed until reaction en- sues. The current of blood which has suffered a temporary arresl under the shock induced by the injury or operation, may be driven by the more violent contra 'thehearfj through the v notwithstanding the obstructions to its passage, and lost in large quantities^cotemporaneously with the development of reaction in the system. This 210 SECONDARY HEMORRHAGE. usually occurs within the first thirty-six hours, and may justly be regarded as a primary hemor- rhage. Secondary Hemorrhage. — As that hemorrhage which occurs before the development of inflam- mation is styled primary, so that which occurs af- ter that proeess has been established is denomina- ted secondary. It may associate itself either with inflammatory fever, sloughing or ulceration, but as regards the time of its occurrence, is always subsequent to the inflammatory reaction: It is now generally agreed anions: Surgeons that any flow of blood which takes place after the thirty sixth-hour succeeding an operation or an injury is to be regarded as a secondary hemor- rhage and should be treated immediately as such upon the principles which will be discussed here- after. A patient upon whom an operation has been performed, or who has received a wound of any magnitude can never be regarded as beyond the possibility of this accident until the work of cica- trization is complete. From the first cut to the last dressing — at any period in the history of the case — hemorrhage is liable to occur, endangering life and calling for the exhibition of skill and courage on the part of the Surgeon. The period at which secondary hemorrhage most likely to occur is still a matter of dispute. Guthrie affirms that it is between the eighth and twentieth day ; Dupuytren thinks it is from the tenth to the twentieth day ; Henman sets it down as from the fifth to the eleventh ; Roux trom the and re is CAUSES OF HEMORRHAGE. 211 sixtli co tho twentieth; and Macleod from tlio fifth to the twenty-fifth. It has been known, how- pver, to occur as late as the seventh wgek, even without the existence of gangrene or ulceration, though after the twenty-fifth day it is fair to pro- nounce the patient in a great measure over his danger. This accident may arise from a variety of cir- cumstances, connected with wounds and opera- tions. In connexion with wounds it proceeds from — 1. The separation of the eschar. 2. Injury by fractured bones. 3. The erosion or tearing of the vessel. • 4. Relaxation of the capillaries produced by general feebleness of the patient. 5. Ulceration either incidental or accidental. 6. Gangrene. 7. Development of tho collateral circulation and the patulous condition of the distal orifice. In connexion with operations it may be the pro- duct of the following causes : 1. Those wl licit are connected with the condi- tion of the artery. 2. Those which are connected with the ligature itself, 3. Those which are connected with tho condition of the blood. 4. Those which are connected with the system at large. 1. Causrs which are connected with, the condi- tion of the artery. The different coats of the ar- tery are subject to diseases of various kinds, and 212 CAUSES OF HEMORRHAGE. when so affected, there will ensue rapid sloughing and ulceration of the vessel at the point of liga- tion, and a consequent escape of blood. Again it frequently occurs that an atheromatous or calcari- ous deposit has developed itself in the artery, ren- dering it brittle, and causing it to give way within a day or two succeeding the operation. So, like- wise, when the arteries, in common with all other structures of the organism, have yielded to the en- ervating influences of asthenic diseases, insufficient diet, and such agencies as tend to diminish vital power and to retard nutrition, the ligature readily divides the weakened coats of the vessel, and per mits the escape of its contents. The slight wound- ing of the artery abovo the ligature, or even of one of its smallest branches, may produce secondar hemorrhage. But the most frequent cause of hem- orrhage which manifests itself in this connexion, originates in the patulous condition of the lower orifice of an artery which has been accidentally divided — a condition which results from the divi- sion of the nervous filaments distributed to the vessel, and at the same time invites the escape of its blood. 2. Causes which associate themselves ivith the liga- ture itself. These may depend either upon the na- ture of the material employed, or upon the man- ner of its application. Thus, as has been already shown, some substances are more irritating to the tissues than others, and by developing too much inflammation in the coats of the artery, cause their disruption, and the development of hemorrhage. Again if the ligature be tied too loosely, or with • CAUSES OF HEMORRHAGE. 213 the inclusion of a piece of nerve, vein, or muscle, so as to become loose after suppuration has ensued, the blood readily and rapidly escapes. It often happens, that, either from some anomalous devel- opment of brandies, or the ignorance of the oper- ator, the ligature is tied too near to a collateral branch above, so that the condition of quiescence so essential to the production of a firm coagulum, cannot be obtained, and the plugging up of the ar- tery is not effected. Under these circumstances the blood ma}' escape at any time, causing great trouble and inconvenience, and seriously endanger- ing the life of the patient. 3. Causes which connect tfa mSi Ives with the condi- tion of the blood. It has been seen that the formation and organization of a clot — of a firm and adequate coagulum — is essential to the complete and per- manent closure of the artery. Physiology teaches that the blood coagulates much better at some periods than at others, and that this difference de- pends upon certain intrinsic changes which take place in the circulating fluid itself. The blood must contain a certain amount of fibrine and red corpuscles — must be in the possession of its normal and healthful constituents, in order to ensure its rea dy coagulation, whether within or without the body- audit must follow, therefore, that alterations in these elements, both as to quantity and quality, have a material though indirect influence in the develop- ment of secondary Hemorrhage. Experience has shown that violent i i; v when ac- companied by nervous excitement, tends to liquify the blood and to interfere with its coagulability 9b b • 214 CAUSES OF HEMORRHAGE. Should not this fact furnish a hint to Surgeons, as regards the treatment of wounded arteries, upon the battle field ? 4. Causes which connect themselves loith the system at large. All material changes in the blood either depend upon or induce certain alterations in the system at large; and to that extent this division of the causes which produce Hemorrhage, belongs properly to the last head. There are other states of the system, however, which exercise a more direct influence in the induction of this accident, and which should be considered in this connexion. It is not only necessary that a firm coagulum should form within the vessel, but the outer coat must be reinforced by a deposit of plastic lymph in order to prevent its rupture. A certain amount of normal and healthful adhesive inflammation is essential to the perfection of this process, — which is impossible in certain diseased states of the system, as when a tendency to erysipelas, phlebitis, suppura- tion, albuminuria, pyaemia, &c, exists. Although secondary Hemorrhage may occur at any time in the history of the case, there are three ■periods at which it is particularly likely to be de- veloped, viz: 1 Within a few clays after the appli- cation of the Ligature, 2 When the Ligature se- paiates; and 3. At an indefinite time after its separa- tion. 1. Within a few days after the application of the Ligature. — The bleeding which appears at this period results from the improper tying of the artery; some disease or defect in its coats; from the development PERIOD OF OCCURRENCE. 215 of the collateral circulation, and the escape of the blood through the patulous orifice of the distal end of the artery; and from the want of proper adhesive inflammation, &c. 2. When the Ligature separates and comes a- way. — This Hemorrhage may be occasioned by any one" of the causes above mentioned; but is mainly due to the improper development of the internal coagulum, and to the absence of the rcenforcement which the external coat requires to enable it to sustain the great burden imposed upon it. 3. After the liyature has separated. — Hemorrhage may appear at any period between the separation of the ligature ami the cicatrization of the wound. This is usually the result of the absorption both of the internal coagulum, and the lymph by which the external coat has been strengthened. Treatment. — The treatment of Hemorrhage con- sists essentially in preventing or arresting the flow of blood, and is modified by the variety, seat and source of the flow. Treatment of Primary Hemorrhage. — The moans employed for the control of hemorrhage are sus- ceptible of division into two classes, viz: Preven tive and Curative measures — the one being em" ployed in advance to prevent the flow and the other afti r the appearance of the Hemorrhage, to restrain it. Preventive measures. — These embrace compres- sion, position, and arterial sedatives. ipivssiou. — The low of blood can be prevented in most cases by shutting off the supply by means of compression made upon the artery between the 216 PRETENTIVE MEASURES. locality of the accident and the part. It may be Digital or Instrumental. Rules for Digital Compression. 1. Find the artery, select the point for compres- sion, and see that the thumb and fingers are applied forcibly upon the vessel. 2. Apply the thumb across the vessel like a seal • or if the fingers be employed form a horizontal plane with their united pulps and range them along the course of the artery. The thumb is placed upon the opposite side and made to constitute a fixed point upon the limb. 3. Press just hard enough to destroy the pulsa- tion in the vessel, and when the fingers become tired, aid them with those of the other hand. 4. Pressure should be made perpendicularly to the artery. 5. When a jet of blood is required, so as to enable the Surgeon to recognize the vessel, the fingers can be slightly raised, without letting the artery escape, and then reapplied. The advantages of digital compression are, these viz: the venous current is not arrested; pressure "is only made upon one point; and the artery can be always discovered by the sense of touch. Instrumental compression is accomplished by means of a key, the winch, the tourniquet, &c. The key may be employed for compressing nearly all the arteries, especially the subclavian. When used it should be well padded and applied directly across the track of the artery and not too firmly pressed upon it. The Winch may be used in cases of absolute ne- PREVENTIVE MEASURES. 217 y, but it is objectionable because it compresse the veins, ami cannot readily be relaxed or lightened The Tourniquet of Petit. This consists of three parts, viz: the pad to compress the artery — which should be firm narrow and flat; — a strong band to embrace the limb; and a screw by which this band is tightened, and the artery more firmly coin | ■. The Tad should. be so placed as to compress the artery against the bone ; and the screw turned lightly until the first incisions are made, or, what is better still, until hemorrhage from the artery demands some additional assistance for its restraint. The advantages of the tourniquet are that it can be more readily used by the ignorant — the patient himself being able to manage it properly-; it ensures a more reliable and permanent pressure; it com- presses all the branches of the artery as well as the main trunk itself; — it never tires, as do the fingers ; it controls hemorrhage as well in anomalous bifur- cations and distributions, as under ordinary cir- cumstances, and it presses upon the neves and thus, to some extent, diminishes the sensibility of the part. The disadvantages of this instrument are that, it interferes with the venous circulation, and by ac- cumulating blood in the part, causes a great loss of that fluid during an operation; and that it may in_ s mortification if ignorantly or too persistently employed, by paralyzing the nerves beneath it so lower the vital energies of tin' tissues to which fchey are distributed, and by cutting oil* the sup- ;' arterial blood. 218 PREVENTIVE MEASURES. The Tourniquet of Siguori. — This instrument consists of an arc of steel with a joint in the mid- dle and a screw by which the padded extremities of the instrument are pressed together. One of these pads can be applied directly over the artery, selecting, if possible, some point above the bone and the other on the opposite side of the limb. — By turning the screw the necessary amount of ex- tension is made. The advantages of this instrument are, that the compression can be rapidly taken from the artery, and that as only two points of the limb are com- presssed, the venous circulation is not interrup- ted. The objections to it are, that the pad is likely to roll off the artery as the screw is turned, and that in relaxing it, the position of the whole in- strument is frequently so much changed as to ren- der a fresh search for the artery necessary. The ligature en masse of Mayor, the compressor of Dupuytren, and other similar instruments are generally abandoned. Comjwession of Particular Arteries. — The primi- tive carotid may be compressed just above the omo-hyoid muscle, against the cervical vertebrae, by means of the fingers, applied perpendicularly. The facial artery may be readily compressed by the finger on the border of the lower jaw, just in front of the masseter muscle. The temporal artery may be readily compressed at a point in frOnt of the external ear, two inches from the base of the tragus, by means of perpen- dicular pressure made with the fingers. Hemor- COMPRESSION OF ARTERIES. 219 rhage from this artery may be checked by employ- ing a common tailor's thimble and applying a com- press over it. The subclavian artery may be compressed by means of a key or other similar instrument, well padded and applied at a point where the vessel passes over the first rib, just above the clavicle and external to the scalenus muscle. Unless the pa- tient is thoroughly under the influence of chloro- form, this procedure cannot be relied on to tke ex- clusion of other measures. The axillary artery may be compressed under the clavicle, and against the second and third ribs, but a complicated apparatus is necessary, and the difficulties are great. It may, however, be easily pressed against the head of the humerus, by means of four lingers only or with the addition of a cush- on. The point of compression is at the union of the anterior and middle third of the axilla. The brachial artery may easily be compressed by the fingers or tourniquet, against the humerus, at any point along the border of the coraco-braehialis above, and the biceps farther down. There arc several important nerves which accompany this ar- tery, and if the pressure is continued too long, the patient suffers great pain. This artery should be compressed in all operations on the upper extrem- ity, below the insertion of the latissimus dorsi muscle, save those of the hand and fingers, ami sometimes in those if (lie pressure made upon the radial and ulna arteries is not sufficient to restrain the hemorrhage. The radial artery is easily compressed at the 220 COMPRESSION OF ARTERIES. lower third of the fore arm, between the radius and the tendon of the flexor carpi radialis, just where the pulse is felt. The ulna artery may be reached at the inferior third of the arm, by pressing the flexor carpi-ulna- ris against the ulna. The external iliac may be compressed, in ex- treme cases, by pressing it against the brim of the pelvis, through the abdominal paricles. The femoral artery may be compressed in two places, viz : upon the pules, and in the middle third of the limb. This is accomplished upon the pubes,by pushing it forcibly with the thumb or fingers against the pectineal eminence. The pressure should be made obliquely, ujywards and backwards, forming with the horizon an angle of 45°. This compression is safe easy, and much used in all operations upon the lower extremities. In the middle third of the limb it may be readily compressed against the femur, by means of the tourniquet, and even the fingers, taking care to flatten the artery against the bone. This is much used in all operations on the lower extremities save at the hip joint [[and upper third of the thigh. The popliteal artery may be compressed opposite the joint, either by means of the tourniquet or the finger The anterior tibial artery may be compressed by forcing it against the tibia at any point from the middle of the leg to the termination of its course- It is to be found on the side of the extensor I-OPTTION. 221 proprius-pollicis*tendon. Compression of this aiv tery is not of much impo*rtauce so far as amputa- tions are concerned, — the femoral being com- pressed in all operations upon the lower extremi- ties. The posterior tibial may be compressed in the lower third of the leg, at any point parallel with the inner margin of the tendo-Achilis, and also be- hind the inner ankle, where it is very superficial — not much employed for the reason given above. Position. — As a means of preventing concurrent hemorrhage, position may be employed to consid- erable advantage. It is manifest that the normal position is best adapted to the necessities of the animal economy, and that while the course of the principal venous trunks is perpendicularly up- wards, the amount of blood carried from the ex- tremities, bears a certain relation to the wants of the various tissues to which the arteries have transported it. A greater amount of the circula- tory fluid must therefore remain in the parts con- cerned so long as this erect position is preserved, than when the vessels are turned perpendicularly downwards, and the force of gravity is superadded to the influences which normally operate in returning the blood from the extremities towards the trunk. The same principles apply to arteries, but inversely, — the force of gravity acting as some restraint upon the heart's action, and in a measure controlling the circulation. Thcoint of division or disease is demanded, are the following: 1. After amputations for the purpose of arrest- ing the flow of blood. 2. In wounds of small arteries when the hemor rhage cannot be otherwise restrained. 3. In local hypertrophies for the purpose of ar- resting the nutritive process by withholding the pabulum supplied by the blood. 4. In connexion with malignant tumours and for the purpose of restraining their develop- ment. X 5. In aneurysmal tumours, according to 'the 236 LIGATION OP ARTERIES. teachings of Hunter, taking care to expose the ar- tery at some distance from the seat of disease. 6. In vounds of large arteries when it is impossi- ble to ligate bojth the proximal and distal end. 7. In hemorrhage from an artery in simple frac- ture, performing Anil's operation according to the views of Dupuytren. 8. In secondary hemorrhage of an uncontrollable character from stumps, &c. 9. In violent inflammations of articular surfaces, when neither resections nor amputations are admis- sible. The circumstances which demands the ligation of the artery, both above and below the point of division or disease are the following : 1. In secondary resections where the collateral circulation has been developed, and the hemorrhage is excessive, — the operation oeing tedious and pro- longed. 2. In traumatic aneurisms, particularly those of the artero- venous variety, the ligature should be thus applied. The older Surgeons treated all aneur- isms in this method, but it is now limited to those of traumatic origin. 8. In wounds generally when an artery of large size is divided, as a means of preventing secon- dary hemorrhage. 4. In secondary hemorrhage when from the dark hue' of the blood, and the continuity of the stream, it is plain that the blood issues from the distal end of the artery. The application of the ligatures both to the proximal and distal ends of the artery, under these circumstances will be readily appreci- LIGATION OF ARTEK1I-. 237 ated when it is remembered that the latter does not close as docs the former, and that, as a natural con. sequence, so soon as the collateral circulation is developed, the blood comes welling up from the patulous oriiiee in obedience to the physical law whirh constrains a fluid to seek its own level under all circumstances. The causes which prevent the closure of of the distal end, depend for their oper- ation upon the division of the nerves distributed to that portion of the vessel, and the retention in if y immediately subsequent to the operation, of too small a quantity of blood to ensure the formation of a clot sufficiently large and firm to block up the vessel. This method of guarding against seconda- ry hemorrhage, and of restraining it when devel- oped, has become one of the axioms of modern surgery, and should be incorporated into the pro- mal creed of every medical man as a cardinal principle. The neglect of this most simple but sig- nificant precept may induce fatal results, for which the Surgeon alone should be responsible, whatever of mortification to him or disgrace to the profes- sion, is incurred thereby. As before remarked, it is not always possible to ascertain from what arte- ry the blood conies, or to find the severed ends of the bleeding vessel : but the operation should not be abandoned for any other, until a diligent search has been instituted and an intelligent effort made to fulfill the indication of the case, in the manner referred to above. The blood from the distal portion of the divided artery may be recognized in the lower extremi- ties by the darkness of its hue, but in the upper 10b 238 LIGATION OF ARTERIES. extremities both ends bleed scarlet blood because of the free anastamoses of the vessels. It is not so important to secure both ends of the smaller arteries, as they can be more readily ob- literated, if necessaiy, or controlled in any event. The circumstances under which the artery is li- gated below the point of division or disease exclu- sively are as follows : 1. In anuerisms of large vessels when the Ilun- terian operation has' failed or is impossible. 2. In aneurisms when the coats of the artery are diseased in consequence of calcarious or arthero- rnatous deposits. 3. In wounds when the hemorrhage is of a dark character and comes in a continuous stream, and the upper portion of the divided artery lias re- tracted beyond the reach of the Surgeon, or is in such close proximity with important organs as precludes its seizure without serious injury to them . Brasdor proposed to cure aneurismal tumours by ligating the artery only on the distal side, ex- pecting thereby to retard and diminish the current passing through the tumours to such an extent as to ensure the consolidation of its contents. Experi- ence has shown that the Hunterian method is far preferable, and that the procedure of Brasdor is a senseless substitution save in those cases where from the peculiar surroundings of the vessel the former cannot be performed. "Wardrop supposed that by tying the artery on the distal side, but be- yond a point of bifercation, that the conditions most essential to solidification of the aneurism -LIGATION OF ARTERIES. 239 would bo secured. The iucorrectness of his views in this regard is demonstrated by the universal abandonment of his operation. Structure of Arteries. — It is important to under- stand the anatomical structure of arteries before entering upon the consideration of the general rules for the application of ligatures. Arteries are tubular vessels of cylindrical form dense in structure, and composed of three coats, the internal, the middle and the external. The internal coat is clastic, and composed of two layers, the innermost one being only a layer of epithelial cells, resting upon an elastic, but ex- tremely thin, brittle, transparent and colorless membrane. The middle coat is composed both of muscular and elastic fibres, being highly elastic, and of a reddish yellow color. These muscular and elastic fibres are arranged in layers, encircling the vessel, and therefore, admitting of an easy division of this coat, under .the presure of a ligature applied in the same direction. The external or elastic coat consists of condens- ed areolar and elastic tissue. In large arteries the elastic tissue forms a distinct layer, the fibres of which run longitudinally, while another layer of condensed areolar invests the whole, — its fibres being disposed more or less obliquely or diagonal* ly around the vessel. The arteries are included in a thin areolar investment known as the sJieath, and are sup- plied with blood vessels and nerves like other or- gans £of the body; while they are accompanied 240 ACTION OF LIGATURES. by satellite veins, called vence comit'es. The nutrient vessels arise from the main artery, from some of its branches, or from a neighboring vessel, and are distributed to the external and middle coats,, and possibly to the internal, also. Minute veins serve to return the blood from the vessel into the venae comites. The veins are derived principally from the sympathetic, and partly from the cerebro spinal system, — forming intricate plexuses upon the surface of the larger trunks, while the small- er branches are accompanied .by single filam These vessels are named arteries from two Greek words signifying "to contain air," from the an-, cient popular but most mistaken ideas respecting their functions. llie action of Ligature*. — "When a ligature is; tightly applied to an artery of considerable size, \ certain pathological phenomena are developed^ worthy the faithful study of the Surgeon. Thesoj effects occur in the following order : An immedi- ate division of the internal and middle coats — thai external remaining in tact;— these coats retraci and contract forming a cul-de-sac, at the bottom of which, there is first deposited a small nodule o^j lymph of i yellowish or buff color.; this coagulun assume.^ a conical shape, its base being downward^ and is c lposecl of exudation matter and fibril closely ; herent to the lower end of the artery, while it ipex is pointed upwards, floats loose iij the vest 2] and is composed of fibrin, of a darl purple < maroon color ; about the tenth day tl plastic \j aph, thrown out in consequence of an ii flammat. ,>n from the divided coats, binds thei iOTION OF LIGATURES. 241 firmly to the inclosed plug, the darker portions of which begin to disappear ; the vessel contracts still more, and the absorption of coloring matter continues, until the base of the plug becomes in- corporated with the contiguous arterial coats and is finally transformed into nbro — cellular tissue. In the external coat a certain amount of inflamma- tion is induced by the pressure of the ligature, and plastic lymph is exuded between the vessel and its sheaths which finally organizes and mate- rially strengthens the artery immediately contigu- ous to the noose as well as over it. The ligature finally ulcerates through the vessel, and its place is still farther supplied by deposits of plastic mat- ter upon the external coat of the vessel. It will be seen therefore that the simple retrac- tion and contraction of the severed coats, together with the formation of a coagulum, are not sufficient to secure the occlusion of the vessel, but that the inflammatory process, accompanied by effusion of plastic lymph, must develop itself in order to effect the desired result. The delicacy of the arterial coat ensures the induction of this inflammation when the ligature is applied under ordinary cir- cumstances, — a provision of immense importance to the Surgeon, and seemingly designed with espe- cial reference to the success of the art.| The instruments and appliances required lor this operation are few and of simple construction. — % There mi luch or too little inflammation, — the one some" tinTcs resulting in the breaking down of the coagulum by suppuri the other causing the exudation of so little ubrine as to preclude the ormation of I ly firm clot to ensure obliteration. 242 OBJECTS IN VIEW. Thus, the Surgeon should always be provided with a bistoury, a grooved director, forceps, aneurismal needles, blunt hook, tenacuke, ligatures, suture needles, adhesive straps, chloroform, styptics, cold water and brandy. 2 he objects to be held in view in the performance of this operation are three in number, viz : 1. To expose the sheath of the vessel. 2. To isolate the artery. 3. To place the ligature around the artery. Uncovering the Artery. — The general rules in this regard, may be summed up thus : 1. Make sure of the position of the artery by un- derstanding the anatomy of the part, causing the muscles to contract, feeling the pulsations, and " make assurance doubly sure," by marking out, upon the limb, the exact course of the vessel. 2. Make the skin tense without altering its rela- tion to the artery ; and if the vessel be superficial, cut directly through the skin and parallel with it; but if it be deep divide the skin obliquely. 3. If the artery lies directly under the superficial fascia, or aponeurosis, these should be opened at the side of the vessel to avoid puncturing it ; but if the artery be deep they should be opened direct- ly above it. Should the artery not be seen after these incisions, make the muscles contract, and separate them at their insterstices, by means of the director or the handle of the knife. When the deep aponeurosis is exposed it should be divided according to the directions given for the superfi- cial. 4. The artery may be recognized by its- pulsa- ISOLATION OF THE ARTERY. 243 lions, by its being thicker than the veins, and by its dull white color. 5. However superficial the artery, two incisions are alwaryi sary to uncover it — the s-kin and the aponeurosis must always he divided, and by separate cuts. The Surgeon should never cut blindly, hut always "with a definite object in view, and with a lull knowledge of what he is doing. — He should have certain anatomical land marks to guide him to the attainment of his object, and should content himself with quietly tin ding each in its turn until the goal is reached, without seek- ing to attain it at a bound, or by an extemporized •'shortcut." The Isolation of the Artery. — The rules for the guidance of the Surgeon in separating the artery from its surroundings are as follows: 1. Hold aside the lips of the wound, and remove all pressure upon the artery so as to distinguish its pulsations, and when the sheath is fairly exposed, and opened, pass in the grooved director, and en- large the opening either by cutting or tearing the membrane. Then, separate the artery from its ac- companying veins and nerves, and pass the grooved director b< ueath, and thus isolate the ves- sel. 2. If the artery be small, or yellow — indicating its sheath should not be opened. If it be large, the sheath, separate it from "Venae comites" and " satellite nerve;" and adily with the finger and thui to pa the director under it. ;3. If important ■ taken up with the arte- 244 APPLYING THE LIGATURE ry by the director, use another to ensure its more complete isolation. 4. Be sure that yon have tied the artery. Some have tied important nerves instead of the vessel, — with the most destructive consequences to the pa- tients, and to their own reputations. Take pains therefore, to feel the pulsations of the vessels before ligating, and to ascertain that the current of blood has been arrested b}' the operation, by examining the artery both above and below the ligature. : — With regard to the veins, their colour will prevent mistakes Applying the Ligature. — The rules for applying the ligature are as follows , 1. The ligature must compress the artery per. pendicularly ; if placed obliquely, it will slip and not sufficiently compress the vessel. 2. The ligature should neither be too small, nor too loose, but should vary according fo the vessel ligated, having a certain relation to "the size of the artery. Thus, the femoral should be tied with a larger thread than the facial, and • so on for the rest. 3. Do not tie an artery immediately below a branch 4. Disturb the ligature, after it has been adjust- ed, as little as possible. When an artery is diseased or brittle, the ligature should be large, and tied loosely. For the other facts in regard to the application of ligatures, the reader is referred to the previous chapter on hemorrhage. Treatment. — After the operation has been per- formed the limb should be placed in such a posi- TREATMENT. ' 245 tion as will permit the blood to flow readily from it, while the muscles are relaxed and the lips of the wound are neither patulous nor puckered. The wound should be closed with adhesive straps ; the ligatures brought out of its upper portion; a Light roller bandage applied; and the cold water treatment instituted. Provision should also be made for preserving the vital warmth of the Limb, by wrapping it in flannel, laying it in a bed ol soft wool or cotton, using friction and employing artificial heat if necessary. The ligatures should not be touched for eight or ten days, if the artery be small, and for two weeks or more if it be of large calibre. If symptoms of plethora appear from the mass of blood being confined within more circum- scribed limits, blood letting and the usual anti- phlogistic treatment should be resorted to without delay. Should gangrene result from the ligation of the artery, amputation offers strong hope for the patient, and it should be employed without hesitation or delay. This accident is particularly likely to appear in connexion with extensive gun shot wounds, or when owing to the ignorance or carelessness of the operator, the large conducting vein from the limb is injured, or an aueurismal communication is formed between the artery and its accompanying vein. Should hemorrhage oc- cur as the ligature separates, compression may be tried, and [f this fail, another operation resorted to as the surest means of arresting the flow. Ligation of Particular Arteries. — Under this head will be considered the rules for the ligation 246 ARTERIA INNOMlNATA. of the arteries of the trunk, and of the superior and inferior extremities. Arteries of the Trunk — UieArteria Innominate; This artery is the first large trunk given off from the arch of the aorta, and ascends obliquely on the right side, to a point opposite the articulation of the clavicle with the sternum, where it termi- dates by dividing into the subclavian and common carotid. It is about one inch and a half in length, in the adult, and is in front of the trachea. PLAN OF RELATIONS. In front. — The-sternuni, sterno-hyoid, and sternothyroid muscles, remains of the thymus gland, left innomenata and inferior thyroid veins. Right side.— Right Vena innomenata, right pneumogastric nerve and pleura. Left side. — Remains of the thymus gland, and left carotid. Behind. — The trachea. Operation. — Directions. — Place the patient in a recumbent position, with the neck slightly flexed and supported with a pillow, — the face being turn- ed in an opposite direction, so as to relax the ster- no-cleido-mastoid muscle. Standing upon the right side, make a transverse incision, three inches long, commencing at the median line, of the neck and extending outwards parallel with the clavicle but half an inch above its upper border ; — then make another incision of the same length along the in- ner border of the sterno-cleido-mastoid, terminating at the commencement of the first ; open the pla- tysmar muscle and superficial fascia carefully, so as to expose the sternal portion of the sterno-clei- do-mastoid ; divide this muscle upon the grooved director ; separate the clavicular origin of the mus- cle upon the inner side of two thirds of its length AIITE1UA INNOMINATA. 247 and reverse it upwards and o\d\oards ; next divide the sternohyoid and thyroid muscles, cautiously upon the grooved director ; open the cellular tissue lying above the vessel with the finger or director avoiding the right internal ingular vein, which is only a quarter of an inch on its outer side, and the inferior thyroid veins which cover it in front and are to be drawn oil' on one side; — find the common carotid first, and trace it down with the finger until the innominata is discovered ; separate the vessel carefully from the vena innominata on its outer side, and press it off from the laryngeal ; and then pass the ligature under it by means of a curved aneurismal needle from without inwards. The longitudinal incision may be made first, and perhaps it is more convenient to do so, as the skin becomes relaxed after the transverse one is made. The parts should be brought together and cold water dressings applied. The propriety of attempting this operation un- der any circumstances is very doubtful though the facts o( thr accidental obliteration of this artery demonstrates the possibility of success. Ligation of th< Common I Artery PLAN OF RELATIONS. /,- Front. — Integument, fascia, platysma, sterno-mastoid, ■terno-tbyroid, i [en noni nerve, *t<-nei_ •1 artery, .superior and mid : thyroid veiny, and anterior ugular. f. — Internal jugular vein and pneumo-gastrie nerve. .—Trachea, thyroid gland, recurrent laryngeal nerve, inferior thyroid artery, larynx and pharynx. stic nerve, rectus anticus muscle, interior thyroid artery and recurrent laryngeal nerve. 248 COMMON CAROTID ARTERY. The common, carotid.arteries extend from a point opposite the articulation of the clavicle and sternum to a point on a level with the superior margin of the thyroid cartilage, where, they divide into the external and internal carotids. Both arteries in- cline backwards as they ascend, while the right is shorter than the left, and somewhat more superior, in consequence of its coming off from the innomina- ta. Each artery is invested in a sheath which contains also, the par vagum nerve and the internal jugular vein — the artery being on the inner side, next to the trachea — the vein on the outer side, and the nerve bchueen the two but a little posterior to them. The place of election is immediately below the bifurcation of the vessel, opposite the thyroid car- tilage, and above the omo-hyoid muscle. The place of necessity is anywhere below the omo-hyoid and in the interior triangle of the neck. Directions for the operation at the place of elec- tion. Place the patient in a recumbent position, with his face turned to the opposite side, well sup- ported by an assistant, and his chin carried back so as to extend the integuments in front of th neck. Make an incision on the anterior edge o the sterno-cleido-mastoicl, beginning an inch below; the angle of the jaw and extending half-way down the neck: raise and divide, on the grooved direc- tor, the platysma muscle and superficial fascia,, avoiding the anterior jugular vein and the superfi]| cial nerves ; divide, in the same manner, the dee layer of fascia, connecting the edge of the stern( :; COMMON CAROTID ARTERY. 249 clcido-mastoid to the sterno-thyroid and hyoid muscles ; lay down the scalpel, lower the chin to its usual position so as to relax the muscles, and hold the margins of the wound asunder with blunt hooks or the lingers of an assistant; then, with the point of the director, the handle of the knife, or the linger, break up the cellular tissue so as to expose the sheath of the vessel, on which is the descendens noni nerve; raise the sheath carefully with the for" and open its inner side, and enlarge the ori- fice on a director so as to expose the vessel; hold the internal jugular vein slightly downwards and outwards, isolate the artery, and pass the ligature under it, by means of an aneurismal needle, from without inwards. If the internal jugulor vein should by anj accident be severed in the operation two pieces through its edges and across the orifice, and immediately apply a ligature both above and below the bleeding point. Bring the wound together ami dress according to the usual rule Directions for the operation at the point of ne- the omo-hyoid muscle. — Make, an incision three inches in length along the inner :in of the stern o-cleido-mastoid terminating »p oi the sternum; an inch from this point, make another incision parallel with the elavi. beyond the stern o clavicular elation ; divide the sternal portion of themus" cle and turn it backwards ; and then proceed to te the artery and to apply the ligature as di- ed under the Last head. , According to Non id artery bae 250 COMMON CAROTID ARTERY. ligated T49 times, and with a Fatal result in 32 cases. The most common cause of death after this operation is a cerebral disturbance, which fact can be readily understood when the pathological susceptibilities of the brain are taken into the ac- count together with the important functions of the carotid as the great blood carrier to that delicate organ. Erichsen gives the following as his con- clusions in regard to this operation : 1. Ligation of one carotid is followed in about one fifth of the cases by cerebral disturbance, more than one half of which are fatal. 2. Ligation of both carotids at the same time in- variably results in death. 3. "When both carotids are ligated, with an in- terval of some days, there is not more clanger than when one is tied. 4. Pathological investigation has shown that even if both the vessels be gradually obliterated the patient may live. Jobert and filler have also called special atten- to the fact that the luugs are secondarily affected after the ligation of the carotids. When the carotids are ligated the head is sup- plied with blood by means of the vertebral arteries, and a communication which exists between the ar- teria — princeps cervicis a branch of the occipital, and the profounda cervicis, a brauch of the subclavian. Ligation of the External Carotid artery. — The com- mon carotid of either side divides into the exter- nal and internal carotids nearly on a line with the upper border of the thyroid cartilage. The external at its origin is slightly in front and V EXTERNAL CAROTID ARTERY. 251 to the inner side of the internal carotid, and may be found without much difficulty, by tracing up the course of the common carotid with the finger. Both the external and internal are sufficiently su- perficial to be readily reached, by the Surgeon ; .but the latter is not a proper subject for operation for many obvious reasons. The external carotid has numerous and impor- tant branches conveying blood'to the thyroid gland, tongue, pharynx, face, posterior aspect of the head, anterior and middle portion of the scalp, carotid gland, «&c. PLAN OF RELATIONS. In front. — Integument, platysma, superficial fascia, deep fascia, hypoglossal nerve, lingual and facial veins, digastric and styto-hyoid muscles, facial nerve, parotid fgland, tempo- ral and maxillary veins. rnally. — Hyoid, pharynx, parotid gland, ramus of the jaw. -Superior laryngeal nerve, styloglossus muscle, styto-pharyngeus and glosso-pharengeal nerves, and paroted gland. It is only in the cervical portion that the artery is tied, just below the digastric muscle. Above that locality the operation becomes much more difficult and dangerous because of the important parts with which it is iu immediate relation. Directions. — Make an incision, common* half an inch below the angle of the jaw and extend- ing as low as the middle of the thyroid cartilage and running parallel with, and half an inch from the edge of the sterno-clcido-mastoid ; divide the platysma and cervical fascia on a grooved direc- tor; separate the sheaths of the submaxillary 252 THYROID ARTERY. upwards and forwards ; lay bare the digastric and stylo-hyoid muscles at the bottom of the wound, by means of the point of the director or the for- ceps and draw them forward with a blunt hook : hold the sides of the incision wide apart, carry the nerve and vein backward with the end of the finger, and cautiously open the sheath of the ves- sel ; and then, with the artery isolated apply the ligature by means of an aneurismal needle. Dress in the usual manner. The external carotid has been tied successfully for wounds, for aneurismal enlargements of its branches, in resections of the jaws, and for tu- mours of the antrim, and for removal of the paro- tid gland. Except for wounds which divide it, there is much doubt as to the propriety of the op- eration, on account ot the secondary hemorrhage which almost necessarily follows the ligation of a large artery so near its point of ramification ; and with such extensive anastomosies. Ligation of the Superior Thyroid artery. — It is only necessary to remark in regard to this artery that from its position on the neck, it is divided gener- ally in abortive attempts at suicide, and hence, the only operation necessary is simply one for secur- ing cut extremities in the existing wound. Should it be impossible to do this in consequence of the effusion of blood in the surrounding cellular tis- sue, and the heaving motion incident to respira- tion, ligation of the common carotid becomes ne- cessary. Ligation of the JAngual Artery. — This is a branch ol the common carotid and is given off a little •above the superior thyroid, from whence it r to the tongue. [t honld be ligs t oppositi pus projection upon the upper border of tl corner of the os-byoides, one or two Hi r cornu. Directions. — Find the great cornu and mak< incision about an inch and a half in length through the skin and platj lei with it: push up the sub-maxillary gland and find the tendon of th trie muscle, and the hypoglossal nervs ■ >• and divide the muscle: open the ofthearteryj isolate and te it. This is a difticuii a bul il may be undertaken in wounds and in o] tions on the tong ;• sal and Mirault artery for the p rpose of arr< the tongue — a mo . nder- taking. Ligdlion of fin I t. — This u off jusi above tlie lingual and si nioii trunk with it. i I rni : ior border • d by an e branch' it. I i.i (pU.'i ti 11 254 SUBCLAVIAN ARTERY. facial nerve ; open the sheath ; isolate and ligate the artery. Ligation of the Sybclavian Artery. — The subcla- vian of the right side arises from the arteria inno- minata, opposite the articulation of the clavicle with the sternum, and extends to a point just below the margin of the first rib. On the left side the subclavian rises directly from the arch of the aorta, and is, consequently, longer than the other, and more deeply seated. It follows therefore that the two vessels must, in the first portion of their course, differ in their length, their direction, and their relations with neighboring parts. Asameans of facilitating the study of this vessel, especially in a surgical point of view, the subclavian has been divided into three parts. T]\e first portion is in- cluded between the origin of the artery and the inner border of the scalenus anticus muscle; the second is immediately behind the scalenus anticus extending from the inner to the outer border of that muscle; and the third extends from the outer margin of the scalenus to the lower border of the first rib. In its first portion, the course of the right artery is obliquely upwards and outwards; in its sectmd, it is transversely outwards; and in its third, ob- liquely downwards and outwards, so that it forms, between its terminal points, an arch whose centre is nearly behind the scalenus anticus muscle. The left artery passes almost perpendicularly upwards to the scalenus muscle and then curves outwards and downwards to the lower border of LAVIAN ARTERY. 255 the first rib. Those three portions will be con- sidered separately. RELATIONS OF THE FIRST PORTION OF THE RIGtHI SUBCLAVIAN. In front. — integument, superficial and deep fascia, pli ma, Bterno-mastoid, sterno-hyoid, and Rterno— thyroid mus- cled, internal jugular and vertebral veinB, pneumogastric, phr«nir and cardiac tier. Behind'— Recurrent laryngeal, and sympathetic nerves^ longus-colli, and trs rocess of the seventh cervical \ ertebra. Beneat /.. — The pleura. The relations of the first portion are not inter eating in a surgical point of view since the artei • cannot be ligatured on account of its greal deptli and close connexion with the pleura. On the righl side the operation has been per. formed with success; but it should never, be un- dertaken when it is possible to ligate the arten either in its second or third portion. Directions. — Place tin 1 patient upon the table in a horizontal position; make an incision along inner border of the clavicle : make a second along the inner border of the sterno-cleido-mastoid, meel Lag the first at right angles ; divide the Menial at- tachment of the muscle and turn it outwards ; cut through a few small veins, and divide the stern o- hyroidand thy-roid upon a grooved director, in the Bame manner mall v the anterior jugular is cm in this Btep of tie on ; cut through the :: with the li jugular vein, which ci rter} ; press this aside and Becure the artery, by passing the nee- dle from belt oat (»im being Hie most desirable position for the ope- ration, because Of the intimate relation of the phren- ic nerve, the internal jugular vein, and the internal mammary artery with the scalenus muscle which must necessarily be divided. There is also anoth- er objection which is based upon the close proximity of the artery to the pleura, — a structure of pecu- liar delicacy of organization- Sometimes the ar- tery passes in iron! oi the scalenus m scle, and oe- >nal)y "through its fibres. PLAN OF THE RELATIONS 0F THE THIRD PORTION OF THE ARTERY. In front. — Integument, fascia, platyama, external jugular, Bupra e nd transverse cervical veins, cervical plexus Bubclavius muscle, supra scapular vessels, and clavicle. , and omohyoid. w — Firpt rib. This is the most eligible position tor the perfor- mance of the operation. Directions. Place the patient upou a table 4 with hi> shoulder- de] and his head well secured : draw down the integuments as much as possible, upon the clavicle ; make au incision through the ski nj thus drawn down, to the hone from the ante- rior ! ;;- to the posterior border of the storno- ; makes short vertical incis- ion meeting the centre of the preceding one at a right divide the platysraa and superficial 258 .SUBCLAVIAN ARTERY. fascia upon a grooved director; hold aside the in- ternal jugular vein, which is on the inner side, as well as the scapular and transverse cervical ; avoid the supra-scapular artery, and find the omo-hyoid muscle, and hold it out of the way ; divide the fas- cia with the finger nail or scalpel and find the outer margin of the scalenus anticus ; and then pass the finger down this margin until it strikes the first rib, where the pulsations of the artery may be felt, as it passes over its surface. This being done, pass the aneurismal needle around the vessel from before backwards, taking care not to include a branch of the brachial plexus in the ligature. Re- member that the subclavian vein passes almost! transversely forwards from the outer margin of the first rib to the sterno-clavicular articulation, in front of the artery, being separated from it by the scalenus anticus muscle and the phrenic nerve. IiCiiiarh.— That portion of the artery which is included between the outer margin of. the scalenus muscle and the lower border of the first rib, is al- ways selected as the proper site tor deligation, when it is possible to do so. The artery in its third part is comparatively superficial, whilst it is most remote from the origin of the large braches, and not so completely environed by important vessels and nerves. This operation may be required on account of aneurisms or wounds of the axillary artery ; and though less difficult than those undertaken at the first and second portions of the vessel, it is of suffi- cient gravity to preclude its employment save in cases of paramount necessity. ILIAC ARTERIES. In ordinary cases the artery is not at a great depth, but when the clavicle is elevated from the presence of a large aneurysmal tumour, it is then very remote from the surface, and the difficulties of the operation are increased. The circulation of the limb is supported after Ligature of the subclavian, principally by means of the superior scapular artery. In persons with short necks the first rib is lower in relation to the clavicle, and the artery is deeper while the very opposite of this is true in persons with longneeks. The artery i^ found invariably on the outside of the project : ng tubercle or the first rib, which gives attachment to the scalenus anticus muscle. Ligation of the Common Hide Arteries. — The ab_ dominal aorta bifurcates opposite the body of the. fourth lumbar vertebra on the left side of the spi- nal column and forms the common iliac arteries. — These are about two inches in length, and diverge o\\ either side, running downwards and outwards upon the margin of the pelvi-, and dividing oppo- site the articulation of the sacrum with the last lumbar vertebra, into the i sternal and internal iliac arteries. The external iliacs are distributed to the inferior extremities while the internal iliacs Bttpply the viscera and parietes of the pelvis. The right common iliac is longer and more ob- lique than the left. In front it is covered by the peritoneum, the intestines, and the branches of the sympathetic nerve, while it is crossed atitsdvision by the ureter. Behind \i\> separated from the last 260 ILIAC ARTERIES. lumbar vertebra by the common iliac veins. On the outer side it is in the relation with the vena cava the right common iliac vein, and the psoas raagn us muscle. The commencement f this vessel corres- ponds with the left side of the umbilicus on a. level with a line drawn from the highest point of one iliac rest to the opposite one, and its course to a line exi nding from from this point downward to- wards , . 3 middle pf Pouparts ligament. Dir< iions. — Make an incision from four to live inche. length, from about two inches above and to the ft of the umbilicus, outwards in a curved direct- i, towards the lumbar region, terminating low the the anterior superior spine of the ilium : livide carefully each abdominal muscle, and the tr< sversalis fascia at the lower part of the wound separate the peritoneum, together with the ureter. ; om the transversal is and iliac fascia, and push it well aside; turn the patient on the sound side, d, with the finger, the sacro-iliac artic- ulation, over which the pulsations of the artery may be felt; expose the artery, together with its accompanying vein, which is in the sheath and on the inner side; isolate the artery and pass the liga- ture under it from u rds. If the iliac region be selected for the operation, make a curved incision about five inch< length, commencing on the left of the umbilicus and carried, first outwards towards the anteri- perior spine of the ilium, and from them along the upper border of Poupart's ligament to its mid- dle and then follow the directions given above. ILIAC ARTERIES. 261 Remarks. — This operation has boon performed with mi jcesa though it is. of course, both difficult of execution and dangerous in its consequences. The indications i'ov its performance are, aneurisms, wounds, involving the external and internal iliac arteries, or secondary hernowpiage after amputa- tion of the superior third of the thigh. it is of the first inaportam >id wounding the peritoneum, lest inllannrliion be developed in that delicate and susceptible membrane, and thins add another source of danger to the patient's life. [t should be carefully held aside, by the finger or a r spatula in the hands of an assistant, and most tenderly hand!. According to Quaiu the length of the vessel va- riee greatly, — rangingin five sevenths of the cases between one and and a half and three inches. When the artery is found to be very short, it is better to tie both the external and internal iliacs below. The points of importance are the relations of the 1 to the Lumba" vertebra, to the crest of the ilium, to the umbilicus, to the vena cava and com- mon iliac veins of the right side, and to the inner side, [n making the incision, care must also be taken not to carry it too Low down or too far for- wards, as in doing so there is danger of wounding the epigastric, and circumflex-ilii arteries. Of - referred to by Erichsen, nine recovered. me ' died. In two of the fetal eas- es the peritoneum was opened, and in four of the others, death seemed mere the result of the orm-i- o nal affection than of the operation. When the 2P>2 ILIAC ARTERIES. depth of theartery is considered, together with its great size, the force of the blood current through it, the intimate relations sustained by it to important structures, and its proximity to the heart, the dan- gers and difficulties of the operation must be suffi- ciently patent ':o inspire the Surgeon with caution and apprehoay.ion in regard to it, notwithstanding the statis;. i^, ^formation furnished by Erichsen and others in tin- connexion. Ligation of the Internal Iliac Artery. — The inter- nal iliac artery is a short and thick vessel which commences at the bifurcation of Ihe common iliac, and, passing to the margin of the greater sacro-sci- atic foramen, divides into two trunks, which are distributed to the subjacent parts. PLAN or RELATIONS. In front. — Peritoneum ami ureter. Outer side. — ■ Psoas magnusmuscle, Behind. — Internal iliac vein, lumbar sacral nerveand p.^oas muscle. This artery and the common iliac as regards their length, bear an inverse ratio to each othei% the one qeino- long when the other is short and vice.versa. The point of division oi the internal iliac varies between the upper margin of the sacrum and the upper border of the sacro-sciatie forarnem. The application of a ligature to the internal iliac nuiv be required in cases of aneurism; in wounds affecting one of its branches, , or in hemorrhage fol- lowing amputation of the thigh, &c. Directions. — Make an incision through the ab- dominal parietes in the iliac region, in a semilu- nar direction and to the same extent as for deliga- ILIAC ARTERIES. 263 tion of the common iliac; cautiously divide the transversalis fascia, push the peritoneum inwards from the iliac fossa, unci distinguish the external iliac at the bottom of the wound : trace thisartery up until the internal iliac is discovered opposite the sacroiliac articulation: separate the vein on the left, iln* external illiac on the right, and the peritoneum and ureter in front of the v. asel ; open the sheath, isolate tin 1 artery, by passing the left fore-Jinger under it from vide, and the from the outer side, and then hook- ing it up upon the finger, or grasping it between the thumb and index finger; and, finally pass the ■ ure around it from within outioards. Rt This operation has been attended with considerable success, but all that was said in »ard to the ligature of the common iliac will ap- p with almost equal force to this deligation of internal iliac. One of the cheif dau ft om j> sritonitis, and the gr< . re should be taken not to injure the ritoneunf, throughout the various steps of the op- eration. Vs soon as it i irered, the surgeon or an tuld bold it carefully aside, and its sepi iration i title tou the left fore fing sr, in the direction of rtebral artie ulation, until the bed. Too nun id caution cannot be exercised in i It is import ■ not to include the ureter in the ligature, wb ild prove a most imfortuua Theur aesjust and is separa- ted \y| ih consid* ifliculty from the vessel. — ^64 ILIAC ARTERIES. distinguish it, however ? and separate it or abandon the operation so that upon nature and not surgery, may rest lie responsibility of a fatal issue. In m? fing the first incifcion, great care should be take- not to divide the epigastric artery, or to penetra the peritoneal cavity, as may be readily done w re the muscles are not poorly developed. Ligc i z of the External Iliac artery. — -This is the chief vc >el by which the lower limb is supplied with It passes obliquely downwards and outward horn the bifurcation of the common iliac, along tli inner border of the psoas muscle, to the femoral arch, where it becomes the femoral artery. The ci of this arl indicated by a drawn fr m the left vide of the umbilicus to a point midway between tht • nor spinous pr of theilium and the symphysis pvbes PLAN OF RELATION;?. Infr&nt. — Peritoneum, intestines and iliac fascia, spermat- ic vessels, genito-crnral nerve, circumflex ilii vein, symphatid vessel and gland. Outer side. — Psoas magnus iliac fascia. Inner side, — External iliac vein of vas deferens ami femoral arch. Behind. — External iliac vein. Ligation of the external iliac artery may be re- quired for wounds and aneurisms, of the femoral artery, and also for secondary hemmorhag-e follow- ing amputations, when all oilier means have failed in arresting the flow of blood. The vessel may be secured in every part of its course save near its upper and lower extremities^ the circulation at these points being too rapid to ILIAC ARTERIES. 265 admit of the formation of a sufficiently firm clot to meet the ends in view. Directions. — Place the patient in a recumbent position; make an incision, commencing an inch above, and to tho inner side of the anterior superi- or spinous process of the ilium, and running down- wards and outwards, to the outer end of Poup ligament, and from thence parallel with its outer half to a little above the middle : divide, the abdo- minal muscles and cut cautiously through thutrans- versalis fascia; separate the peritoneum carefulh from the iliac fossa, and push it towards the pelvis i introduce t e index linger, and find the artery pul- sating at the bottom of the wound along the border of the psoas muscle : separate the ilia< from the artery, on the inner side, by means of the c nail : Oj en the sheath, isolate the artery ally, and pass the ligature under the artery from within outwards, i. e., between the vein and artery, leaving out the small nerve which accom panies the latter. Remarks. — The direction of the external incii een much varied by different surgeons. Thus Abernethy cut o sel ; Sir A. Cooper made the incision from t 1 ■ ternal margin of the external ring to the anterior superior spinous process of tb following the ion of Poupart's ligament; while Velpeau modified this precedure, without improving on it in the I • The tbjection to Abernethy' s plan is the '••'• of subse [uenl hernial protrusion in conse- quence of the abdomen beingmuch weakened by 2<% ILIAC ARTERIES. the free incisions through its muscular fibres. It lias the advantage however ofpermitting the dele- gation of the artery at any portion of its coarse, and of allowing the incision to be extended op- wards if necessary' 90 as to expose the common iliac. The incision recommended by Cooper ts direct- ' ly across the track of the epigastric and circumflex ilii arteries, as well as the circumflex vein. The spermatic cord is somewhat in the way of this operation. Its chief recommendations are the pro- tection afforded to the peritoneum, and the im- munity secured from subsequent hernial protru- sions. The most common evil followingthese operations, hgangr£neoi the limb, resultingfrom the curtailment of the sanguinious supply to the part, in conse- quence of the obliteration of the main channel and the tardy development of circuitous ones. The period at which this mortification occurs is usually about the third or fourth week ; and the only means of saving the life of the patient is a speedy, resort to amputation. The greatest possible attention- must be be- stowed upon the preservation of the peritoneum from all wounds or injury, at every step of the op- ration. Peritonitis is one of the mast serious (•■..im- plications by which the Surgeon can be embarrass, ed, and the patient's life endangered. It is important to hava the incision as long as practicable, but it must not be carried far enough to implicate the external ring, lest it induce a ten- dency to hernial protrusion. ILIAC ARTERIES. 267 Before beginning the operation shave thepubes, and empty the colon by means of an enema. This operation was first attempted by Aber- nethy, in 1796, and since that period it has been performed at least loo times, with a mortality of only 26 per cent. Sir A. Cooper declares that, "this operation may be performed without the least difficulty, and is as easy as tying the femoral artery, there being only one circumstance that occasions the least danger, and that is the epi- gastric artery which passes up from the iliac- ves- sel, and on the inner side of the incision ; but this however may be avoided." The distance of the artery from the surface, the great danger of wounding the peritoneum, and its close proximity to important veins and nerves, as well as to the spermatic oord, all goto prove that the deligation of this artery is a more serious and im- portant thing than is supposed by Cooper, and to warn the conscientious Surgeon against an opera- tion into which the mere desire for eclat might pos- sibly hurry him. The circulation is carried on after the ligation of this artery by means of the gluteal and ischiatic arteries, — the former being the principal one con- cerned. It cannot be denied that, operations on the iliac vessels generally, are far more success- ful than upon those vessels above the heart which pertain especially to the trunk, notwith- standing that the former are more deeply seated. surrounded by more delicate structures, and are even oi' larger calibre. 268 axillary artery. Ligation of the Arteries of the Superior Ex- tremity. — Ligation of the Axillary Artery. — The axillary artery commences where the subclavian termiates, at the lower border of the first rib, and becomes the brachial at the lower border of the tendon of the latissimus-dorsi and teres major muscle. In the normal quiescent position of the limb, the artery forms a gentle curve, the convexity of which is outwards and upwards. For convenience of description this artery may be divided into three portions, viz : the portion above the pectoralis major, or first part; the por- tion beneath the pectoralis muscle, or the second part ; and that portion below the muscle and in the axillary space, the third part. Eelations the first portion of the axillary artery : Infront. — Pectoralis major, costo-coraooid membrane, ce- phalic vein. Outer side. — Brachial plexus, Inner side. — Axillary vein., Behind., — First intercostal space and muscle, first serration ot serratus magnus, posterior thoracic nerve, The artery maybe tied in this portion, in case of aneurisms or wounds of the second portion, but it is not the point of election. In some few cases it has been performed with success, but it is always difficult and dangerous. Directions. — Place the patient on his back, with his shoulders slightly raised, and his elbow a little removed from his body , make an incision three inches long, three quarters of an inch below, and parallel to the clavicle, and terminating at the AXILLARY ARTERY. 269 junction of the deltoid and pectoralia major; cut through the platysnia and pectoralia carefully," lay- er by layer ; divide, on a director, the posterior Sheath of this muscle which doubles back and lias the appearance of an aponeurosis; then bring the arm to the body, and with the end of the director, or the handle of the knife, tear aside the cellular >veriug the vessel, and carry the finger be- hind the upp< oralis mi cle ; draw the vein inwards by means of a blunt hook, and pass the iieedh en it and the ar m within outwards. Remarks. — This ligature is one of the most diffi- cult to apply, ,both from the large muscles which have to be cut through, the depth ofthe vessel, and and the number oi jels which have to be di- vid( it is ofthe first importance to avoid the cephalic and axillary veins, — the former running along the external border of the pectoralis major, cro the artery to join the axillary on the inner side of that vessel. The vein is an admirable land mark, and when found should be drawn care- fully aside, so that the artery maj be reached a lit- tle to tin iind it. It. is better to tie th vian in the third.part maud e the middle por- lu oeral pracl upon and lying the \ d below th ■ wound should be rigidly ad- : to under all cil 270 AXILLARY ARTERY. RELATIONS 01 THE SECOND PORTION OF THE AXILLARY ARTERY. Infront. — Pectoralis major and minor. Outer side. — Brachial plexus. Inner side. — , Axillary vein. Behind. — Subscapularis, The brachial plexus surrounds the artery and separates it from direct contact with the veins and muscles. This vessel is so deeply seated and so completely surrounded by important structures that an operation for its ligation is very seldom at- tempted. Desau It and Pelpceh. have given direc- tions for the proper performance of the operation, but it is now generally condemned because of the facts mentioned above, and the additional consider- ation of the great depth of the artery and its close investment by important nerves. RELATIONS OF THE THIRD PORTION OF THE AXILLARY ARTERY. In front. — Integument, fascia, and pectoralis major muscle. Outer side. — Coraco-braclnalis median nerve, musculo-cu ta- neous nerve. Inner side. — Ulnar nerve, interna! cutaneous nerve, axillary vein. Behind — Subscapulars, tendons of latiesirnus dorsi and teres major, spinal and circumflex r.erves. The artery is usually ligated in this portion, be- cause it is more readily reached and easily iso- lated. Directions. — Place the patient upon a bed ; sep- arate the arm from the side and supinate the hand ; having found the head of the humerus, make an irmision over it, through the integuments, about two inches in length, and a little nearer the poste- rior than the anterior fold of the axilla ; carefully WILLARY ARTERY. 271 dissect through the fascia and areolar tissue, until the median nerve and axillary vein are exposed; displace the former to the outer, and the latter to the inner side of the arm, bending the elbow so as to relax the muscles ; and then, having isolated the artery, pass the needle from the ulnar to the radial side. Remarks. — It must be remembered that the axill- ary artery in about one case in ten gives off a large branch which forms either one of the arteries of the fore arm or a large muscular trunk. Ligature of this artery is called for in cases of wounds and aneurisms at the upper part of the arm: and, when circumstances admit of its appli- cation in the lower portion of the vessel, the oper- ation is simple and e:i>\ . Ligation of the Brachial Artery.— This artery commences at the lower margin of the tendon of the teres major, where the axillary terminates, and extends to about one inch below the bend of the elbow, where it is divided into the radial and ul- nar. The direction ot this vessel is marked by a line extruding from the outer side of the axillary space bo a point midway between the condylee of the hu- merus, which corresponds with the depression along the inner border oi the coraco-brachialis and bicejys muscles. Tn the upper part of it.- course, the artery is less interna! to the humerus, but below, it is in front of that bone. 272 BRACHIAL ARTERY. RELATIONS OF THE BRACHIAL ARTERY. In front. — Integument and fascia, bicipital fascia, median basilic vein, median nerve. Outer sale. — Median nerve, coraco-bvachialis, biceps. Inner side. — Internal cutaneous, ulnar and median nerves. Behind. — Triceps, musculospinal nerve, superior profunda artery, coraco-brachialis, bracialis anttcus, and bend of the elbow. The median nerve, at the upper portion of it- course is external to it; about the middle of tjie arm it is mfroiit of the artery ; and further down towards the elbow, it is upon the inner side of the vessel. The basilic vein is at first on the inner side, and then gets in front of the artery, and lies in the line of it, for the remainder of its course. The artery is accompanied by two veins, the vense comites, which lie within the sheath, in close contact with the main vessel, and arc connected together at intervals by transversa commu- nicating branches. At the bend of the elbow, the brachial artery sinks deeply into a triangular space, which contains, also, the radial and ulnar arteries, the median and musculo spiral nerves, and the tendon of the biceps muscle. Occasionally the ar- tery is divided high up the arm, either to unite before reaching the elbow or to be continued, t« the fore arm as the radial and ulnar arteries. The artery may be ligatured either in the uppei third of the arm or in the middle third of that mem- ber. In the upper portion the coraco-brachialit muscle is the guide for the operation ; while in the lower portion the inner margin of the biceps, furnish- es the proper indication. Directions for applying the ligature in the uppei portion.-— Place the patient horizontally upon the BRAOHIA] JlRTEB 273 table, raise the affected limb from the side, and su- pinate the hand ; make an incision two inches in length on the ulnar side of. the coraco-brachialis muscle, anddividcthe fascia carefully as high as the axilla : rut carefully through the cellular tissue and separate the ulna nerve on the inner side, the med- ian on the outer side; open the sheath, and detach the vena? comites which are on either side of the vessel ; and. then, pass the aneurismal needle un- der the artery from the ulnar to the radial side. The vein is on the inner side, and should be care- fully avoided- Lisfranc recommends that the posi- tion of the median nerve should be found, and thai then, placing the four lingers of the left hand, an incision should be made on the inner side ot it. ('arc should be taken in every operation to ascer- tain whether there are two arteries in the arm, consequent upon a high division of the main trunk, and. in such a contingency, to ligature both of ' them. Directions for applying the ligature in. the mid- the arm. — Place the patient horizontally up- blc, with the attected limb raised from the side; make an incision along the inner margin of ■ biceps muscle, two indies and a half in 'length ily including the skin ; open the brachial appn- rosis and carefully carry- the basilic vein out of ic way: then find the median i erve which is im- diately on the edge, of the muscle ami above the and draw it and the muscle aside, with the blunt In. ok : carefully avoid the interna] cutaneous nerve on the inner side of the VCBael, and open the eath of the vess< 1 ; then separate the venae com- "274 BRACHIAL ARTERY. ites isolate the artery, and pass the needle under it from iviihin outwards. The lower ipart of the. artery is interesting be- cause of its connexion with the veins usually opened in venesection. The median basilic vein passes immediately in front of the artery, only being sep- arated from it by the fibrous expansion given off from the tendon of the biceps to the fascia covering the flexor muscles. It is important therefore, not to open this vein, if either of the others be large enough to justify an operation, lest the artery be injured by the lancet. Should it become necessary, however, to open it, great care should be observed by the Surgeon, not to wound the artery, &c. . If the vein is parallel with the artery, pronate the hand violently, so as to increase the distance between the two vessels, and if the muscles are in the way flex the fore arm slightly, for the same pur- pose. When the vein is situated immediately over the artery, introduce the lancet horizontally, and compress the artery at the moment of bleeding. Should the artery be punctured, the bleeding may be arrested temporarily, at least, by flexing the fore arm, putting it in a state of pronation, and apply- ing a compress over the wound. It is well also to qandage the whole limb. Remarks. — As this is the main arterial branch by which the arm, the most useful and exposed of all the members, is supplied with blood, it follows that its deligation, both on account of injury and disease, is a task of very frequent performance. In the battles before Richmond, the number of wounds received in the arm was the subject of universal re- BADI'AI ARTERY. • 275 mark. No accurate statisical information has yet been furnished in regard to this subject, but the author feels assured, from his own personal obser- vation, as well as the assurances of others, thai of all the operations performed upon the jield, at least half were for injuries of the superior extremities. The management of the musket and the sabre, the removal of obstructions, &C., necessitate the con- stant use and exposure of the arms, and thus fur- nishe an explanation of the fact just mentioned. Again, the brachial artery is verY frequently in- jured in venesection, both by direct puncture, and development of aneurisms, so as to require the ap- plication of the ligature. The operation 1 may be readily, rapidly, andsafely performed, if the anatomical relations of the parts are properly understood, and remembered. Ligation of the Radial Artery. — The radial artery, judgingfrom its position, is a veritable continuation of the brachial, though it is smaller in size than the ulnar. It commences at the bifurcation of the brachial, an inch below the bend of the elbow, passes along the radial side of the tore arm to the wrist, then runs backwards round the outer side of the carjms, beneath the extensor tendons of the thumb, and runs forward between the two heads of the first dorsal interosseous muscle into the palm o\' the hand. Aiter reaehing tin- palm it form* with th inch oftheulnar, the deep pal- it may be therefore divided, for conve- nience of description, into three papts,viz : that 'on in fnmt of i: rm; that at thebaekof tlir wrist; and thai in the hand. 27 G RADIAL ARTEL i. RELATIONS OF THE RADIAL ARTERY. In front. — Integ'iment, fascia and supinator longus. Outer side. — Supinator longus, radial nerve, (middle third.) . — Pronator radii teres, flexor carpi radialis. Behind. — Tendon of biceps, &c. In the upper third of its course, it lies between the pronator radii teres aud the supinator longus ; and in the lower third, between the tendons of the supinator longus and the flexor carpi radialis. In the middle third of its course, the radial nerve lies along the. outer side of the artery; and some filaments of the* musculocutaneous nerve run along the lower part of the artery as it winds around the wrist. The vessel is accompanied by vena; comites throughout its coure This artery is tied for wounds and aneurisms. — The tendon of the\ pi radialis is the the guide for the operation in the middle and lower parts of the arm. Directions for applying a ligature in the lower third of the fore arm. — Make an incision from half an inch above the wrist joint, two inches in length on the radial side of the tendon of the flexor carpi radialis ; divide with another incision the aponeurosis of this tendon ; open the sheath and separate the vense comites ; and then isolate aud ligate the artery by passing the needle from without inwards. Directions for applying a ligature on the upper third of the fore arm — Make an incision two inch- es and a half in length, beginning at a point half an inch outside of the middle of the elbow, this should divide the skin only, for fear of injuring the median vein, which ordinarily is on the inner side RADIAL ARTERY. 277 make another incision, laying bear the supinator longus ; raise the internal border of this muscle with the linger or director : then open the sheath isolate, and ligate, — passing the needle from with- out inwards so as to avoid the nei Directions for applying the ligature on the dor- sum of the wrist. — Extend the thumb Btronelv, so as to cause the abductor longus, and extensor lon- gus pollicis to become prominent; seek for the ar- tery in the depression between these muf known as tk la taba parate the thumb from the index finger, and make an incision about an inch loug, in the direction of the tendons above referred to; separate the nervous filaments and veins carefully ; and then isolate the artery and apply the ligature. The artery is readily exposed throughout its who' . but the operation in tho upper third is atl ended with more difficulty than at other por- tions of the vessel, on account of its greater depth, and the position of the supinator longus muscle. The operation upon the dorsum of the thumb is fit only for the dis >m. [t is useless to lig are the radial artery on ac- count ofhemorrl] :her the superficial or ■ palmar arch, as the supply of blood from one direction only is thus cut iving a chan- iqually as broad and (hep, communicating with the severed artery. - such cir.< umstan- ces, as wcil as tor am and wounds of the hand and Pore aim generally, the brachial mu&t he Ligatured. In woun Is, she general rule must, be followed of applying the ligatures at the seat of I -J ULNAR ARTERY. : ajury, both above and below the divided surface ci' the vessel ; and when this is impossible, either compression or ligature of the brachial must bo substituted. The origin of the radial varies in the propor- tion of one in eight cases. Sometimes its point of origin is lower but more frequently higher up. It is thought by some Surgeons that the liga- tion of the artery should not be attempted above the middle third, as the operation in the upper third is not only difficult, but calculated seriously pair the integrity of the muscles. Ligation of the Ulnar Artery. — This is the larger of the two terminal branches of the brachial. It commences a little below the elbow, then crosses the inner side of the fore arm obliquely to the commencement of its lower half, and runs along the ulnar side of the wrist, until it enters the palm, by crossing the annular ligament, on the outer side of the pisiform bone. After reaching the hand, it forms with the superficialis vohe, a branch of the radial, the superficial palmar arch. RELATIONS OF THE ULNAR ARTERY. In front. — Superficial flexor muscles, median nerve, superfi- cial and deep fascia. side. — Flexor sublimis digitorum. r side. — Flexor carpi ulnar is, ulnar nerve, (lower f.) J. — Brachialis anticus, profundus digitorum. 'he wrist the ulnar artery is covered by integ- uments and fascia, and lies upon the anterior an- gular ligament, with the pisiform bone and ulnar IRTERY. 279 nerve on the inn< r swfc,- the latter being somewhat behind the vessel. The ial palmar arch is covered by the palmaris brevis, the palmar fascia, and the integ; utnent. Direction. — The artery is deeply seated in the upper half of the fore arm, beneath the su- perficial flexor muscles, which in cases of recent wounds, may be divided, but under no other cir- cumstanc In the middlt and inferior thirds of the lore arm, this vessel may be secured in this manner: Make an incision on the radial side erf the tendon of the flexor carpi ulnaris; divide the deep fascia, and separate the flexor carpi ulnaris from the flexor sublimis; open the sheath, separate the veins, iso- late the artery, and pass the needle from the ulnar to the radial side, taking care not to injure the ulnar nerve. This artery may he deligated in cases i^l' aneu- risms, wounds. i •.. in either of its main trunks or branchi It should not be ligatured above the middle third save in exceptional cases of injury, for fear of per manently injuring the superficial flexor muscle, which must necessarily he cut through in the ope- ration. In wounds of the palmar arch, it is better to seek tor the bleeding and to ligature each, as com] roduce much irritation and at best are rather paliativetlian curative measures. If the hemorrhage cannot If arrested in thin was . both the radial and ulnar, or the brachial alone may 280 FEMORALJARTERl . be tied, which will effectually arrest the flow of blood from the part. When a compress is used for hemorrhage from the palmar arch, it should be in the shape of a ball — the hand being made to grasp it firmly and the graduated compress applied to the arm,' for the pur- pose of diminishing the amount of blood sent to the part, Ligature of the arteries of the inferior ex- tremity. — Ligation of the Femoral Artery. — The femoral is a continuation of the external iliac, and extends from Poupart's ligament to the middle of the lower third of the thigh, where it becomes the popliteal. It commences at a point midway be- tween the anterior superior spine of the ilium, and the S}'ph. pubes, passes down the inner aspect of the thigh, and penetrates (he adductor ma-gnus •hiuscle. A line drawn from the point just referred to, i. e., midway between the anterior superior spine of the ilium, and the syph. pubes, to the inner side of the internal condyle of the femur corresponds with the direction of the artery, and is nearly above and parallel to it. In the upper part of the thigh , the artery is very superficial, and lies in ".Scarper 's triangle." This triangle is bounded thus : external/.// by the sartor- ius muscle, internally, by the adductor lung us, and above hy Poupart's Ligament, which is its base, its apex being downwards. This triangle corresponds to the depression seen immediately below the fold of the groin, and is nearly equally divided by the FEMORAL ARTERY. 281 femoral artery aud vein which run from base to apex. In this space the artery is crossed in front by the crural branch ofthe genito crural nerve, and be- hind by tlie branch to the pectineus from the ante- rior crural nerve : while the anterior crural nerve lies about half an inch to the outer side, imbedded between the iliacus and psoas muscles, The vein, which is included in the sheath with the artery, is on the inner side, the vessels being separated from each oilier by a thin fibrous partition. En the middle third ofthe thigh, the artery is less superficial; being covered by the integuments and fascia, and overlapped by the sartorious muscle. — also enveloped in an aponeurotic canal formed by a dense band which extends from the vastus interims muscle to the tendons of the adductor longus and magnus. The femoral vein passes beneath the artery, and lies upt n its oiidr side: and still more externally,, is the the long saphenous nerve, but not included in ame sheath. Ligatures are frequently applied to the femoral artery, princi] allj for aneurisms and wounds, and the vessel may i ited at any point in its course. Theoperation is however much more dif- ficult in the middle third thigh than in the upper part of the course ofthe artery, because of reater depth, and the thickness of its aponeu- rotic covering. The artery may be tied : 1. Above the origin ofthe profunda. 2. In the triangle of Scarpa, just above the point 282 FEMORAL ARTERY. where the artery is crossed by the sartorious mus- cle. 3 Under the sartorious, j ust below the apex of the triangle, where the artery is only slightly overlap- ped by the muscle. 4 Under the sartorins, in the middle part of the thigh. 5 At the outer side of the sartorious, below the middle of the thigh, when the vessel is lodged in the sheath formed by the adductor magnus mus- cle. Of these various points, the one just below tJie apex of the triangle, where the artery is slightly over- lappedby the muscle, presents the fewest difficulties, and the greatest advantages. This point is about U inches from Poupart's ligament, and is suffi- ciently below the origin of the profunda to admit of the speedy formation of a firm coagulum w T ithin the vessel. The artery can also he readily reach- ed at this point, as it is only covered by the in- ner edge of the sartorins which can easily be raised, while it serves as a guide to the operator. Directions. — Place the patient upon his back, with the pelvis slightly elevated; isolate the thigh outwards, and partially rlex the limb ; follow the course of the artery to the apex of Scarpa's triangle where it ceases to pulsate and is covered by the sartorins. The ligature is to be applied about fof an inch below this point. Make an incision three inches long commencing lour ringers' breadth be- low the fold of the groin, and running directly- over the course of the artery ; look for the great saphena vein, in the superficial fascia, at the inner MORAL LRTERY. side oi the incision, and carry it carefully to one aide; divide the superficial fascia upon the groov- ed director ; open the cellular tissue beneath with the point of the director, for the whole length of the wound: puncture the fascia-lata. which comes in view, and divide it on the director for about half the extent of the iirst incision ; then draw the inner edge of the sartorius outwards; open the sheath oftheartery, isolate the vessel, and pas aneurism needle carefully lest the vein which is posterior to the artery be wounded. The application of a ligature to the femoral arte- ry ma} be requiredin aneurism or wound oi the arteries of the leg, or when hemorrhag istent" character follows amputations of the lower extremity . Larreytied it above the profunda before am tating at the hip joint, but subsequent exper has demonstrated that this is an unnecessary com- plication, — increasing materially the difficulty and danger of (he operation. It is ;i matter of importance not to apply the lig- ature in the neighborhood of a large branch by so doing, the m of the blocking <■< lum be prevented. The deligation of the artery within the sheath of the adductor maguus ie to be avoided becaue the difficuly of reaching the vessel, and the u sibility of preventing the the accumulation of pus within the wound. The poinl indicated aim- incomparably the best for the operation. In opening the sheath of the artery, care sh oid a small nerve which en 284 FEMORAL ARTERY. and ah not to make too large a wound, lest the nutrition of the coats of the vessel he interfered with, a I muscular branches, which are irregular in their erigiu, divided. In order to avoid the femoral vein which lies be- hind and somewhat on the inner side of the artery the needle should be passed from within outwards, the inner side of the sheath being at the same time put upon the stretch. Wounds of this vein are tiie most serious accidents which associate themselves with this operation, and are usually fatal, producing phlebitis or gangrene. The ligature of the temoral artery is attended with more success than of any of the large trunks of the body, as is established by the statistics of published cases. In 100 cases collected by Dr. Crisp, only 12 were reported to have died. Secon- dary hemorrhage and gangrene are perhaps the most frequent accidents which follow this opera- tion, and jeopard its success. Should secondary hemorrhage occur, four plans of treatment are open to the Surgeon, viz : the employment of pressure ; the ligature of the vessel at a higher point ; the delegation of the bleeding orifice in the wound ; or amputation of the limb. In determining what course to pursue in such a con- tingency, the Surgeon must follow the light of his own judgment, as no general rules can be estab- lished on the subject, and each case prevents fea- tures sui generis such as furnish the clue to the proper method of treatment. After the ligature has been applied, the edges of the wound should be brought together with adhe- FEMORAL ARTERY. 285 sive plaster and stitches, and the limb semi-flexed, Bomewhal raised, and wrapped in soft flannel or COtt< ■ The severe pain about the knee which follows this operation, may be relieved by the exhibition of full doses of opium 1>\ the mouth, or 'the admin- istration of morphia subcutaneously. Ligation of the Popliteal artery. — The popliteal artery extends from the tefminatii n of, the femoral at the opening in tire abductor magnns, to the low. er border of the popliteal space, where it divides into the anterior and posterior tibial arteries. This Bpace*is l< and is bounded thus: Ex. the joint by the biceps, and below the articulation, by the plantaris and the external head of the gastrocnemius. Internally, above, the joint, by the semi-membranosus, semi-tendinosus, gra- cilis and sartorius ; and below, by the inner head of the gastrocnemius. A.bpve it is limited by the apposition of the inner and outer hamstring mus- and below by the junction ofthe twoheadsof tin 1 gastrocnemius. The artery i d superficially above by the 6emi-membranosus ; in the middle of its course, by a quantity if fat ; and below by the margins of the gastrocnemius, plantaris and soleus muscles, the popliteal vein and internal popliteal nerve The win is - • rnal to it until near the termination of its course when it over, and on its inn The nerve is still more su- perficial and external, bul Grosses the artery below the joint, and then, remains upon its inner side. 12b 28fi PfiMORAL ARTERY. Laterally it is bounded by the muscles -which fbrifl the confines of the popliteal space. • The operation may be performed in the upper or the loioer part of its course ; but in the middle of the space, its deligation is attended with much diffi- culty from the great depth of the artery, and the tension of its lateral boundaries. Directions for the upper part of its course. Place the Patient in the prone position and extend his limbs; make an incision three inches in length through the integument along the posterior border of the semi-membranosus; divide the fascia lata and draw the muscle inwards; find the artery by means of its pulsations; separate the vein, which is on the inner side, and the nerve on the outer side, from the artery, taking care to injure neither the one nor the other; isolate the artery, and pass the needle from without inwards. Directions f of Loioer portion of its course. Place the patient as before ; make an incision through the integument, and in the middle line, com- mencing opposite the bend of the knee joint, taking care to avoid the saphena vein and nerve; divide the deep fascia on the grooved director, and break up the cellular tissue with its point; separate the' vein and nerve from the artery, by drawing the one outwards and the other inwards; isolate the artery and pass the needle from without inwards. Remarks. — Ligature of the Popliteal should only be attempted for wounds of that vessel; but for aneurisms below the joint, it is far better to tie the femoral above. The Popliteal space is so filled with important structures, and the vein, nerve and BRI0R XIBIAt AKTERT. artery are in such close contact, that some of t< best Surgeons, declare it is best not to open th - e even in punctured wounds of the Poplite artery. Operations in this space are also likely to lea . burrowing abscesses which may involve the jo - " and produce the most serious consequences. Ligation of the Anterior Tibial , Artery '. — The Anterior Tibial Artery extends from the point vt which the Popliteal bifurcates, to the front of ankle joint where it becomes the Dorsalis Pi A line drawn from the inner side of the head, of 'ibula to midway between the two mall. will be parallel with the course of this artery. PLAN OF RELATIONS. —Integument, superficial and deen fascia, t'. ia, extensor longus digitorum, extensor propriue pollicie, anh rior tibial nerve. ner stefe.— Tibialis* an ticue, extensor pfropriug pollicis. side. — Anterior tibial nerve, extensor longus digi- n, extensor propriue pofticis. id.— Interosseous membrane, tibia, anterior ligemcnt ie joint. third of its course it lies between or longus digitor third, between the tibialis anti< us propriue pollicis; and in the third, betwc» lendon of the proprius •mennost tendon- of the exi - rum. The anterior tibial nerve lie a le; then, about the middle to it; and in the lower •in on th -!de. ecompanied by "two v< 288 ANTERIOR TIBIAL ARTERIES. venee comites, which lie upon either side through out the whole of its course. The artery may be tied either in the upper or the lower part. Directions for the operation in the upper Part.— Place the patient upon his back and extend the limb make an incision about four inches in length mid- way between the spine of the tibia, and the outer margin of the fibula; divide the fascia and in- termuscular septum between the tibialis anticus and extensor communis digitorum, placing the foot so as to relax these muscles and separate them from eaci' other with the finger; having thui posed th< trtery, separate the vena?, comites on either si , and the nerve on the outer side ; isolate the arte and pass the aneurismal needle under it from i hout inwards so as to avoid the anterior tibial ik e. Directions for the operation in iht middle third the Leg.— -Vlake an incisiou about three inch length al ng the external border of the tibialis anticus n .scle ; slit the superficial fascia and apo- neurosis J ".r the whole length of the wound and divide them transversely for half an inch or more at each end of the wound, so as to facilitate the separation at the muscles ; find the first yellowish intermuscular line which separates the tibialis anticus and the extensor communis digitorum, and open it thoroughly with the finger or the ^oint of the director ; flex the foot so as to relax these muscles, and then hold them asunder by meai the finger, or blunt hooks; draw the nerve to one side; then open the sheath, and isolate the -artery ANTERIOR TIBIAL ARTERY. 289 from its accompanying veins, and pass the needlo under the art( Directions for ligation of the artery at the low< r third just above the ankle joint -The same general rules will apply. The artery is very superficial and may be readily de alsations between the tend ma of the extensor communis, and ex- tensor pollicis. The nerve is on its outer side, and should ho recognized and held carefully aside. The anterior artery should not ! for wounds. The point of election is the middle third of the limh, as it is more readily reached and isolati point fn the upper third it is covered by muscles, and cannot b< exposed with- out disturbing them greatly. In the \rd of the limb, though the artery is superficial and can be readily found, it is too closely in relation with the sheaths of the tendons, and the ankle joint to justify its ligation save in cases of absolute ne T he necessity for the double application of the ligature, i. e. above and below the point of division ur injury, augments in p u to the remoteness of the artery from the heart, in intercommunication nastomosing branches, which is developed as the vi edes from the centre of the tin tion. In isolating the artery advantage will be ga by curving the point of the director. Especial pains should beta iparate the vepaa comites so as to avoid the induction of phlebitis. jatioi of the Voralis Pedis Artery. — A u atony The dornalisped ontiuuation of the ant< 290 DORSAL ARTERY. tibial artery, and extends from the bend of the ankle to the back part of the first interosseous space, where it divides into two brunches, the dorsalis hallucis and the communicating. PLAN OP RELATIONS. In front, — Integument and fascia, innermost tendon of the extensor brevis digitorum. Tibula side. — Extensor proprius pollicis. Tibrila side. — Extensor longus digitorum, anterior tibial nerve. Behind. — Astragalus, scaphoid, internal cuneiform, and their ligaments, and the anterior tibial nerve. It is accompanied by veme comites which lie on its outer side. Directions. — Make an incision through the in- tegument two inches and a half in length, on the fibula side of the extensor proprius pollicis, in the interval between it and the inner border of the short extensor muscle; divide the fascia and ex- pose the artery; separate it from the vena; comites, and anterior tibial nerve on the outer side, and pass the aueurismal needle beneath it from within outwards. This is a simple operation and may be perform* edin cases of recent wounds or of hemorrhage fol- lowing amputations of the toes. Care should be taken not to malic the incision farther down than the back part of the first interosseous space a artery divides at that point. It may be tied at any part of its course, but the i ot the tarsal arch is the point usually selected. ■ Compression may be easily effected by pr against the tarsal bones, and this should always be fully tried POSTERIOR TIBIAL 291 before resorting to an operation. Occasionally the Dorsalis Pedis is developed into a vessel of large size, but not unfrequently it is almost entirely de- ficient. When it does not send terminal brandies to the toes, they are supplied by branches from the internal plantar artery. Sometimes the place is entirely supplied by a anterior peroneal artery. Ligation of the Posterior Tibial artery. — The Pos- terior Tibial is larger than the anterior and extends from the lower border of the popUteus muscle, to the fossa between the inner ankle and heel, where, beneath the origin of the abductor pollieis, it divides intotheinternal and external plantar arteries. Atits origin it lies opposite the interval between thefibula and tibia; as it descends, it approaches the inner side of the leg, lying behind the tibia; and in the lower part of its course, it is situated midway be- tween the inner malleolus and the tuberosity of the os-calcis. PLAN OF RELATIONS. In front. — Tibialis posticus, flexor longus digitorum, tibia and ankle joint. Inner side. — Posterior tibial nerve, upper third, Outcrsirfe. — Posterior tibial nerve, lower two thi: ■ eoleue, deep fascia and integu- ment. It is otfvered bv the intermuscular fascia, which ;i<(^ii . gastrocnemius and soh-us: ™i : :• third, where it is more su] i ' the integument and fascia, and i ms • pith the inner border of tills. J: ipanied by two veins, 292 POSTERIOR TIBIAL NERVE. and by the posterior tibial nerve which is just on the inner side of the artery, but soon crosses it, and. is on its outer side for the greater portion of , its course. ^1/ the ankle, the tendons and blood vessels are arranged in the following order : First the tendons of the tibialis posticus and flexor longus digitorum, lying in the same groove, behind the inner malleo- lus, the former beiug the more internal. Exter- nally is the posterior tibial artery, having a vein on either side, and still more externally, is the posterior tibial nerve. About half an inch nearer the heel is the tendon of the flexor longus pollicis. Directions for the application, of a ligature in the upper third. — Half flex the leg and lay it upon- the inner side; make an incision four inches in extent beginning at a point f to 1 inch behind the inner edge of the tibia, and running parallel with that bone; divide the superficial fascia and aponeurosis, to the same extent, taking care to avoid the saphena vein, which runs up nearly in the direction of the cut; make an incision across the aponeurosis at the two extremities of the wound; separate the cellular connexions of the internal head of the gastrocnemius, on the anterior surface, with the fore linger or director, and draw the muscle aside with 'e blunt hook; divide the belly of the soleus layer hv tayer in the direction of the .external wound, and at the distance of | of an inch from the tibia; cut the tendonous fibres of thrs^ muscle on the grooved director, for the whole length of the original incision; then divide the deep seated aponeurosis, cautiously and in the same manner; POSTERIOR TIBIAL ARTERY. 203 open the sheath of the artery, isolate the vessel, and pass the needle below, from within Outwards. Directions for the application bf a ligature at the rniddle third of (he leg. — Place the Patient as before ; make an incision three inches long obliquely down- wards and backwards from the posterior angle of (lie tibia to the inner border of the tendo Achillis, so as to crpss diagonally over the intermuscular e in which arc lodged the vessels ; divide the superficial fascia and aponeurosis in the same direction ; glide the forefinger into the bottom of the wound, and under the tendo Aehillis, so as to detach its cellular connexions freely; draw the belly of the soleus, which now comes in view up- wards and backwards, or divide it if necessary; puncture the deep seated aponeurosis, insert the tor and divide carefully ; then open the sheath bf the vessel, isolate, and tie the artery. Dir ' /• the application of a ligature to the i atthe ankle joint. — Place the limb as before: make a similunar. incision through the integument, two inches and a half in length, midway between the heel and the inner ankle; divide the subcutaneous cellular membrane, and then cat through the internal annular ligament, cautiously upon the grooved director; open the sheath of the ves from the veUse comites, isolate, and pass the needle from the heel towards'the ankle in order to avoid the posterior tibial nerve, care being taken not to include the vein r!'' application of aligature to the /'<>. - lihial arU ry in the low( r third oftht leg. — Place 201 POSTERIOR TIBIAL ARTERY. tlie Patient as before ; make an incision about three inches in length, parallel with the inner margin of the tendo Achiilis; carefully avoid the internal saphena vein, and divide the two layers of fascia upon a grooved director; open the sheath, separate the artery from the veil* comites, isolate, and introduce the needle so as to avoid the nerve which is on the external side. The depth of the artery in the upper and middle thirds renders it very difficult to tie the vessel at these points, and it is only justifiable in cases of wounds of the vessel. In aneurismeal tumours of the middle third, it- is better to ligate the femoral, rather than to operate in these localities. When the sole of the foot is woanded or when obstinate hemorrhage follows amputation of the toes, &c, the artery should be tied either at the ankle joint or in the lower third of its course. The latter steps of all these operations may be much facilitated, by flexing the leg upon the thigh and extending the foot so as to relax the muscles. The incision must be made from above down- wards when the right leg is operated on, and from below upwards where the ligature is applied to the left limb. Guthrie recommended and practised ligation of the popliteal artery in cases of wounds compli- cated with extensive effusion of blood between the muscle ; but it would be far better to tie the fem- oral under such circumstances. When this artery is tied for wounds, no regular operation can be performed, but an incision of suf- POS'J ERIOP TIBIAL lRTBR"i . 295 ficienl length should be made through the gaatrbc nemius and soleus, taking the wound for its ceu- tre. Two ligatures must invariably be applied un- der these circumstances, the one above and the other below the point of division, so as to prevent the possibility of hemorrhage either from the car- diac orthe distal side of the vessel. In wounds of the foot, compression should be made upon the artery, at a point about a finger's breadth behind the inner malleolus, before resort- ing to an operation. Pressure upon this point •on becomes very painful, and should not be per- sisted in. jation of /■< Peroneal Artery.- -The peroneal artery rises from the posterior tibial, about an inch below the popliteus muscle, and terminates upon the outer side of the os-calcis. It rests first upon the tibialis posticus, and for the greater part of its course in the fibres of the flexor longus pollicis, in a groove between the interosseous ligament and the ' bone. It is covered in the upper part of its course by the sole as [and deep fascia ; and below by the flexor longus pollicis. PLA* LATIONS. la front. — Tibialis posticus, flexor longus pollicis. . — Fibula. Behind. — Soleus. deep fascia, flexor longus pollicis. This artery rarely requires to be tied, except in cases of :ompound fracture, or punctured wounds, when no general rules can be followed. It is too deeply seat< d above, and too small below for an op- eration, so thai it is only in its middle portion that; 296 PBRONEAL ARTERY. a ligature is applied. This artery lies between the tendo Achillis and the fibula, while the posteri- or tibial is on the opposite side, between the ten- do achillis and the internal malleolus. For statistical information in regard to the liga- tion of arteries in the city of Richmond, refer to ta- ble "H" of appendix. C H A P T E R VII. DISLOCATIONS. Lawrence defines dislocation to be "a perma- nent separation of one, two, or more bones that arc naturally articnl ed — a separation that is gener- ally produced by external violence." According to this definition every bone in tbe body is liable to this accident, yet many of them are so firmly at- tached ns to preclude the possibility of such a re- sult save by the employment of an amount of force which produces other effects of so much graver character as to render their mere separation a matter of subordinate consideration. The bones which compose the skull, for instance, hardly ad- mit of being detached the one from the other, save by a degree of violence which produces the most Berious consequences to themselves and the subja- cent purls. The same remark applies to bones of the pelvis, and, in fact, to all bones, connected by plain surfaces almost as brOad as themselves, such the vertebrae, the tarsus and the carpus. Far the greater number of these accidents occur al those articulations which are known as (he gin- 298 VARIETIES OP DISLOCATION. glymoid or hinge like joints, unci the orbicular or ball and socket joints.! The former arc neither so firmly held together by ligaments nor so strongly supported by muscles, and hence, their separation is a matter of easy accomplishment. The orbicular, for the same reason, require less force to separate them than the ginglymoid ; thus dislocations occur with more ease and frequency at the shoulder than at the elbow, at the hip than at the knee, and so on for other similar articula- tions. Varieties of Dislocation. — Dislocations may be complete, incomplete, spontaneous, simple, com- pound, complicated, congenital, recent, ancient primitive or consecutive. Complete Dislocation. — When the articular sur- faces are entirely separated, the dislocation is said to be complete. Incomplete Dislocation. — When the bones are on- ly partially separated, the dislocation is said to be incomplete. Practically, there is not a great deal known concerning this variety of dislocation atthe orbicular joints ; but instances have occurred where the head of the humerus was found on the edge of the glenoid cavity. In the hinge like joints, asthe knee, elbow, and ankle, the osseous surfaces com- monly remain partially in contact. Sponta?ieous D : slocation. — This occurs in conse- quence of disease. When the ligaments which I ' • Much more depends upon the relative exposure of th« joint," remarks Hamilton, • than upon its anatomical structure." VARIETIES OF DISLOCATION. 299 connect the bonds are altered by disease of the joint, one of the bones may be thrown out of posi- tion by the action ol' the muscles, the ordinary cheeks and balances being removed — au occurrence which not (infrequently takes place at the Hip joint, and is occasionally seen in the knee. Some- times, in children, there seems to be an entire re- laxation both of the muscles and ligaments sur- rounding the shoulder joint, and spontaneous dis- location occurs, the limb falling from its nor- mal position, by the force of gravity alone. Tins is a grave accident, requiring time, patience, and skill to secure a permanent retention of the parts in their natural position. Sim/pie Dislocation. — This dislocation is called simple when unattended by fracture of the hone. laceration of muscular tissue, injury to nerves. division of blood vessels, &c. Compound Dislocation. — A compound dislocation LS one in which there is an external wound connect- ing with the separated parts. The skin is usually made tense by the presence oi a portion of the bone in an abnormal position, and in some in- stances it is ruptured, making an external wound. through which the osseous structures protrude or not, according to the circumstances of the case. When this rupture occurs a compound dislocation is the result. Complicated Dislocation. — When in conjunction with the separation of the bones, there occurs frac- ture of the arti ulating surfaces, muscular lacera- tion, injury of important nerves, division of large 300 CAUSES OF DISLOCATION. arteries, &c., the dislocation is said to be compli- cated- Congenital Dislocation. — When from malforrna- tiou of the articulation the hones cannot remain in contact, the dislocation is styled congenital. Recent Dislocation. — A luxation which has taken place within a period of a few days or at least a few weeks is styled "recent. " Ancient Dislocation. — 'A luxation which has ex- isted for a lunger period is considered an "ancient dislocation, " though the exact point of time at which it ceases to he "recent" and becomes "an- cient" has not been fully determined. Primitive Dislocation. — When the hone remains nearly or precisely in the position into which it lias been first thrown by the force brought to bear upon it, the luxation is "primitive.''' Consecutive Dislocation. — When the original po- sition of the bone has been changed, in consequence of muscular action, attempts at reduction, or from any other cause, the luxation is called "consecu- tive." Thus a "primitive" dislocation upon ischiatic notch may become a "consecutive" dis- location upon the dorsum-ilii or vice versa. Causes of Dislocation.! — The causes which operate in the production of dislocations may be divided into immediate and remote. I Malgaigne after an analysis of six hundred aud forty three of dislocation, states that " hexations are. very rare in "infancy, and that the frequency increases gradually up to the fifteenth year— then , more rapidly up to the sixty fifth year, trom which period onward they become more rare." The deduction from this statement is that age, as a" predisposing cause, is most active in middle life, lass ir advanced lift and ioast active in early life. CAUSES OP DISLOCATION. 301 Immediate causes are those agencies which exer- cise a direct instrumentality in separating the .M'ti- eglatcd bones. Under this head are comprised external violence, muscular contraction, and a com- bination of the two. External violence. — This may act either directly by pulling or twisting the parts asunder — as when the foot is displaced by a turn of the ankle, w hen the thumb is dislocated backward by a blow, or when the arm is torn from its socket by machine- ry — or indirect'.-/ when the force acts at a disi from the joint and the bone is thrown from its socket by the "lever like movement of the shaft " — as takes place when the head of the humerus is dis- Iocated by a fall. Muscular action. — Muscular action may cruse the displacement of a bone even when the parts ore in a healthy condition. Thus the lower jaw may be dislocated by excessive gaping, and the humerus driven from its place by making a violent muscular effort as in throwing a stone, strikil - a blow, &c. When the joint has been weakened by previous disease, dislocation readily results from muscular action as can be easily "understood. Combination of external violence and muscular action. — That dislocation may be occasioned by the combined influence of these two causes, when neither would be sufficient of itself to produce such a result, is evident. The usual manner, however, in which these two agencis act together is conjointly but not contemporaneously. Thus, in dislocation at the orbicular joint, after the head of the bone has been thrown out of the cavity by 13 302 SYMPTOMS OF DISLOCATION. external violence, it is still farther displaced by the action of the muscles which surround the part. Remote causes are those influences which, by re- laxing the ligaments, weakening the muscles, tering the articular surfaces, &c, &c, predispose the parts to separate, and facilitate the action of the various agencies described in detail in the pre- ceding paragraph. An abundant secretion of synovia, even when no organic change has taken place in connexion with the articulation, belongs properly to the catagory now under consideration. Symptoms of Dislocation. — The symptoms or signs by which dislocations may be recognised are ; paift;| loss of symmetry ; change in the direction of the Hmb ; alteration in the length of the member ; preternatural immobility: swelling of the surround- ing parts ; and loss of normal function. It may be distinguished from fracture by the absence of crepitus; by the fixedness of the mem- ber; and by the failure of the bones to separate after having been properly approximated. Not- withstanding*, that these three signs constitute the usual distinction between dislocation and fracture, it is impossible to rely exclusively upon any one of them in determining the diagnosis. Each may in turn associate itself with either accident, and it is only by considering them together as whole, in conjunction with other circumstances, that a correct opinion may be formed in a multitude of cases. 2 % The pain, of dislocation is more intense than that of fractures in «MMSe%ntHce of the pressure of the ends of the bone upon the nerves Treatment of dislocation. 303 Treatment of Dislocation. — The general treat- ment of dislocation consists in : The reduction or return of the bones to their normal relations. The retention of the bones in their original position. Reduction. — In returning the bones to their original relations, the Surgeon has four great ob- stacles to contend with and to overcome, viz : Muscular contraction ; the anatomical construc- tion of the joint ; the smallness of the tear in the capsule and the difficulty of finding its direction and position — this is especially true of the hip joint; — and the development ot ligamentous bands forming new but powerful attachments between the head of the bone and the surrounding parts. The first obstacle is to be overcome by means of what is known as manipulation ; % and by extension and counter extension; — aided by the administra- tion of Chloroform, by the exhibition of nauseants and depressants; by bleeding; by the warm-bath; by the subcutaneous introduction of opium or some one of its preparations, particularly the salts of morphia. In regard to the latter mode of reaching and relaxing muscular tibre. the author would state, that after much experience and many care- fully conducted experiments, he is so thoroughly convinced ot the great value o\' this practice gen- erally as to induce him to recommend it in the X This is familiarly known a* Raid's method, though it dates us lar back as Hippocrates, and was successfully practised by Wiseman in 167(5, lor certain luxations at the hip joint. So far as 'the United State? are concerned, to Phytic and Nathan Smith the credit is due of introducing this method of treating dislocations. Reid did not make his report until the year 1851, some forty years after th« suc- cessful experiment of the above named Surgeons. 304 TREATMENT OF DISLOCATION. most unqualified terms, to the profession. Under the head of extension and counter extension are in- cluded the various mechanical contrivances which are employed for the purpose of overcoming mus- cular contraction and of returning the bones to their original position. "When manipulation has failed, extension and counter extension may be made with the hands of the Surgeon or his assistants, with the compound Pulleys, with the simple rope Windlass, with Jarvis' adjuster, and with such other similar ap- pliances as may suggest themselves in this con- nexion. In this way we are enabled to exert much more power and to overcome the contraction of the muscles by steady and gradual resistance, but there is always danger of doing serious injury to the soft parts; and hence, the importance of using uo more force than is absolutely necessary and of proceeding with great caution and circumspection. When individual dislocations are considered, the proper directions for using of these various mechanical contrivances will lie explained in de- tail. The general rules for the application of exten- sion may be thus summed up. 1. Protect the skin by means of a wet roller be- fore applying any powerful extending force. 2. Apply the force slowly, gently aud continu- ously, carefully avoiding any jerking of the parts, lest the artery be severed, the muscles excited to still stronger contractions, &c. 3. The traction should be made in the axis which . the limb has acquired by its change of position. [TREATMENT 0? DISLOCATION. 306 without reference to its normal direction or the situation of the articulation. 4. In dislocations at the hip joint, apply the extending force to the femur, — the bone displaced; but in dislocations at the shoulder joint, apply the extending force to the fore-arm, using the whole limb as a lever. 5. Do not employ the Pulleys, the adjuster, &c, until an effort at reduction has been attempted by making traction with the hands, &c, aided by Chloroform and such other. agents as tend to relax the muscles. The author has succeeded in relaxing muscular contraction of an obstinate and decided character by the subcutaneous injection of morphia imme- diately over the track of those muscles offering most resistence to the return of the bone and he therefore recommends this procedure as an invalu- able adjuvant in the accomplishment of the indica- tion in question, particularly if there be but little tumefaction about the parts, and only a slight de velopment of adipose tissue. The second obstacle is to be overcome by obtain- ing an exact knowledge of the anatomical structure of the joint, and using such mechanical appliances as may be n< to tilt or lift the head of the bone over any projecting and opposing eminence into its proper cavity. Some times this is effected by using the limb as a lever df various degrees, and then again by the direct application of force in such awa raise the limb bodily over the obstruction, relying upon muscular contraction to carry it into its normal position. This subject will 306 TBEATMENT OF DISLOCATION. also be more particularly dwelt upon under the next section of this work. The third obstacle is to be met and disposed of by endeavouring to find the. particular locality of the tear, and ascertaining the direction and posi- tion in which the dislocated head corresponds to the hole in the capsule. The dislocated head does not always preserve the original position in which the luxating force places it, but by means of an abduction, flexion, &c, which subsequently follows, is forced into a new position. Alt attempts at re- duction must therefore be commenced by restoring the dislocated bone to its primitive position, and causing i to glide from that into its normal situation. These observations, of course, apply only to ball and socket joint, and have a particular reference, to disloca- tions of the hip. The fourth difficulty is to be surmounted by operating before the new attachments have formed, or rather before they have become thoroughly or- ganized. The period beyond which reduction should not be attempted varies according to the nature of the dislocation and the concomitant circumstances. It may be practised at a much later day in luxations of the orbicular than of the giuglymoid joints and this remark applies particularly to those at the shoulder, as all experience demonstrates. Sir A. Cooper declares, emphatically, that "the latest period at which reduction can be safely effected, even in this dislocation, does not exceed '• three months; while for the hip tight weeks is the proper limit." It is undoutedly true, that these disjoca- TREATMENT OF DISLOCATION. 307 tion3 have been reduced, with entire safety 1 .he patients ; but these are the exceptions rathe- .nan the rule, and should be so regarded by the Surgeon. Retention. — When the bone has been returned to normal situation, it must be retained there by proper splints and bandages, and rest enjoined, at least for several days. If symptoms of inflammation show themselves, they should be arrested by the prompt and persis- tent application of cold water. In dislocation, it shrjuld be remembered, that the principal indications as well as the chief difficulty consists in reduction, that is, restoring the parts to their natural status; while on the other hand, in fracture, the most important desideratum is to em- ploy means to retain the parts in apposition, after they have been reduced. The above rules hold good for the treatment of simple dislocation. Treatment of Compound Dislocations?. — These are very serious injuries, owing to the peculiar suscep* tibility of the parts which enter into the formation of joints, to take an inflammatory action^ There is usually little or no difficulty in reducing the dis- location, or in retaining the bones in position ; but the great danger is in the subsequent infLammatiom suppuration, &c, which are likely to ensue. If there be a reasonable probability of securing union by the first intention, the parts should be brought gether and cold water dressings employed ; but on the other hand, if the joint be large, and there b much laceration of the soft parts, the limb should be amputated. .308 TREATMENT OP DISLOCATION. Wounds of this character are more favorable when occurring in their upper than the lower extremity for reasons already given at length in another por- tion of this work* Ireatmentof Complicated Dislocations. — Should be treated on the same principles, precisely as the st. Indeed the two so frequently occurr contem- poraneously that it is unnecessary to establish dif- ferent rules for their management. If the bony parts immediately involved are fractured, resection nay be successfully practised unless the soft parts are too much injured, when amputation must be speedily resorted to. as the only means of preserv- ing life. When fracture of the shaft of a bone is complica- ted with dislocation of its head, great difficulties will necessarily present themselves in the way of a proper reduction. It is much safer to reduce the dislocation without waiting for the bone to unite as the period required for this process, would car- ry the surgeon far beyond the time when reduction is esteemed a practicable measure. The fractured limb must be put up very carefully in wooden splints, before extension is made. Particular Dislocations. — Dislocation of the lower Jaw. — The inferior maxillary bone may be either completely or partially dislocated. When completely dislocated, both condyles slip beyond the eminenthearticularisinto the zygomatic fossa, while the coronoid process hitches against the malar bone and the axis of the same is directed obliquely forwards. When the bone is partially DISLOCATION OF LOWER JAW. 300 dislocated, one condyle remains in position while the other is carried forwards into the zygomatic fossa. A sub-luxation is also described by Sir Ashly Cooper, which is most frequently met with in young; and delicate women, in which the head of the bone appears to slip before the internal articular cartilage, so as to prevent the closure of of the mouth. Causes. — Sometimes this dislocation is caused by direct violence, — as by blows, kicks, falls, &c. Again, in gaping, yawning and laughing, the mus- cles are put too violently upon the stretch and the condyle is carried beyond the glenoid cavity. The jaw has also been dislocated in attempts made to draw teeth, by a sudden action of the hand, depres- sing the chin to too great an extent. An imperfect dislocation of the jaw is sometimes occasioned by a relaxation of the ligaments sur- rounding the joint. Symptoms. — In partial dislocation the mouth is not so widely open as in complete dislocation, but the patient cannot close it in consequence of the condyloid process being carried against the zygo- ma. The chin is carried to the opposite side ; the incisor teeth are advanced upon the upper jaw- saliva is somewhat increased in quantity; and ar- ticulation is difficult. In complete dislocation the mouth is widely op- ened and cannot be closed ; deglutition and speech are much impaired ; the chin is lengthend; the sa- liva dribbles over the lips in consequence of press, ure on the parotid glands; the cheeks are flattened; 13b 310 DISLOCATION OP LOWER JAW. the lower line of teeth are advanced beyond the upper; and there is a depression in front of the meatus, and a prominence in the temporal fossa between the eye and the ear. ; Treatment. — Stand before the patient and apply the thumbs well protected to the molar teeth on either side; and then depress the angle of the jaw forcibly, and at the same time raise the chin by means of the fingers passed under it. When only one side is luxated, the efforts at. reduction should be confined to that side alone li\ subluxation, constitutional remedies, such as iron, valerian, & 2., should be administered, and repeated blisters ap. plied directly over the joint. Should the ordinary means fail of their object, the following plan may be resorted to : Place some hard substance, as the handle of a spatula, a piece of wood or ivory, between the molar teeth or the upper and lower gum, on either side, or transverse- ly from one to the other; step behind the patient, and pass the hands forward under the chin ; push the chin up forcibly, so that by means of the wood between the teeth, as & fulcrum, and the bone itself as a lever, the head may be prized out of its new socket, and carried by the muscles over the eminen- tia articularis into the glenoid cavity. The four-tailed bandage may then be applied, and the patient made to refrain from talking, eat- ing solid food, laughing, &c. Very old disloca- tions may be reduced by the process last des- cribed. Dislocations of the clavicle.— The clavicle may be dislocated at either of its extremities, that is, at DISLOCATIONS OF CLAVICLE, 311 its eternal or acromial end, but this accident is rare compared with that of fracture of the hone, be- cause of the strength of its ligamentous attach- ments. Tne eternal end may be luxated either fa-wards, backwards, or upwards, being thrown before, behind, or above the sternum. The acromial end may be dislocated and placed upon the upper surface of the acromion, upon tho -'or part of the tpine of the scapula, under the acromion and beneath the coracoid process. Symptoms. — As the clavicle is very superficial, the changes of conformation which accompanies these various dislocations are so obvious . j to render a recognition of the accident a matter of great facility. The head, of the bone can be dis- tinctly felt in each of the dislocations referr to, making its diagnosis easy and certain. ^Causes. — External violence, — as blows, kici fee. iment. — Reduction is easy but retention iffi- cult, because the accident cannot occur withe \ the rupture of the strong ligaments which ordinarily ho id it in position. Treatment of dislocations of the sternal end. — The dislocation forwards is to be reduced by pushing the ohoulder outwards and bending it backwards, and the parts retained in position by means of a pad and a figure of 8 bandage applied firmly over lisplaced end of the bone — strips of adhesive er may be substituted with advantage for the ■ dislocation upwards is of extremely rare occurrence, but when ascertained, should be treated 312 DISLOCATIONS OF CLAVICLE. by means of a bandage and pad, together with the elevation of the elbow. The dislocation backwards is not of common occurrence, though there are quite a number of cases on record. It generally results from the point of the shoulder having been driven upwards; or by the hand being drawn violently forwards; or by the direct pressure of the clavicle backwards. The treatment consists in making a fulcrum of the fist or knee in the axilla, and then bringing the elbow well to the side. In this way the dislocation is reduced with facility. Retention is difficult, and must be accomplished by the figure of 8 bandage tightly applied to the shoulders, and crossed over a large pad placed in the middle of the back, the elbow being at the same time fixed to the side. Adhesive straps may be substituted for the ordinary bandage as they adhere to the skin and remain much more permanently in position. Treatment of luxations of the, Acromial end.— The dislocation of the head of the bone upon the uppet surface of the acromion can be recognized and reduced easily by manipulation. The shoulder should be pushed upwards, outwards, and backwards, and held in that position by the same means as those employed for fracture of the clavicle, — all of whic will be fully described under the head of fraet s, &c. Adhesive straps passed from the she. 'r to the elbow, embracing the arm, are admi >le substitutes for other and more compli- cate rangenients. It may be well also to place a pacl . the axilla and to bind the arm to the side. Diei >cation under the Acromion. — ISTelaton states DISLOCATION OF SIIOULDER. 313 that there are only three cases of this luxation on record. It certainly is of very rare occurrence. The treatment is precisely the same as for fracture of the clavicle. Dislocation beneath the coracoid process simply requires the clavicular bandage. Dislocations at the Shoulder Joint. — The humerus may be dislocated in four directions, viz: down- wards in the axilla; forwards under the clavicle; backwards upon the scapula. Dislocation downwards. — This dislocation is of most frequent occurrence. Causes. — Falls upon the top of the shoulder; blows upon the shoulder; violent abduction of the arm ; &c. Symptoms. — The Acromion projects; the rotun- lity- o\' the shoulder is lost; a round body can bo Cell in the axilla; the arm is lengthened, numbed, and carried out from the body three or four inches the hand cannot be placed upon the opposite shoulder while the elbow touches the thorax; there is great pain when the elbow is forced against the side. Treatment. — Reduction is accomplished either by manipulation or by the employment offeree. Manipulation. — Administer Chloroform ; carry the elbow about 45° from the side; flex the fore- arm at a right angle with the arm so that the palm of the hand presents to the patient's abdomen* then, using the forearm as a lever, rotate the head of the humerus forwards and upwards by making the hand describe a semi-circle from before back- wards until the palm of the hand looks up, the elbow being kept oil from the side; holding fj u> 314 DISLOCATIONS OF SHOULDER. forearm in its semi-flexed position, with the palm of the hand looking to the operator, carry the elbow gently into the side; then quickly rotate the head backward and upwards by reversing the mo- tion of the forearm so as to cause the hand to de- scribe an entire circle. In the anterior and posterior dislocations carry the arm as nearly perpendicularly upwards as possible, or in such a position as will throw the head of the bone into the axilla, and then proceed as before. During the operation the scapula should be firm- ly fixed and firmly held by reliable assistants. Employment of force. — The dislocation may be reduced, when manipulation has failed, by means of the heel in the axilla; by means of the knee; by means of Pulleys; by Jarvis' adjuster, &c. By the heel placed in the axilla. — This is th6 oldest and most convenient process, and will answer for a majority of recent dislocations. Directions. — Place the patient upon his back; administer Chloroform or Ether freely ; seat your- self along side, and place the foot in the axilla; take hold of the wrist, and fix one foot firmly on the ground; then draw the limb steadily down- wards ; and when the head of the humerus is dis- engaged, and drawn out of its new bed, carry the hand across the patient's body, employing the foot as a fulcrum to turn the bone into its proper situa- tion. Additional force may be employed by fasten- ing a bandage around the arm and carrying it over the shoulders of the Surgeon, so that the weight of the body may be used also as an extending force. DISLOCATIONS OP SHOULDER. 315 If this be not sufficient, still greater power may be gained by passing a towel under the axilla, and making an assistant pull upwards and backwards while the extending force is applied as just describ- ed. Process with the knee. — This is precisely the ame in principle as the last. Directions. — Seat the patient in the chair; take a stand by his side, rest one foot upon the chair, and place the knee in the axilla ; then seize the arm i bout the elbow with the right hand; steady- ing the acromion with the left, and draw the limb forcibly downwards; and, when the head has been disengaged, carry the arm inwards across the patients body. Process by the Pulleys. — If the muscles contract vig or the dislocation be of long standing, so that it does not yield to the various processes described above, it may become necessary to use still additional force and the Pulleys may be employed. Directions. — Place the patient in a firm chair; fold a table cloth or sheet to the breadth of eight or ten inches, and place it around the chest so that its middle portion is applied to the axilla, and attach its ends to some fixed point in the floor or wall ; pass a wet. roller round the arm just above the elbow, and upon this fasten either a strong worsted tape, by means of a clove-hitch, or a towel properly adjust I to excoriate as little as possible: and to this hitch a towel, apply the ex- tending force, and make firm but steady traction. While this is being done by assistants, stand on the outside of the arm. keep it bent,, and rotate 316 DISLOCATIONS OF SHOULDER. the humerus on its own axis as much as possible. Sometimes by placing the knee in the arm pit, the redaction will be much facilitated. The treatment after reduction is simple. Brace the arm by the side of the body, either by long strips of adhesive plaster, or the roller bandage and support the forearm and hand in a sling. Con- tinue this until the tear in the capsular ligament has united, and the muscular tissues have returned to their normal condition of quiesence. Compound and complicated dislocations should be treated upon the principles already established in the section which treats of dislocation in general. Dislocation forward under the clavicle. — Causes. The causes are the same as for the last dislocation, except that the direction of the impulse slightly varies. In many instances this is consecutive upon a dislocation into the axilla. Symptoms. — There is a depression under the outer end of the acromion ; the elbow is separated from the bod}^ and carried a little backward ; the axis of the arm is thrown inwards towards the middle of the clavicle ; the head of the bone may be felt under the clavicle ; the hand cannot be placed upon the opposite shoulder while the elbow remains in contact with the chest ; and there is pain or numbness. Treatment. — The treatment is the same as for the last dislocation, save that the extension 'to be made at first somewhat in a line backwards from the body until the head of the bone has escaped beneath the coracoid process ; the extension must be made downwards and outwards. Subsequently DISLLOCATIONB OF SHOULDER. 317 pull downwards or even upwards, and press the head of the bone into its soeket. Retain as before. Dislocation backwards upon the scapula. This form of dislocation is seldom met with. Causes. — Falls and muscular exertion, with the arm in a position exactly the reverse of the last. Symptoms, — There is a projection under the spine of the scapula ; and a corresponding depression under the acromion; there is a wide space between the head of the bone and thecoracoid process; the ax is of the shaft is directed upwards and outwards the arm is in contact with the body and carried across the chest ; the humerus is rotated inwards; and the hand cannot )>e placed upon the opposite Bhoulder. Treatment. — Sir Astley Cooper recommends the same plan of treatment with pulleys, &c, as in the downward dislocation, and that the extension should he made downwards and outwards. Vidal de Cassis insists that extension shall be made in the direction in which the limb is found : and in this he is sustained by a majority of those who have had the accident to manage. Try citherplan. or both in turn. Inn take especial care to fix -the scapula. The bole- is retained in place by placing a compress against th'e head of the humerus and beneath the spine of the scapula, and retaining them in position by means of a roller bandage. ther partial dislocations of the hum- for an account of which the reader is referred to standard works on the subject. Dislocations at tin Elbow Joint. — Numerous luxa- tions ojcur at this joint, viz : dislocation of the ra 318 DISLOCATIONS OF ELBOW. dius and ulna backwards; dislocation of radius and ulna forwards ; dislocation of both bones laterally; dislocation of the ulna backwards ; dislocation of radius forwards ; dislocation of radius backwards ; and dislocation of radius outwaads. Dislocation of Ulna and Radius backwards. — This accident is plainly marked by the change in$ the form of the joint, and by its great loss) of mo-* tion. There is a considerable projection posteriorly; on each side of the olecranon there is a depression; the articulating end of the humerus can be felt in front ; the hand and fore arm are in a state of su* piuation, and cannot be pronated ; and the fore arm is slightly flexed on the arm. The coronoid process is frequently broken, and if so, may be felt loose in front of the joint ; but if not, it will be found fixed against the posterior surface of the hu- merus. Ireatmeni. — This dislocation ma}' be reduced thus : seat the patient ; take hold of his wrist, and place your knee on the inner side of the elbow joint ; bend the fore aim and press upon the radi us and ulna firmly with the knee, so as to separate them from the humerus, and to remove the coro : noid process from the posterior fossa of that bone ; while this is being done, gradually flex the for< arm, and the bones will slip into their respective sockets. Apply a bandage, keep the arm in a flexed posi- tion, use cold lotions, and support the limb with a sling. When the coronoid piocess is broken, keep it firmly in its place by means of a compress and adhesive straps. DISLOCATIONS OF ELBOW. 319 This accident is usually caused by an attempt to catch, on the imperfectly extended arm, while falling". Dislocation of both Bones forward. — It is almost impossible for this accident to occur without a fracture of the olecranon process: though it may do so in rare cases. It may be recognized by the elongation of the fore arm; the projection of the condyles of the humerus ; the depression of the posterior surface of that bone: and, when the ole- cranon is broken off by the presence of that pro- cess behind, and the great mobility of the fore arm. Treatment. — The same process is to be followed as in the last case, only the foree used must be greater. Put the arm up in firm angular splints, keep the hand semi-pronated, apply cold lotions, and use the sling. Dislocation of both Bones laterally. — This dislo- • ion may occur on either side, but generally is an incomplete one, either the radiushitches against the internal condyle, or the ulna against the ex- nal, and prevents an entire separation ol' the articular surfaces. This may be recognized by the peculiar deformity ; lossof motion : the movements oftheradiu the hand when the arm is rota- ted ; the position of the ulnar either on the inner mdyle; the radius forming a protuber- nd on the outer Bide ofthc humerus; bj of the condyle ; and by the hollow above thi Tin the dislocation by bending the arm powerfully over the knee and making 320 DISLOCATIONS OF ELBOW. traction at the wrist. As soon as the radius and ulna are separated from the humerus, the biceps and brachialis pull the bones into their proper po- sitions. Retain the parts insitu by the angular splints I supf ort the arm with a pad ; and keep the limit quiescent. Nelaton declares that he has seen but! one case of this variety of dislocation. Dislocation of the Ulna Backwards.— This is the only displacement to which the ulna alone is subS ject; and this, seldom presents itself without more or less dislocation of the head of the radius. It may be distinguished by the great deformity of the member,— the olecranon being thrown backwards,' and the fore arm and hand very much twisted inj wards. The radius remains in its norma! position, and its movements under the hand can be easily recog. nized when the limb is rotated. The coronoid Is frequently fractured in this accident, and crepitates when moved. If this be the case, the dislocation can be reduced and produced at pleasure. It is also impossible to extend the arm or to bend it at right angles, in uncomplicated cases of this injury. Treatment.— Reduction is effected precisely as in the last accident, described. The Radius, act a lever under these circumstances, and aids the muscles in bringing the bone into position. Retentiou may be accomplished by the use ut the. appliances, & Ci , described above. Dislocation of the Radius forwards.— This i most unusual accident, It may occur however, DISLOCATIONS OF ELBOW. 321 |he result of a fall on the palm of the hand, by which the lower end of the bone is pushed back- wards, and its upper extremity carried forwards, rapturing the annular ligament, and throwing its lead against the external condyle, [t may be dis- ' wnguished by the following signs, viz.: the for is slightly bent, and can neither be extended nor bron.irlit at a right angle with the arm; the hand is fixed midway between pronation and supination, Rough neither motion can be perfected; on relation, the bone can be distinctly felt, and, the pain is very great; the whole of the nppe" side of llm arm is carried somewhat upwards, producing great de- formity; and the constant disposition of the head if the radius to slip out of place because of the rupture of the annular ligament. Treatment. — Reduce by applying extension after [having firmly fixed the upper arm, and then bend- ing the arm and pushing the head into its place. Retain by applying a pad immediately over the head of the radius, binding it firmly by means oi' jdhesive strips, and keep the forearm well Hexed. Dislocation of radius backwards. — This may hi' Known by the head of the bone being felt subcii- mneoustybehindtheexln'nalcondyka.nd by the move- the elbow being limited and extremely fcinful. atment. — Reduoeby bending the forearm, and making traction. . Retained by keeping the arm tlexed. Sir, A. Cooper declared that he had never seen a ease of this particular dislocation, in the, living bodv, and but once upon the dead subject. 322 DISLOCATIONS OF ELBOW. Dislocation of the Radius outwards. — Thh acci- dent occurs more frequently than the last, accord- ing to the testimony of every Surgeon of practical experience. The head of the bone is then on the outer side of the external condyle, where it may be felt under the skin, rolling as the hand is moved. W The natural motions of the joint are materially in- terfered with, and pain follows every movement. Treatment. — Reduction is accomplished by mak- ing traction at the wrist, and bending the limb at the elbow. Retention is effected as in the other cases of dis- location already described. In compound dislocations of the elbow joint, the arm must be flexed and placed in the most comfort- able and convenient position, the angular splints applied, when practicable, and the antiphlogistic treatment resorted to. After a few weeks have expired, and the external wound is in good condi- tion an effort may be made to reduce the disloca- tion. Dislocations of the Wrist Joint. — Fractures of the lower end of the radius are frequently mistaken for dislocations of the wrist joint, sofrequently in fact that some Surgeons have denied the existence o such dislocations under all circumstances. The . carpus as a whole may be dislocated either back wards or forwards. The existence of a smooth con vex swelling corresponding with $ie first row carpal bones either upon the upper or under surface of the wrist together with some shortening of the forearm, and an unusual prominence of the styloic DISLOCATIONS OF WRIST. 323 processes of the radius and ulna, are the guides bv which these dislocations may bo recognized. Reduction is readily accomplished by the em- ployment of i isieh, — a cir- ■ curostance which will facilitate the diagnosis be- . tween this accident and impacted fracture ot the radius. .Retention is effected by means of anterior and ' posterior splints. The radius alone is sometimes thrown forwards 1 upon the carpus. • Symptoms.— The outer side of the hand is displaced •• backwards and the inner forwards, while the extre- mity of the bone forms a protuberance upon the fore- part of the wrist. Reduction and retention nre effected as when both bones are displaced. The ulna is sometimes separated from the radius by the rupture of the sacriform ligament, and , usually projects backwards. Symptoms. — This accident may be known by an elevation immediately above the level of the os- pmeiform, which is easily reduced by pressure to ita former situation. Treatment. — Press the bone bank to its proper place, with the linger. Apply a compress of leather to the extremity of the ulna; place splints along the forearm: and I use a roller to keep them in position. Dislocation of the bones of the Carpus. — This ac- I cident is of rare occurrence, and is usually the re- sult of falls upon the hand. The os-r^gnum is the bone most frequently dis- placed. 234 DISLOCATIONS OF THUMB. Symptoms. — A round hard tumour on the back of the wrist, opposite the metacarpal bone of the little finger, presenting itself .immediately suhse-, quent to a fall upon the hand. Reduction. — Extend the hand and apply pressure upon the tumour. Retention. — Apply compresses, ami enjoin abso- lute rest. Instances are on record of the dislocation of the pisiform and semilunar bones, but these are very un- usual accidents. Sometimes ganglia arc mistaken for dislocations of these bones, but these are easily, removed by striking them sharply with the fiat surface of a book, Avhen the supposed dislocation immediately disappears. A compound dislocation of the carpal bones fre- quently happens, and is generally produced by the bursting of guns, by the hand being caught in ma- chinery, or by the passiug of heavy bodies over it. In such cases one or two of the carpal bones may be dissected away, without destroying the hand or Re'-* riously interfering with its motions. If great injury be done, amputation becomes ab- solutely necessary. Dislocation of the Metacarpal bone of the Thumb. — This is the only metacarpal bone ihat admits of dis location, and this accident seldom occurs. These luxations have been observed in two directions : • backwards and forwards, and can readily be recog- nized and reduced — extension being mad flfrom the thumb by means of a piece of tar>» applied around the first phalanx. DISLOCATIONS OF THUMB. 325 Dislocation of the First Phalanx of the 7hwrib. — Theboue is usually dislocated backwards but may be thrown forwards also. Symptoms. — The proximal extremity of the ] anx slides back upon the distal extremity of the metacarpal bone, in the backward dislocation, and stands off from it at nearly a right angle, while the metacarpal bone projects strongly in the pi lm of the hand. In very rare cases the phalange: tre extended upon the metacarpal bone in a straight line. In the forward dislocation, the first phalanx is in front or the metacarpal bone, and in the same plane; while the • last phalanx is inclined slightly back. • Ireatment. — If the dislocation be backward, ben the dislocated phalanx forcibly backwards until it stands upon its articulation, hold it in th t position, and at the same time press against tbe distal extremity of the metacarpal bone. Mai e firm pressure againsl the base of the disloe phalanx, and slid" it into its place. If this fail, bend the thumb towards he palm of the hand, in order to relax the flexor i cles as much as. possible, and then make extension by means of the clove-hitch. The apparatus of Le- vis may be also used in this connexion. If the dido- cation cannot be reduced by these means, div,. e one of the short floxoBS of the thumb, and the re- duction can be readily effected. The author ig convinced that this is more properly speaking, in many instances, a dislocation w'the distal end of the metacarpal bone, and that reduction, can bi- ll 2b DISLOCATIONS OF THIGH. most readily ensured by fixing the thumb firmly, and manipulating from the direction of the arm. "When the dislocation is forward, reduction may be effected by seizing the thumb in the palm of the hand, and, with the fingers resting upon the back of the patient's hand, forcing the phalanges into flexion by firm and steady pressure. Dislocations of the phalanges of the fingers may be reduced on the same principles. Dislocations of the Lower Extremities. — Dis- locations'of the Thigh. — There are four principal dis- locations of the femur which should be thorough- ly studied and understood by the Surgeon, viz : upwards and backwards upon the dorsum ilii ; up- wards and backwards into the ischiatic notch ; downwards and forwards into the thyroid foramen; and upwards and forwards on the pubes. 1. Dislocation upwards and backwards on the dorsum ilii. Causes. — Falls from a height when the force of the concussion is received upon the outside of the, knee ; falls upon the foot or knee when the limb is abducted ; a heavy weight striking the pelvis from above, the body being bent forward ; or any thing which forces the thigh into extreme abduction or abduction united with rotation inwards. Symptoms. — The limb is shortened ; the thigh is rotated inwards and somewhat flexed ; the great toe rests upon the instep of the foot of the sound limb ; the knee touches the opposite thigh near the upper margin of the patella ; the body of the patient is slightly bent forwardi ; the roundnesa of DISLOCATIONS OP THIGH. 327 the hip is lost ; the trochanter major is depressed ; aud the head of the bone can be felt in its new po- sition. Treatment. — The dislocation may be reduced by manipulation or by mechanical force, (extension and counter extension). Manipulation. — Hippocrates first described this method of reduction, though it has been variously modified, illustrated and improved by Wiseman, Turner, Anderson, Physic, Smith, Oolombat. Reid and others. Directions. — Place the patient in the horizontal posture on a narrow table covered with blankets. and on his sound side. Secure the body firmly by folding a sheet several times lengthwise, then ap- ply the middle of the band thus made, to the inner and upper part of the sound thigh, carry its extremities under "the table, pass them obliquely up, cross them again firmly over the trunk above the injured hip, and secure the ends under the ta- ble. Administer chloroform freely ; stand at the pa- tient's back; grasp the knee of the dislocated limb with the right hand and the ankle with the left — if the left femur be dislocated reverse the hands ; flex the leg upon the thigh ; rotate the thigh outwards ; then slightly abduct the thigh by pressing the knee outwards ; and lastly thrust the knee upwards towards the face, so as to flex the thigh freely, and at the 3ame moment increase the abduction of the limb. This is the plan of Nathan Smith, as described by his son, the distinguished Professor of Surgery in the University ff Mary- land. 328 DISLOCATIONS OF THIGH. Mechanical Means. — Reduction by extension dates back to Hippocrates, but Ambrose Pare was the first to recommend the use of pullies. The plan to be pursued in this connexion is as follows: place the patient upon a bed of suitable height, on his back and slightly turned on the sound side; drive a staple into the wall oi the room upon one side and another into the wall upon the opposite side, both corresponding with the line of the shaft of the femur, but the one in front being higher . and the one behind being lower than the bed ; lay two pieces of strong cloth, four inches wide and four feet long, on either side of the limb, the centre of each being just above the two condyles ; over the centre of these two strips apply a strong roller tightly, previously wetted in water ; bring down the upper ends of the side strips and fasten them to the lower, so as to form two loops, upon which one of the hooks of the compound pulley is to be made fast, while the other hook is secured to the front staple in the wall ; fold a sheet diagonally, and adjust it so that its centre applies to the peri- toneum while its ends are tied to the lower staple ; pass underneath the upper part of the dislocated limb, a strong, broad bandage of sufficient length to tie over the neck of the Surgeon when stand- ing about half bent; place assistants on either side of the patient to keep him in position ; everything thus prepared, administer chloroform, make exten- sion by means of the pulley, and counter exten- sion by means of the sheet, in the line of the axis of the dislocated limb ; place the hand carefully upon the trochanter major, and watch carefully its DISLOCATIONS OF THIGH. 329 descent; and then when the head of the bone has nearly or quite reached its socket, if it does imme- diately get into position, lift up the thigh by means of the hand, which has been passed under it, and the luxation will generally be reduced. If, after all, the bone does not enter the socket, the flexion of the limb may be increased or dimin- ished, the tension suddenly released, and "mani- pulation " attempted- The extending force may be applied also by means of a leather belt, strips of adhesive plaster, &c : while a small rope doubled upon itself, with a stick passed through it, may be substituted for the pulley. Bloxham, u dislocating tourniquet," and Jarvis' adjuster may also be employed in this con- nexion. 2. Dislocation upwards and backwards into the great ischiatic notch. Causes. — Falls upon the foot or knee, when the limb is very much in advance of the body; heavy blows upon the back and pelvis when the thigh is nearly at right angle with the body, &c. Symptoms. — The limb is shortened, but not so much as in the last named dislocation ; the thigh is flexed, adducted and rotated inwards ; the toe of the dislocated limb touches the ball of the great toe on the other side ; the knee is not carried so far over the other as in the former luxation ; the tro- chanter major is approximated towards the anteri- or superior spinous process of the ilium; and the lumbar part of the spine is so arched that it can- not be straightened so long as the thigh is straight or on a line with the patient's trunk. DISL0CATIN8 OF THIGH. Treatment. — Manipulation maybe employed, pre- cisely as described above, though, the extentofthe circuit to be described by the head of the bone is inconsiderable, while there is great danger of its being thrown into the foramen thyroideum. Extension. — Arrange every thing as before des- cribed, taking care to have the "front staple " at a greater height from the floor ; administer chlo- roform ; make extension at an angle of 45° ; and when sufficient force has been applied lift the thigh upwards by means of the band passed under the thigh and carried over the operator's shoulder. Bransly Cooper says that the limb should be flexed quite to a right angle while extension is being made. Be careful that the " counter extending " band does not slide off the pelvis toward the upper part of the thigh. 3. Dislocations downwards and forwards into the foramen thyroideum. Causes. — Falls upon the foot or knee while the limb is abducted, and the falling- of a heavy weight upon the back the body being bent and the thighs spread asunder. Symptoms. — The thigh is lengthened one or two inches, abducted, flexed, and advanced ; the body is bent forwards or slightly flexed upon the thigh ; the toes point directly forwards as a general thing ; the hip is flattened ; the trochanter is less promin- ent ; and the head -..-f the bone may be often felt in its new position. Treatment.-- Manipulation, This dislocation may be readily reduced by manipulation if conducted DISLOCATIONS OF THKJH. 881 in the following manner ; abduct the limb ; carry it up towards the body until the progress : £ the knee is arrested; then carry the limb inward ; and finally bring it down adducted. 'When th :nee is opposite the pubes, rotate the femur quk^ / in- wards, and give it a slight rocking motior. Ex- tension: Sir A. Cooper advises that exten 1 be made in the following manner; place the ient on his back with thighs separated ; make the ' leys fast to a band drawn through the perineum oi the affected side, in a direction upwards and out vr.rds; pass a counter band around the pelvis through the band attached to the pulleys, and attach it to a staple driven in the wall; administer Chloroform; make traction with the pulleys until the head of the bone is felt moving from its position ; then seize the ankle and adduct the limb forcibly. Place the patient in bed and rotate the lirab in wards, keeping the knees together. 4. Dislocation upwards and forwards upon the pubes. Causes. — Falls upon the - foot, when the leg is thrown backwards ; putting one foot into a hole while walking and falling backwards; and falls or blows upon the back of the pelvis. Symptoms — The thigh is shortened, flexed slight- ly and rotated outwards ; tiie trochanter cannot be distinguished; the head of the bone can be felt on the pubes or outside of the femoral artery. Treatment. — Manipulation. Numerous instances of the reduction of this dislocation by manipula- tion, are on record, though the methods pursued were different. The best plan, is as follows, ab- * 1 DISLOCATIONS OF THIGH. ict the limb and forcibly rotate it outwards ; flex upon the body; then adduct it, and bring it vra upon the table. Care should be taken not > continue the rotation outwards after the head '"the femur Las risen above the pubes, but on the Qtrarv to rotate it gently inwards so as to enable ae head to slide under the psoas and iliacus in- mus muscles towards its socket. Extension. i ay the patient on his back upon the table ; make fh 3 extending band fast above the knee and attach 'o a staple driven in the floor; pass the counter 'ending band ur^er the perineum and attach it . staple above the level of the table ; administer , of'orm ; make steady and persistent extension ; i \ when the head of the femur has begun to move, iie upper part of the thigh, as before described, >> to carry the head of the bone into its socket. .ere are three cardinal principles which should ; membered in this connexion, viz : in reducing by manipulation, carry the limb in those directions in which it is found to easily. In reducing by extension apply the force in ction of the axis of the dislocated limb." eduction has been effected, particular- much force has been used, keep the patient <• ly in bed, with his knees brought together u t : all danger of inflammation and recurrence of accident, have passed. V T i rious other anomalous dislocations may occur ib is connexion, for an account of which the •is referred to the standard works on the oU >kct, DISLOCATIONS OF PATELLA. 358 Dislocations of the Patella. — This bone may b« dislocated either outwards, inwards, upwards or upon its own axis. Causes. — Muscular action of a sudden and spas- modic character; blows ; falls, &c. Symptoms. — The altered position of the bone ; the prominence of either condyle ; the immovable condition of the limb; great pain; and slightly bent condition of the knee. Treatment. — The treatment consists in relaxing the quadriceps extensor muscle, in extending the leg, in carrying the body forward, and then press- ing the bone into position. Dislocation of Hie Lead of the Tibia. — The head of the Tibia may be dislocated backwards, forwards, inwards, outwards, and backwards and outwards though the accident is of rare occurrence. Dislocation of the head of the Tibia backwards. Canses. Violent blows upon the lower end of the femur or upper end of the tibia ; and by the twist- ing of the tibia when the foot is made fast in a hole and the body swings around upon the knee. Symptoms. — The head of tibia may be felt in pop- liteal space pain in consequence of pressure upon the popliteal nerve; a depression immediately be- low the patilla ; the condyles of the femur project- and the limb usually somewhat flexed. Treakjirat. — Manipulation may succeed if the injury be very recent or the shock great. The limb should be carried in those positions in which it moves most easily ; but if this fails then forced flexion should be resorted to, rocking the limb from one side to another, »«d making strong 334 DISLOCATIONS OF TIBIA. pressure upon the projecting bones of the joint. Extension may be practised by making a strong assistant seize the limb above the ankle, and pull forcibly in the direction of the axis of the limb. The pulleys may also be employed. Counter ex- tension may be made from the perineum, or from the lower and under part of the thigh. Disloca- tion forwards. The causes by which this accident is produced, are similar to those mentioned above. Symptoms. — The patella, fibula and tibia are prominent in front, while the condyles of the femur may be felt behind; the limb is shortened; and the circulation is interrupted by pressure upon the artery. Treatment. — Manipulation may possibly succeed if attempted immediately. Extension and counter extension should be made as described above. Dislocation outwards.— Causes. A violeut wrench of the knee joint, may rupture the ligaments, and cause this accident. Symptoms. — The inner condyle of the femur projects, while the head of the tibia and fibula can be distinctly felt on the outer side of the joint. Treatment. — The treatment does not differ from that of the other dislocations just described. In the dislocations inward and outward and backward there is nothing peculiar, and the acci- dent, should be treated on general principles. Dislocations of the Lower end of the Tibia. — The tibia may be dislocated at its lower end in four directions, namely : Inwards, outwards, forwards and backwards. Most of these accidents compli- DISLOCATIONS OF TIBIA. 335 cate themselves with fractures, of the two bones of the leg, one or both. Dislocation inward, Causes. Falls from a height upon the bottom of the foot, which at the same time is turned outwards ; blows, and violents twists of the foot outwards. Symptoms. — Foot is abducted ; the internal mal- leolus projects strongly; there is a corresponding depression upon the outer side of the ankle ; the pain is great ; motion is lost, though the surgeon can move the foot ; and, fracture of fibula when the dislocation is complete. treatment. — Seize upon the foot, and forcibly adducting it, taking pains to Ilex the leg so as to relax the gastrocnemius muscle, and to give the part a gentle rocking motion. If this fails, bend the leg up a right angle to the thigh ; pass a coun- ter extending band around the thigh ; attach the pulleys to the foot by means of a bandage carried around it ; and then make forcible extension. Dislocation outwards. — Causes. — The causes are similar to those which produce the last named ac- cident, only the position of the foot is reversed. Symptoms. — The foot is adducted ; the external malleolus projects ; there is a depression upon the inner side of the foot, &c. Treatment. — The outward dislocation may be re- duced precisely in the same manner as the disloca- tion inwards. Dislocation forwards. — Causes. — Violent exten- sion of the foot upon the leg ; falls upon an in- clined plane ; blows upon the tibia, &c. Symptoms.— The length of foot in front of tibia is 236 DISLOCATIONS OF TIBIA. diminished, while the projection of the heel is in- creased ; the toes are turned downwards; the heel :s drawn upwards ; the end of the tibia can be felt; and the tendo-Achillis is curved forwards and tense. Treatment. — Flex the leg upon the thigh, make extension from the foot; and at the same time^ press in front of the tibia and against the heel. 11 the bone begins to slide into its place, the fov) should be forcibly flexed upon the leg. T islocation backwards. This is so rare an acci- dent that Malgjugne has only succeeded in collec- ting five examples. It is produced by causes ex- actly the reverse of those which operate in the pro- duction of the last, while the signs which distin- guish itare directly opposite to those last described. Reduction should be attempted by a method simi- lar to that recommended for other dislocations of the ankle joint. The Fibula may also be dislocated both at its upper and lower end, but these accidents are of such rare occurrence, and so readily distinguished as to preclude the necessity for a more detailed account of them. Dislocation of t fie Astragalus. — Ca uses. — The same as those which produce dislocation of the Tibia. Symptoms. — Prominences according as the bone is displaced inwards, outwards, backwards or for- wards; lateral deviation of the foot; shortening of the leg, &c. Jreament.-^ Reduce if possibly by means of ex- tension pressure, &c, but if unsuccessful, resect or amputate. Keep down tlje inflammation, which always intense. DISLOCATIONS OF CALCANEUS. 387 The Astragalus may also be separated from the Scaphoid bone, and should be treated on the same principles. Dislocation of the Calcanevm. — Causes. — Falls upon the heel and direct blows. Symptoms. — Prominences and depressions ac- cording as the dislocation is outward, upwards and inwards. Treatment. — Bend the thigh and knee on the body; Hex the leg ; seize the metatarsus and the heel; draw the foot directly from the leg; and press the knee against the outside of the joint. The Scaphoid, the Cuneiform bones, the ps-cu- boides and metatarsal bones are all subject to dis- locations, which can be recognized without much difficulty and which should be treated on the same general principles as the bones of the foot already referred to above. CHAPTER VIII FRACTURES. Fractures in General. — The term fracture is derived from a Greek word which signifies "to break," and is employed to convey the idea of a division, by violence, of bone or cartilage. Classification. — The following is the most simple and convenient classification of fractures: All fractures are : INCOMPLETE Embracing. Fissures, Depression, Curvature, Flexion, Splintering, Perforations. OR COMPLETE. Embracing. Transverse fractures, Serrated " Oblique Impacted " Stellated. EITHER OF WHICH MAY BE : Simple, Compound, Comminuted, Complicated. Incomplete Fractures. — These involve the divis- ion of only a portion of the thickness of the bone, and embrace. INCOMPLETE FRACTURE*. 339 1. Fissures. — The experience of all Surgeons confirms the fact that both flat and long bones may be cracked, in any direction as the result of violence, without a solution' of their entire continuity. The symptoms which mark this accident are those of contusion of the bone, and depend upon the devel- opment of periostitis, or of suppuration in the me- dullary canal or internal structure of the bone. 2. Depression. — This term is employed to de- signate the circumscribed fracture of a part of the thickness of a flat bone with more or less flexion of the portion which remains intact. Depression has been observed in the bones of the cranium, ribs, scapula, neck of the femur, and of the dia- physes generally. This accident can readily be determined, in a majority of cases, by thrusting the finger into the depressions. 3. Flexion. — The long bones may all be bent in the direction of their diameter, as the result of a similar lesion. Under these circumstances there is not simple curvature, but positive fracture of a portion of the thickness of the bone, save in the case of very young subjects. This accident occurs most commonly in the bones of the fore arm ; then in the thigh ; and lastly in the leg. The young — those between the ages of five and thirteen — are more subject to it than persons of mature years. The bone is generally more or less curved, with a salient angle on the side of the fracture ; while the curvature can be diminished but rarely over- come by pressure. 4. Splintering.— There may be a complete sepo- 340 INCOMPLETE FRACTURES. ration of a mere splinter while the houe itself re- mains nearly solid. Fractures of this description are usually produced by blows of a sabre, or by falls grazing the bone, and may occur in any part of the body, though the skull is most frequently the locality of the accident* The splinter can usu- ally be felt and the diagnosis is not difficult. 5. Perforations. — The bone may be perforated through and through or in one portion of its thick- ness by foreign bodies, particularly by balls, with- out the complication of splinters or comminution. In the one instance the perforation is said to be complete and in the other, incomplete. These lesions have been observed in all the bones of the body, and are of constant occurrence, though true perfo- rations occur most frequently in the bones of the skull, and the head of tht' femur and tibia. These accidents are generally serious. The surrounding soft parts swell and inflame ; the bone also takes on inflammatory action ; the limb becomes cede- matous ; a foetid reddish pus flows from the wound ; while a probe introduced into it shows that the bone is soft and easily broken down. The splinters are detached and float' out with the puru- lent matter ; and either the work of repair is com- menced, or caries is developed, fistula? are produced, a tedious suppuration ensues, and amputation or resection becomes the only available remedy. The great indication is to extract the foreign body, in the premises, if the perforation be an incomplete one. The wound should then be detached on gen- eral principles. Complete Fractures. When the bone is divided COMPLETE FRACTURES. 341 to the extent of its whole thickness, the fracture is said to be complete. Fractures of this kind are: 1. Transverse. When the line of fracture forms a right angle with the long diameter of the bone, or deviates from the perpendicular so slightly a? per- mits the ends of the bone to rest upon each other, or when replaced not to become spontaneously dis- placed, the fracture is transverse. 2. Serrated Fractures. — When the opposite sur- faces denticulate, the elevations upon one fragment being reflected by corresponding depressions in the other, the fracture is serrated. A majority of frac- ture from simple blows are of this character; but they occur principally in the clavicle, humerus, radius, ulna, femur, and tibia. 3. Oblique Fractures. — When the line of frac- ture forms an angle with the shaft of the bone not far from 45°, the fracture is oblique. When the obliquity is less than forty-five degrees, the frac- ture becomes transverse, when greater, it is styled a fracture en bee dc flute, and when it approaches parallism to the axis of the bone, it is called a lon- gitudinal fracture. These fractures are generally produced by indirect violence, and usually have something peculiar in their aspect, according to the cause producing them. 4. Impacted fractures. — When the ends of the bone are driven into each other, the lamellated structy«| of one fragment penetrating the cancel- lous structure of the other, the fracture is said to be impacted. 6. Stellated Fractures. — When some cutting in- £42 COMPLETE FRAOTUaES. gtrument or a ball is driven through the bone, par- ticularly if it be a flat one, innumerable spiculee will in many instances be found projecting from the margins of the perforation. The projection or radiation of these fragments from a central point gives the fracture a stellated or star like appear- ance; and hence, the name of the fracture. This \accident occurs frequently in connexion with the bones of the cranium, most seriously compli- cating those accidents. In addition to these distinctive characteristics, there are some features which may connect them- selves with either incomplete or complete frac- tures. Thus both varieties of fracture may be either simple, compound, comminuted or compli- cated. 1. Simple Fracture. — By this term is usually meant the fracture of a bone simply at one point, without reference to the question of complications. A more correct and convenient arrangement would extend its meaning thus : "a fracture simply at one point without injury to the soft parts." 2. Compound Fracture. — "When there is an ex- ternal wound communicating with a fracture of the bone, whether complete or incomplete, the in- jury is recognized as a compound Fracture. 3. Comminuted Fracture. — When the bone is broken at more than one point, and there are more than two fragments, the fracture is " multiple " or comminuted. 4. Complicated Fracture. — A fracture is said to be complicated, when in addition to the division of the bone, there is injury either of some impor-i AAT7SB* OV FRACTURM. S4S tant vessel or nerve, great contusion or laceration of the soft parts, fracture of neighbouring bones, dislocation, or constitutional injury. ( 'uses of Fractures. — The causes of fractures are predisposing and exciting. ! disposing Causes. — In childhood the bones arc soft and easily bent, and in old age they are harder and more brittle. 'Females are less liable to fracture than males except in old age. Moro fractures occur in winter than in summer. Mol- Ossiurn, Fragilitas Ossiuin, Rickets, Cancer, Syphilis, Scrofula, Gout, Scurvy, Mercurializatiou, &c.j ill predispose to the occurrence of fractures. Exciting causes. — The exciting causes of fracture ai- mechanical violence, and muscular action Mechanical violence, may act either directly or by .com tor stroke. Muscular action most frequently produces fractures of the patella, calcaneum, humerus, femur, tibia, and olecranon process of the ulna, and usually implies some predisposition to the accident. General Symptoms of Fracture. — The most com- mon and important signs are crepitus ; mobility ; inability of the parts to remain in position when reduced ; pain at the seat of fracture ; swelling ; ecchymosis; deformity ; and inability to move the limb. The examination of a suspected fracture should be made as early and as quickly as possible, Chloroform being employed if there is the least difficulty in regard to the diagnosis. Treatment of Fractures. — The treatment of frac- tures divides itself, naturally into two processes, viz : reduction and retention. Before discussing 344 TREATMENT OF FRACTURES. them however, it will not be amiss to consider th< manner in which a man who has sustained a seri ous fracture should be cared for in advance of re gular Surgical treatment. If the upper member) are broken, the patient, as a general thing, can tak< care of himself, but when the inferior extremitie are involved, he should be most tenderly and in telligently cared for. An army should not only b. The patient cannot be roused, and is speechless. ]. Special sensation is des- troyed. 4. Respiration slow, labori- ous, stertorous, and blowing. 5. The pulse is slow and full. 6. The Stomach is quiet and insensible to emetics. 7. The bowels are const ipa- ed. 8. The blad ler is paralysed, and the use of the catheter is necessary. 9. There is always paralysis, and on the opposite side from the wound. 10. The pupils are widely dilated. II. The brain is compressed. 12. The surface is not pale and cold, but rather the re- verse. 13. The pulse grows weaK- er as health returns — collapse frequently ensuts. 14. The symptoms indicate a state of cerebral apoplexy. Concussion may terminate in compression in consequence of the pouring out of blood from the small vessels which have been divided by the oscillation of the brain, after reaction lias taken place; while either of these conditions may even tuate in the development of inflammatory action, with its chat acteristic phenomena and terminations. Compression may be caused by either or all of the 352 FRACTURES OF CRANIUM. ■ following causes: depressed bono ; extravasated blood; and purulent deposit — the first producing its effects immediately, the other after the lapse of some little time, and the last, at a more remote period in the history of the case. 3. Fracture with comminution of the bone. — The skull is frequently the seat of multiple fractures. Either from the abnormal condition of the bones or the peculiarity of the injury, it often happens that the bones are broken into a number of fragments. Balls usually pa$s through the bones without splintering them, but it sometimes occurs that the injurying force disseminates itself, producing ex- tensive comminution of both tablets. Under these circumstances the danger is from inflammation of the brain and its membranes ; and from fungus of the brain. There may be depression with its usual symptoms, but, as there is extensive solution of the bony continuity, the fragments are not held down upon the surface of the brain by any considerable force, and not unfrequently rise again to their original level, relieving the cerebral- sub- stance of the disasterous consequences of their presence. Many of the detached fragments become necrosed, dying slowly and endangering the deli- cate structures beneath them until the work of elimination has been perfected. The substance of the brain may be injured contemporaneously with the fracture of the bone, causing a speedy extra- vasation of blood, and the development of cerebral inflammation. 4. Removal of a portion of the bone. Portions of tile skull are sometimes carried away by sword FRACTURES OF CRANIUM. 353 cuts, which it' promptly reapplied will adhere with- out unfavorable consequences; There is always danger of hernia and inflammation of the brain; 5. Fractures with splintering of the internal table. These accidents result from bayonet, dirk and ball wounds, and are of the greatest interesl to the Surgeon. They are always complicated with injury to the cerebral surface, and frequently, by the actual presence of a foreign body in the wound. While connected with the General Hospital at; Charlottesville, Va., it fell to my lot to make an autopsy of a soldier who had died from the effects of a gunshot wound of the head. A conical ball had entered the left parietal bone about one inch from the sagittal suture, making a smooth, round hole in the external tablet, and imbedding itself in the substance of the brain. The patient was at- tacked with violent convulsions on the fourteenth day subsequent to the receipt of the injury, and died comatose in a few hours afterwards. Upon removing the upper half of the cranium, a large abscess was found immediately beneath the orifice in the bone, containing the ball and a quantityof puss; and the whole dura mater was injected with b ood ; while at the point of the inner tablet through which the missile had passed, was a round hole, from the entire circumference oi which there radiated numerous spicuhv which had penetrate the membranes of the brain and acted as foreign and offending bodies to them, as well as to the de- cate structure beneath. This case is but a type of hundreds of others, and throws much light upon the pathological con- 354 FRACTURES OF CRANIUM. ditions which such injuries develop. Whatever may be said of the trephine, it is plain that it might have been employed to advantage in this con- nexion, for the following reasons. 1. It would have ensured the removal of the ball. 2. It would have accomplished the evacuation of the pus. 3. It would have removed the spieulse which were sources of inflammatory disturbance to the cerebral substance. As a matter of curiosity, an attempt was made to remove the spicule which radiated from the circumference of the inner orifice, in order to determine to some extent how far such a procedure could be regarded as "meddlesome Surgery" in actual practice. By means of a de- licate pair of forceps, and with a little care, all of them were speedily removed through the external orifice of the wound — the whole thing being ac- complished with so much facility as to convince ail present of the practicability and propriety of such an operation under any circumstances, provided the opening be large enough. When the fracture has been occasioned by puncture with a sharp instrument, the legion should oe esteemed one of importance and gravity. The danger is from cerebral inflammation, which ensues within a few days, and generally destroys life. This accident can always be recognized by digital compression aided by a probe, particularly if the previous history of the case can be obtained. Treatment. — In fissures and simple fractures without local or general complications, keep the FRACTURES OF CRANIUM. oo5 patient quiet ; give a mild purgative ; and apply cold applications to the seat of injury. Guthrie has wisely remarked that ''injuries of the head affecting the brain are difficult of distincj tion, doubtful* in character, treacherous in their course, and for the most part fatal in their results: " while Macleod declares that, of all the accidents met with in the field, these are the most serious, both directly and indirectly — the must confused in their manifestations and the least determined in their treatment." In the truth of these observa- tions all military Surgeons must agree, since this elass of injuries still constitute the opprobrium of their art notwithstanding the researches and labors o\' its ablest masters. A remarkable disparity presents itself between the injury inflicted and the effects prod need by it. Thus, in many instances wounds, apparently of the most trivial character, are followed by the gravest results : while in other cases, extensive comminu- tion of the bones of the cranium, together with considerable destruction of the cerebral substances itself, produces but an inconsiderable disturbance in the economy. As regards the prognosis in this connexion, the rule is to hope for everything, what- ever the nature ot the injury, but to be confident of nothing, since recovery may follow the gravest accident and death ensue upon the slight- Cunningham relates the case of a boy who lived for twenty four days with the breech of a pistol \\ eighing nine drachms lying on the tentorium and resting against tin' occipital bone. ()'( lallaghan has recorded the case of an officer who lived seven 356 FRACTURES OF CRANIUM. years with the breech of a fowling piece, weighing three ounces, lodged in the forehead and in contact with the brain. Ellerslie Wallace, gives the case of a girl who rapidly recovered without an unto ward symptom, from a wound inflicted by a cir- cular saw, four inches and a quarter in length, by one sixth of an inch in width, extending across the skull, wounding the brain, and dividing the longi- tudinal sinus. Henuen states that he has seen five cases in which bullets were lodged in the brain without proving immediately fatal; and also me - tions an instance in which the bone was depressed in a "funnel shape " to the extent of an inch and a half, without producing an unfavorable symptom. The most remarkable case is that reported by Bigelow, in* which, by the premature explosion of a blast, a tamping-iron, three feet four inches in length, one and a quarter inches in diameter, and weighing thirteen and a quarter pounds, traversed the cranium from the angle of the lower jaw on one side to the centre of the frontal bone above, near the sagittal suture. From this extraordinary lesion the patient recovered, with the loss only of the sight of the injured eye. The effects of an injury inflicted by balls strik- ing the skull will depend upon the following cir- cumstances : 1. Upon the manner in which the ball strikes the skull. "When the direction of the projectile is very oblique, and its force considerably exhausted, the injury inflicted may be only a slight contusion of the soft parts or of the bone. When the force is greater, the scalp may be extensively lacerated FRACTURES OK CRANH M . •'••« and the bone bruised and broken through out its whole extent, or through one oi its tables only, and the cerebral substance beneath considerably in- jured. Under these circumstances concussion is likely to ensue, terminating, it may be, in " en- cephalic inflammation and compression from ef- fusion." Again, a shot which merely grazes the head and "brushes" over the skull, may completely smash the bones of the cranium without injuring the scalp, or by only opening the veins immediately beneath the skull, produce instant death. 2. Upon the character of the ball. — Conieal halls crush through both tables, with great violence, producing orifices of equal seize, comminuting the bone extensively, and carrying the fragments de< p into the substance of the brain. Wound halls, on the contrary, neither produce so"great a destruction of the outer table, nor SO extensive and minute a comminution of the bones. The greater splintering of the inner than of the outer table, which usually occurs in wounds of the head, is explicable by the fact that the latterisbet ter supported by the parts beneath it, and that the momentum ot the ball is necessarily diminished in passing through them. The same principles inter- pret tho difference between the wounds of en- trance and exit in the soft parts, fii this connexion it may be well to sum up the differences by which the wounds of entrance and exit, in the soft parts, can be distinguished. 15b 358 FRACTURES OP CRANIUM. THE WOUND OF ENTRANCE IS : 1. Regular and inverted. 2. White, depressed, and ad- herent to the underlying parts. 3. Characterized by positive loss of substance, and some- times by the presence of foreign substances, as clothing, &c. 4. More disposed to bleed than the wound of exit. THE WOUND OF EXIT IS : 1. Irregular and everted 2. More discolored, but indis tinct and not adherent. 3. Characterized by a flap like tearing, and by no compli- cation of foreign substances, &c. 4. Lees disposed to bleed than the wound of entrance. These differences are by no means constant and invariable. The speed of the ball, the mode of impingement, the nature of the wounded structure^ and the distance at which the gun is fired, exercise a material influence in determining and modifying their character. The great velocity and peculiar motion of coni- cal balls impress upon wounds a character materi- ally different from that caused by round balls. — When the distance is short, and the parts fleshy, there is less laceration of the soft parts ; but " when the range is greater and the part struck bony, the tearing especially at the place of exit is greatly more marked." They, also, may lodge beneath the outer table without penetrating the cranium, or, after striking against a bony angle or projection, split into two fragments,! one entering the skull and the other flying off ; and again, in some instances, they have been known to be deflected from their course, af- 3 Maclcod, in speaking of this subject, refers to the fact that round hulls frequently split, nut remarks that he does not behove that " the conical ball wltn its immense foree of propulsion could he so split." In the, clothes'ofa friend of the author, who was killed at Malvern, one half of a conical hall was found, tin: other half having penetruted the body and produced his death. TRACTURES OF CRANIUM. o59 tor dividing the sculp, and, without fracturing the bones, to make the entire circuit of the head. 3. Upon the part struck. — Wounds of the side of the head, especially anterior to the ear, arc the most dangerous, — thus, a descending scale will givejthe following order: the fore part, thievertex, and the upper part of the occipital region. Wounds of the base of the brain, especially ot the pons and medulla, are necessarily and immediately fatal. When large vessels are divided, especially the sinuses, death takes place as a matter of nece's? siry. 1. rpon the age anil temperament, &c, of the patient. — In the young the same danger is not to be apprehended from injuries of the head as in adults. It can also be readily understood how the tem- perament, and the general surroundings of the suf- ferer exert an influence updn the prognosis, by in- creasing or diminishing the tendency to control inflammation, and assisting or interfering with the proper treatment of the ease. Shell wounds, though comparatively rare, pro- duce the most fearful injuries and speedily termi- nate in death. For all wounds of the scalp, danger from erysip- elas is to be apprehended. btXtiswcs. Macleod reports 680 cases "f mere contusion, with s deaths : 1 35 -cases di fracture with depres- sion, with 7o* deaths: 67 cases of penetration, with 67 deaths ; and in cfcses of perforation with 360 FRACTURES OJF CRANIUM. deaths. Alcock reports 28 cases of fracture with gunshot wounds, with 22 deaths. Mauiere reports 10 penetrating wounds, with 10 deaths. Lente re- ports 128 cases of fracture of the skull, with 106 deaths. Stromyer reports 41 cases of gunshot frac- tures of the skull, with only 7 deaths. Treatment. — The treatment of fractures of the skull has a direct reference either to the existence or to the possible development of the various com- plication, which have just been referred to. The following general plan will be found most availa- ble, if carried out either in part or wholly, according to the necessities of the case. Control the hemorrhage ; remove, at once, all foreign bodies, which can be readily reached — such as balls, spicula?, wadding, dirt, &c. ; wash and bring the edges of the wound gently together ; treat symptoms of compression, if present, by placing the patient in the recumbent position with his head lower than his body, using external stimu- lation, if the pulse fails ; when reaction is establish- ed, or when there are symptoms of compression or inflammation from the start, bleed and purge freely, use cold applications to the head, enjoin perfect rest, give repose to the special senses, as far as practica- ble, enforce the lowest diet ; and, finally, when, all other means have failed, and symptoms of cere- bral compression, inflammation, effusion of blood, or the formation of pus exist to such an extent as to render the diagnosis a matter of no difficulty, re- sort to the trephine and give the patient the last chance for his life. It is true that the weight of authority, so far a* FRACTURES OF CRANIUM. 361 writers on modern Surgery arc concerned, prepon- derates against such an employment of this instru- ment; but, after a due consideration of their argu- ments and statistics, an attentive study of the works of the older masters, and no little personal obser- vation and experience, the advice in regard to this instrument, is freely given with the full assurance of its reliability and propriety in this connexion. In some instances of compound fracture with depres- sion, or with the penetration of a foreign body in- to the substance of the brain, the trephine may ho immediately employed, but this is not the general rule, as has been previously stated. Neither chlo- roform nor ether should be used in this operation for fear of inducing inflammation of the brain. Portions of the skull sliced off" by the sabre or sword should be replaced and secured by wire su- tures, even if they are attached by small shreds of the scalp. In all scalp wounds, however caused, avoid the use of sutures, and guard against the development ot erysipelas. In simple divisions of the scalp, from blows or cuts, the edges of the wound may be readily kept in apposition by crossing the hairs at different points and binding them by means of small shot. Hernia cerebri should be treated in its earlier stages by well condueted, systematic compression. Pressure should be made with a piece of sheet lead, a compress and a roller changed as often as may be necessary to ensure firmness and cleanliness. As the mass recedes, the compress is gradually 362 FRACTURES OF FACIAL BONES. pushed into an osseous opening until it is reduced to the level of the brain. • If by any accident the protrusion has attained to considerable bulk, the proper plan is to exercise all that is accessible or to destroy it with Vienna paste or the actual cautery. Fracture of the Bones of the Face. — The hones of the face which present the greatest importance in this connexion are the malar, the nasal and the upper and lower maxillary. Frmtures of Malar Bone Causes. — Direct violence — such as blows or falls. Symptoms. — Depression of the bone, tilting up- wards of orbital plate, and protrusion of the eye. Treatment. — Push the bone into position by carrying the finger through the mouth into the temporal fossa. Fracture of the Nose. — Causes. — Falls or blows. Symptoms. — Depression of the bone, and inter- ference with nasal breathing, — or lateral devia- tion of the nose. Treatment. — Insert the finger or some suitable instrument and elevate the bone. In lateral de- viations restore the nose to its proper position, and keep it there by means of adhesive strips. iracture of Upper Maxillary Bone. — Causes. — Falls, blows and wounds. Symptoms. — Dispjacenient, deformity, and sepa- ration of the bones. Treatment.. — Mould the bones into shape; save every osseous fragment; and keep parts in appo- sition by means of adhesive plaster. FRACTURES OF LOWER JAW. 363 Fracture of Inferior Mi ciliary Bone — This bone may be fractured tltrough its body, angle or ramus and condyles. Causes. — Direct blows, kicks From horses, sword cuts, bullets, &c. Symptoms. — Fractures of the body are character- ized by displacement, mobility, crepitus and pain. The displacement is greater in proportion as tbe fracture is nearer the symphysis, and less as it ap- proaches the angle. Salivation and swelling of the sub-maxilla rv gland, together with difficulty of speech and deglu- tition are soon developed. A fracture of the ramus may be distinguished by a grating noise at the seat of the injury and great pain about the ear. A fracture ot the neck maybe determined by crepitation in moving the jaw, preternatural mo- bility in front of the ear and the dragging forward of the bone by the external pterygoid muscle. Fracture of the condyle may be readily distin- guished in the same way. In connexion with com- pound fractures of this bone and the bones of the face generally ; hemorrhage, paralysis — from di- vision of the branches of the facial nerve — inflam- mation, and constitutional irritation ; produced by swallowing the secretions from the wound, are likely to occur. Treatment. — In cases of simple fracture, seat the patient upon a chair ; support his head upon the breast of an assistant and let it be firmly held ; pass the fingers along the base of the jaw. or the fractured portion of the bone; mould the parts into proper shape : close the mouth, take care that 3t>4 FRACTURES OF LOWER JAW. the lower teeth rest firmly against the upper; then adapt a piece of paste hoard of* felt wet with hot water to the base and sides of the jaw ; and finally apply either Gibson's or Barton's bandages, so as to press the lower jaw firmly against the other. If the bone be comminuted and the teeth forced from their socket, the latter should be returned, and secured to the sound ones by silver wire. In compound fractures care should be taken to preserve as much of the bone as possible, to keep the fragments in apposition, to arrest hemorrhage by compressing or ligating either the external carotid or the facial artery, to counteract the dis- turbing agency of muscles by compresses, band- ages and adhesive strips, and to see that the secre- tions from the wound are not swallowed. Inflam- mation should be treated \n general principles- Fluid food must be administered for several weeks when semi-solid nourishment may be substituted. Fractures of the Bones of the Trunk. — Frac- ture of the Clavicle.— Causes. — Falls, blows, wounds from sabres, bullets, shells, &c. Varieties. — Eractures of the clavicle may be sim- ple, compound, comminuted, complicated, unilat- eral, bilateral, transverse or oblique. The usual seat of fracture is. at the middle of the bone where it is weakest. Symptoms. — Sunken appearance of the shoulder; shoulder drawn downwards, inwards and forward by the weight of the limb and the action of the deltoid, subclavius and pectorial muscles; inclina tion of head and trunk to affected side; impossi FRACTURES 01 CLAVICLE, 365 bility of rotating the arm by carrying hand to the face ; crepitation, elicited by pushing the shoulder upwards, outwards and backwards ; separation of the fragments, the outer being drawn downwards inwards and forwards, and the inner fragment, slightly upwards by the stern o-cleido-mastoid mus- cle. Ireaiment. — The great indication is to carry the shoulder upwards, outwards and backwards, until the outer fragment reaches the level of the inner fragment, and to retain it there. The reduction of the fracture may be readily accomplished, but retention is more difficult. The simplest and most effectual method of keeping the fragments in ap- position, is to place a pad in the axilla ; to bring the elbow against the antero-lateral aspect of the chest and to place the fore-arm against the front ; to carry the fingers across the opposite clavicle ; and then to apply adhesive strips, reaching around the limb and shoulders, and binding the arm down to the chest. If this is not sufficient the apparatus of Velpeau, Fox, Levis or Dugas may be employed. Compound, comminuted and com- plicated fractures should be treated on general principles, remembering that the great indication is to carry the shoulder upwards, backwards and outwards and to retain it there until union has taken place. Fractures of the Scajmla. — These are of rare oc- currence, especially in civil Surgery. When the (u-romioii process is broken the accident generally produced by violence applied to the upper and outer parts of the should, r. 366 FRADTURES OP SCAPULA. Symptoms. — Tlie shoulder loses its rotundity; the fractured portion is drawn downwards and for* wards by the action of the deltoid muscle ; the fragments rests upon the front and upper part of the head of the humerus ; and the limb is movable ; while the signs ot the accident are effaced when the arm is elevated. Treatment. — The indication is to relax the del- toid muscle by carrying the arm forward across the chest, and by raising the elbow up so that the head of the humerus may press against the acro- mion process. The same apparatus as for frac- tured clavicle may bo used, dispensing with the axillary pad. When the Coracoid process is broken — which i s a rare accident — the fragment is carried inward and downwards, by the conjoined action of the pec- toralis major and the coraco-brachialis muscles. Treatment. — Flex the fore arm and carry the arm forwards across the chest ; place a pad in the axilla; and push the humerus upwards. Retain the arm in position by means of adhesive strips. When the body of the bone is broken, there is no displacement. The bone should be steadied by applying pads and keeping them in position by means of adhesive strips or rollers carried around the chest. Fractures of the Ribs. — Causes. Violence of all kinds, such as falls, blows, gunshot wounds, and muscular action, &c. The central ribs being more exposed are most frequently broken. Symptoms.— Displacement of fragments with crep- itation- such as can be felt with the hands when the FRATURES" OF THE Rl • 367 patient coughs; a peculiar cracking noise follow- ing a deep inspiration ; pain at the seat of injury, increased by the respiratory efforts; spitting of blood, together with pleuritic and pneumonic symptoms, dyspnoea and emphysema, if either fragments or spieuhe have been pushed inwards; andcopiusexteanal hemorrhage when, the intercostal artery has been divided. It not unfrequently hap- pens in compound fractures of the ribs that largo spicuhvof bone are driven deeply into the parenchy- ma of the lungs, causing violent inflammation, he- morrhage, escape of air into the cavity of the: pleura, disappearance of the respiratory murmur unusual resonance, &c, followed either by speedy death or protracted suppuration. Again, a spent ball may impinge with some violence against a rib, not fracturing the bone but seriously implicating the delicate structures beneath it. Ireatmcnt. — In simple fracture without serious displacement, encircle the chest with a broad band- age or strip of adhesive plaster, so that the inter- costal muscles may be put in motion as little as possible in connexion with the respiratory func- tion. If there be outward displacement the same apparatus, with the addition of compresses may be employed. If the displacement be inwards it should not be interfered with, unless complicated by serious symptoms connecting themselves with the lungs or pleura. In such a contingency, after failing to afford relief to the patient by a proper use of pressure and antiphlogistic remedies, the fragment may be raised by mechanical means. H there be dangerous hemorrhage from an iptercos- 368 FRACTURES OF THE RIBS. tal artery it may be compressed against a rib or drawn out and tied. In compound fractures the depressed portions' should be elevated; the spieuhe and foreign bodies removed ; the pain, cough, &c, incident to pul- monary lesious treated with opium administered in large doses ; hemorrhage arrested by copious bleeding from the arm, so as to produce syncope and induce the formation of clots in the divided vessels ; the wound closed as soon as hemorrhage ceases; the patient placed upon the wounded sidej so as to promote adhesion and facilitate the escape of all fluids ; digitalis or veratrum administered to control the circulation ; inflammation treated on general principles; and pus or air evacuated, if it forms in sufficient quantity to embarrass the circu- lation seriously. If there be the serious dyspnoea the bandage should not be applied; and in exam- ining the wound, the finger instead of the probe should be employed, lest the delicate tissue of the lung be more seriously irritated. When inflam- mation of the lung and pleura supervene upon blows which do not fracture the rib, opium should be freely administered, and the symptoms treated on general principles. In penetrating wounds of the lung the danger is primarily from hemorrhage and collaps and secon- darily from inflammation and its products. Dis- tinct plans of treatment are consequently demand- ed at different periods in the history of the case : + In wounds from stabs this rule should be rigidly adhered to, but in gun shot wounds the patient may )>e allowed to assume the poei- tion most agreeable to him. n; VCTUBE8 Ofl THE RIBS. 369 1. The employment of means for arresting the How of blood — such as venesection, opium, &c. 2. The employment of such remedies as arc re- quired to arrest inflammatory reaction, or to guard the system against the deleterious effects of the products of that process. If venesection be attempted, the patient should he placed in the ereel position and a large opening made, so that syncope may he as speedily produced as possible. The question of the propriety of bleed- ing is one which frequently exercises all the judg- ment at the command of the Surgeon, for though venesection is tin remedy when properly employed, it s far from being of universal application. The following circumstances may be regarded as fur- nishing contra-indications to the employment of the lancet in wounds of the lung. 1. "When a considerable time has elapsed after the receipt of the wound, and a large amount of blood has been lost. 2. When the patient is weak and amende in consequeuce of the debilitating influences incident to the regime of camps and hospitals. 3. When the patient has been debilitated by previous disease Or wounds. 4. When the large vessels leading to or from the heart are severed. 5. When the patient has received other wounds of a serious charai 6. When the nervous shock incident to the wound is overwhelming. 7. When the erect posture cannot be borne. 8. When proper subsequent treatment is impos- 370 FRACTURES OF THE RIBS. sible as in hurried marches, hasty retreats, want of the means of transportation, the impossibility of securing reliable and continuous surgical assis- tance, &c. 9. When the patient is manifestly in articulo mortis. Wounds of the lung are far from being so fatal as might be supposed in. advance. Numerous cases have come under my own observation, during the present war, in which rapid recoveries have followed the most severe penetrating wounds of this delicate organ. The experience of Confeder- ate Surgeons will confirm the assertion that unless death speedily results from hemorrhage and col- lapse a favorable prognosis may be formed in a majority of such case, c . STATISTICS. Reported l>y Maclcod, 122 cases. 9S deaths. " Legouest, 6 " 3 " " i Guthrie, 106 " 53 " «| Meniere, 29 " 'J " Fracture of the Pelvis. — Causes. — Great violence and gunshot wounds. Symptoms. — The usual signs of fracture in con- nexion with some serious complication, such as laceration of bladder or rectum, injury to the peri- toneum, division of arteries and veins. Treatment. — Keep the patient in bed and treat the complication on general principles. When the Os-coccygis is broken, the finger should be in- troduced into the rectum and the fragments re- placed. PRADT1 RES OF lir MERUS. ^71 Fractures of the bones op the Superior Ex- tremites. — Fractures of the Humerus. — The Head, anatomical neck, surgical neck, shaft and con- dyles of the Humerus may be fractured. ture of the head.— The head ofthe Humerus is frequently fractured by balls, though this ac- cident from other causes, is very uncommon. If the fracture be compound the fragments can readi- ly be felt with the lingers. The treatment under these circumstances, is resection. Boyer states that there can be no bony union when the fracture is is intra-capsular, and that death is generally the alt. Anatomical w^ck.— Causes.— Falls and hi .•ws.arare accident. — Symptoms. The head can be fell in the glenoid cavity; slight hollow be- low the acromion; axis directed inward-: crepita- ion very faint; and the bones shortened slightly. itmcfit. — A pad in the axilla, splints to the . and a sling to keep the elbow slightly raised. Fracture of the Surgical neck. — Causes. — Falls the hand: direct violence, and muscular ac- •The upper fragment slightly elevat- ed by the muscles attached to the tuberosities; the upper end of lower fragment drawn inwards by latissimu pectoralis major and teres major muscles; humerus thrown obliquely outwards by •id muscl sometimes elevated so as to project beneath and in front of the coracoid treatment. — The Indications arc to counteract the action ofthe opposing muscles and to keep the 372 FRACTURES OF HUMERUS. fragments in position. Draw the arm from the body ; apply four paste board splints on its sides; place a large conical shaped pad with its base up- wards, in the axilla ; approximate the elbow to the side and retain it there by strips of adhesive plaster or a broad roller passed around the chest ; flex the forearm and support it in a sling. Fracture of the Shaft. — Causes. — Falls, violence; muscular contraction, &e. Symptoms. — Deformity, preternatural mobility and crepitus. There is but little shortening, as the weight of the arm counteracts it. If the frac- ture be below the deltoid the inferior fragment will be drawn inwards, but it above that point, out- wards. The limb is powerless and is supported by the patient at the wrist. The fracture may also be compound, complicated or comminuted, the diagnosis being easy in each case. When the fracture occurs just above the condyles the lower fragment is carried backward and upwards by the action of the triceps. Ireatment. — In simple fracture, apply a roller from the fingers to the axilla; adjust either two three or four splints, made of paste board, sole leather or thin wood, to the arm, — one extending from the axilla to within an inch of the condyle, another from the shoulder joint to an inch above the corresponding condyle, a third in front and a. fourth behind; flex the forearm and support in a" sling. Reunion will generally occur in a month. When the fracture is complicated with a division of the artery, ligation in the wound, should be im- mediately resorted to. When the fracture is corn- FRACTURES OF HUMERUS. 373 pound, the patient should be put to bed, and the injured limb supported upon a pillow, the forearm being kept at an obtuse angle with the arm, the elbow on a level with the shoulder, and the hand little higher than the elbow. No bandage should be applied, but support may be given either by wire splints — permitting irrigation — or two lateral wooden splints. The patient must be kept per- fectly quiet, so that the upper fragment may not be disturbed by any movement of the trunk. When the swelling has subsided, and the inflam- mation has been subdued, — the starch bandage may be used with advantage. Fracture of the Condyles. — The causes producing Ibis fracture are the same as those already referred to under previous heads. Symptoms. — The detached condyle can usually be felt with the finger ; crepitus is perceived on bending the arm ; there is pain at the seat of injury with deformity. If the inner condyle be fractured the ulna projects backward, but resumes its natural position when the arm is extended; while the humerus advances in front of the ulna. If the ex- ternal condyle be separated the joint is immovable, the hand remains supine, and there is constant semiflexion of the forearm. r lreatment. — Ooaptate the fragments; retain them in position by means of compresses, and strips of adhesive plaster, applied around the joint in the form of a figure of eight ; apply the angular splint; and support the forearm in a sling. Fractures of the Ulna. — The Olecranon process, 1G 374 FRACTURES OF ULNA. coronoid process and shaft of this bone are liable to be broken. Fracture of the Olecranon. — Causes. — Direct vio- lence, and muscular action. Symptoms. — Semiflexion of the limb ; impossibili- ty of extending the forearm ; a hollow at the back of the elbow; a prominence at the posterier in- ferior surface of the arm; pain, swelling, &c. ; crepitus when the radius is rotated Treatment. — Bring the separated parts into position ; confine them by means of compresses and adhesive strips; apply a wooden splint in front of the joint; and keep the arm extended. Fracture of the Coronoid process. — Causes. — Di- rect injury, as the passage of the wheel of a coach, or force applied to the hand, impelling the ulna and radius violently upwards against the lower ex- tremity of the humerus. Symptoms. — The ulna is carried backwards and upwards; the olecranon is prominent; the limb cannot be flexed; the detached bone can be felt above the elbow; crepitation, pain and swelling, present themselves. Treatment. — Bandage the forearm carefully from the fingers and the upper arm from the shoulder downwards; flex the forearm at a right angle; and enclose the arm in a tin case or angular splints. Adhesive plaster may be carried around the joint so as to keep the fragment in position. Fracture of the Shaft. — Causes. — Direct viol- ence, counter stroke, muscular action, &c. Synvptoms. — A marked depression at the inner border of the forearm, mobility of the fragments, FRACT! RES OF ULNA. 375 crepitation, pain, swelling, and displacement of the lower Fragment. Treatment. — Apply a long splint in front with a compress adjusted so as to preserve the interosse- ous space, and another behind, — both extending from the elbow to the end of the fingers, and wider than the arm; have the forearm in a position mid- way between pronation and supination; let the thumb project as a guide; and then bind the splints to the forearm by means of a roller bandage. Or the hand may be permanently inclined towards the thumb, by .means of two splints the extremities of which arc made somewhat sloping from behind forwards. Fracture of tht Radius. — The superior extremity, shaft and inferior extremity of this bone may be broken. Fracture ;;f Superior Extremity. — Causes. Direct violence. Symptoms. — Deformity below the joint; projec- tion of the upper end of the lower fragment; im- possibility of rotating the forearm; the refusal of the upper fragment to follow the motions of the lower, &c. Treatment. — Place the limb at right angles with the arm in a position midway between pronation and supination, and employ the same splints as for fracture of both bones of the forearm. Fracture of the Shaft. — Causes. — Violence direct or indirect. Symptoms. — The fragments approach the inter- osseous space ; while there is more or less of de- formity, preternatural mobility, absence of thepow- er to pronatc and supinate the army, and crepitus. Treatment. — Precisely the same as for fracture FRACTURES OF RADIUS. oftheulna. When the curved or pistol handlo splints arc used they should bo sloped from before backwai Tin ! tdius and Ulna are frequently fractured together by a direct blow or indirect violence. The fragments arc drawn inwards by the pronator quadratus, tending to destroy the in- readily made by extension from the wrist, and retention is effected by means of spliuts, padded 80 as to preserve the interosaeous id extending from the elbow to "the end of the The splints, should b wider than the arm, and no attempt should be made to I the limb before their application, aid be in tion midway between pronation and supination and the thumb left out to preserve the intero pace and to prevent the upper frag- ment of the radius from being too much supinated. Fracture of low the Radius. — The radius may be broken cither directly at the joint, or an inch and a half above it. The former is known as Barton's and the latter as Colic's fracture. Causes. Violence either direct or indirect. Symptoms, — The lower fragment is drawn up- wards and backwards behind the upper fragment, by the combind action of the supinator longus and the flexors and extensors of the thumb and carpus, producing a prominence on the back of the wrist and a deep depression behind. The upper frag- ment projects forward, and is drawn by the prona- torquadratus in close contact with the ulna, causing a projection on the anterior surface of the forearm FRACTURES OF RADIUS. 3<7 just above the carpus — all the usual signs of frac- ture are also present. Ireatment. — The treatment - in Hexing the forearm, nnd making powerful extension from the wrist and elbow, depressing at the same time the radial side of the hand, and retaining the parts m position by compressing each projecting point and the use of well padded pistol shaped splints- Bond's and Smith's splints are regarded as the best for this fracture. In compound fractures of the forearm, the pa- tient should be put to bed, and the arm placed upon a pillow or in a well padded fracture box. Cold water should be allowed to drip upon it from above. Care should be taken to keep the arm semipronated, to, ensure the parallelism of the bones, and to have the pillow made firm by placing a wide board beneath it. When the swelling and in- flammation have subsided, the arm may be placed in a starch bandage or on a wide splint and sup- ported by a sling, when the patient can walk about. Fracture of the Carpal Bones should be treated on general principles. Fractures of the Metacarpal Bones. — Causes. — Di- rect and indirect blows, gunshot, wounds, &c. Symptoms. — One fragment is elevated above the other. The deformity can be readily reduced but again shows itself when the pressure is removed. Treatment. — Make moderate extension upon the linger corresponding to the broken bone; force the fragments into position ; apply paste board splints to the palm, back oi' the hand and fingers. The splints should be well padded. 378 FRACTURES OF FINGERS. Fractures of the fingers can be readily detected. "When the extreme phalanx is broken, the re- medy is amputation. When the other phalanges are broken, coaptation may be ensured by exten- sion, and the fragments retained in position by means of a splint made of paste board or felt, moulded accurately to either the dorsal or palmar aspect of the finger. Compound fractures should be treated on general principles. Conservative Surgery holds a proud pre-eminence in this con- nexion, and the operator should endeavor to save as much of the member as possible. Fractures of tJte Femur. — This bone may be bro- ken either in its upper extremity, in its shaft or in its inferior extremity. Fracture of the neck, internal to the capsular ligament. Causes. — Direct violence, indirect vio- lence, such as slipping off the edge of a curbstone, gunshot wounds, &c. Symptoms. — Slight shortening of the limb ; ever- sion of the foot from the combined action of the external rotator muscles, together with the psoas, iliacue; preternatural mobility — shown by rotating the limb upon its axis, flexing it upon the pelvi'Bj or extending it behind the line of the sound limb ; change of position in the grent trochanter — being drawn upwards towards the ilium and in close contact with the acetabulum, and also describing a smaller segment when the limb is rotated ; change of attitude — the body is thrown forward ; the sound limb is firmly planted on the floor, the unsound one hangs off in a constrained and awk- ward manner — the foot and knee being everted, - FRACTURES OF FEMUR. 379 the leg is supported upon the ball of the toes, while the heel is elevated two or three inches, the natu- ral prominence of the hip is destroyed, and the patient cannot walk. This accident usually oc- curs in persons of advanced age, because the neck of the bone is more horizontal at that period, and the bone contains more earthly matter. The un- ion between the fragments is always of a fitoro-lig- amentons nature, when it takes place at all. Treatment. — The plan recommended by Sir A.st- ley Cooper, and persue'd by most surgeons, is to keep the patient quietly in bed for two or three weeks and then permit him to walk about on crutches. The long splint such as will be descri- bed in connexion with factiires of the shaft, may also be employed. In compound fractures at this point, resection may be attempted under (he modifications alluded to in another portion of this volume. Fracture at the base of the neck, (extra capsular.) Causes. — Falls upon the hip; blows: falls upon the foot or knee ; gunshot wounds, &c. Symptoms. — Shortening-: eversion of the foot or knee; mobility of the fragments; distinct crepita- tion ; elevation of the trochanter: severe pain; great swelling; considerable shock followed by excessive reaction. Treatment. — Place the limb in the straight posi- tion ; apply splints on either side : and make exten- sion and counter extension according t<> the plans which will be more fully explained when fractures of the slud't are considered. The foot should be inclined slightly outwards to relax the rotator mus- 380 FRACTURES OF FEMUR. cles and great care should be taken to prevent over lapping of the fragments or angular deformi- ty. Continue the dressings for at least five weeks. It is a matter of great moment to distinguish between intra-capsular fracture and iliac disloca- tion and between fracture within and without the capsular ligament. The following signs will es- tablish the diagnosis. INTRA-CAPSULAR FRACTURE. 1. Occurs generally in old persons and most common in women. 2. Produced usually by slight causes. 3. Foot strongly everted. 4. Great shortening, which returns readily after reduction 5. Crepitation. 6. Preternatural mobility. INTRA-CArSULAR FRACTURE. 1. Slight shortening which gradually increases to two inches and upwards. 2. Crepitation indistinct. 3. Function impaired. 4. Trochanter moves on rO' tation, as it were, upon a pivot ILIAC DISLOCATION. 1. Most frequently in adult and middle life — and is com- mon to both 88X68. 2. Produced by great vio- lence. 3. The foot is inverted. 4. Shortening does not re- turn after reduction. 5. No crepitation. 6. The bone is fixed and in a constrained position. EXTRA-CAPSULAR FRACTURES. 1. Shortening is lees but more persistent. 2. Crepitation very distinct. 3. Loss of function complete. 4. The trochanter is only partially separated and imper- fectly obeys the movements of the limb. 5. Pain severe and located near the great trochanter. 6. Severe contusion with considerable swelling, ecchy- mosis and discoloration. In compound fractures from gunshot wounds resection may possibly be resorted to, but the wisest plan is to attempt to save the limb. After much 5. Pain greatest in the direc- tion of the small trochanter. G. But slight swelling, con- tusion or dislocation. FRACTURES OF FEMUR. 381 observation and reflection, I am convinced that the probabilities of a favorable issue, are much in- creased by the rejection of all appliances in the way of inclined planes, extending and counter ex- tending forces, &c. They tend to increase irrita- tion and inflammation, to interfere with water dressings, and the free discharge of pus, and to render the patient more uncomfortable, while they do not secure better results so far as the usefulness and symmetry of the limb arc concerned. Smith's anterior splint may be tried in the premises, but if the case does not progress favorably, all dressings should be removed, and the limb placed on such a position upon pillows as will best secure the com- fort of the patient. The preservation of the suffer- er's life is the great desideratum, while the useful- ness and symmetry of the member arc matters of secondary consideration in this connexion. Fracture of the shaft in its upper third. The most common scat of this fracture is from two and a half to three inches below the trochanter minor. Causes. — Direct or indirect violence, &c. /Symptoms. — The upper fragment is carried for wards by the action of the psoas and lliacus inter- ims, and at the same time everted and drawn out- wards by the external rotator and glutei muscles, causing a marked prominence at the outer side of the thigh and great pain from the laceration oJ the muscles; the lower fragment is drawn upwards, by the rectus, biceps, semi-membranosus and semi- tendinous muscles, whilst its upper end is thrown outwards and its lower end inwards by the pecti- neus and adductor muscles ; crepitation, preterna- 16b 382 FRACTURES OF FEMUR. tural mobility and the ordinary signs of fracture, are also present. Ireatment. — This fracture may be treated, when simple, either by direct relaxation of all the oppo- sing muscles by means of the double inclined plane, or by overcoming the contraction of the muscles by the use of the long splints. Of these two plans of treatment preference should be given to that for relaxing the muscles, which can be most success- fully accomplished by the doubled inclined plane. Mode of procedure. Obtain if possible a- proper bed ; apply a roller from the toes to the groin ; secure two splints made of binder's boards, sof- tened in hot water and nearly meeting in front, to the thigh; lay the limb over the double inclined plane, which should- be well cushioned : attach the foot to the foot board, so as to prevent inversion or eversion of the member ; raise the body slightly so as to relax the psoas and iliacus muscles ; adjust the angle beneath the knee in such a manner as to relax the muscles by which the lower fragment is kept out of position, and to keep the two frag- ments upon the same plane, and in the same line ; bind the limb to the apparatus by means of a roller bandage ; and retain it in positiou either by means of pegs placed on the side, or by side boards so arranged as to form with the splint a kind of trough. By means of Smith's anterior splint the conjoint advantages of relaxation and exten- sion may be secured. This apparatus is nothing more than a double enclined plane made of strong iron wire as long as the limb and applied anteriorly, with cords passing from, the upper and lower cross FRACTURES OF FEMUR. 383 wires and uniting into a common one which passes in an oblique direction to the wall and suspends the limb. The muscles are not only relaxed, as by the ordinnry inclined plane, but all ten den C} 7 to con. traction is obviated by the obliquity of the cord, which acts as the extending force below, and by the weight of the body, which serves as the coun- ter extending force above. The suspension of the limb precludes such displacements as are likely to occur in consequence of the movements of the body, thus securing a much greater latitude in that regard and contributing materially to the comfort of the patient. 1 f (here be trouble in keeping the upper frag- ment in place, a compress or fln additional splint, may be applied above it, so as to force it in posi- tion. Care must be taken not to apply the blind- age too tightly, or to permit the bed clothes to rest upon the limb. In compound fractures of the upper third of the thigh from gunshot wounds, the same principles will apply as enumerated above. The long splint tends to augment both the local and constitutional irritation, while the double euclined plane, and even Smith's apparatus, soon become irksome to the sufterer and tend to interfere with the free escape of pus, by causing it to gravitate towards the body. The better plan is to reject them in the lii>t instance, to place the limb in a comfortable position upon a pillow, to resort at once and per- sistently to the cold water treatment, and to direct, everj energy towards the preservation of the pa tieufs life, reserving tbe question of deformity for 384: FRACTURES OP FEMUR. a later period in the history of the case. An at- tempt should be made to save the limb on account of the extreme fatality of amputations in this lo- cality. Fracture of the middle third. Causes. — Same as last. Symptoms. — The superior fragment overlaps the inferior ; the lower end of the superior fragment is drawn inwards and upwards by the flexor mus- cles ; the limb is shortened from 2 to 4 inches, and everted ; the upper end of the inferior fragment forms a projection on the forepart of the thigh ; while mobility, crepitus, pain and swelling contri- bute their quota to the perfection of the diagnosis. Ireatment. — Numerous plans have been de- vised for the treatment of this fracture, but the following seems to possess the greatest advantages. Directions : lay the perineal band in its place and place four pieces of bandage transversely where the broken thigh is to rest ; over these lay a splint as wide as the diameter of the thigh, well padded, and long enough to reach from the tuberosity of the ischium to the lower margin of the ham ; lay the patient upon the bed, with his thigh reposing upon the back splint and his head and body -slight- ly raised ; make an assistent seize the knee firmly and make moderate traction, so as to steady the limb ; lay long strips of adhesive plaster upon the leg from the knee down, forming loope below, and and secured to the limb by other strips and a roller carried spirally around it, taking care to protect the ankles by small pieces of cotton batting ; apply then a roller from the toes to the ham ; lay the FRACTURES OF FEMUR. 385 long splint on the outside of the limb, extending from four to five inches below the foot either to the crest of the ilium, according to Desault, or to the axilla as suggested by Physick ; adjust the perineal baud, and attach the upper extremitj of the long splint to the body by menus of a band passed around it ; twist the adhesive strips below the foot into a small rope, attach them to the extending screw in the foot piece, and tighten them moderately so that the assistant may release his hold upon the knee ; lay a padded splint upon the inside of the limb extending from the groin to a point immediately below the knee ; apply another splint in front ex- tending front the groin to within one inch of the knee ; bring up the four transverse bands, previ- ously placed under the limb, so as to include the three short splints and the l«ng splint; then carry extension to the utmost point of tolerance ; fill up all the inequalities and insterstices with soft cot- ton ; and complete the dressing by applying a roller bandage over the splints from the foot to the groin. Increase the extension daily for a week, and then maintain it until union is complete. About the twenty eighth day relax the extension, and lift the limb regularly, rubbing and gently Hexing the knee. For two months the patient should walk on crutches and bear but little weight upon the limb. In compound fractures, especially where there is much comminution, but little advantage can be expected from extension with the long splint until the violence of the inflammatory action has subsi- ded ; while the inclined plane is liable to the ob- S86 FRACTURES OF FEMUR. jections which have already been referred to. Gentle extension may be attempted by applying and securing adhesive strips to the leg, then attach- ing a weight to them and suspending it over a pul- ley at the foot of the bed ; but if the case does not progress favorably even this should be discarded and the fracture treated upon the plan suggested in connexion with similar injuries in the upper bird. For statistical information in regard to the treatment of "compound fractures of the femur, see table "I," of the Appendix. Malgaigne declares that in the attempt to save the limb, under these circumstances, no greater risk is run than in amputating it. This is certainly an extreme view of the ease, as is established by the statistics of Stone and Baudens, — who themselves arc advocates of conservative surgery — in connexion with these accidents. The femur has frequently been resec- ted for injuries of this character, but the expedi- ency of this procedure is very questionable. Fracture of the Lower third — immediately above the condyles. Causes, Direct or indirect violence. Symptoms. — The lower fragment may be felt in the popliteal space being drawn back by the gas- trocnemius, soleus and plantaris muscles, and up- wards by the rectus ; the end of the upper fragment is drawn inwards by the pectineous and adductor muscles, and forwards by the psoas and iliaeus; the limb is shortened; while crepitation, pain, swelling, &c., are also present. Treatment. — The indication is to relax the oppos- ing muscles, and approximate the broken frag- FRACTURES. OF FEMUR. 387 raents. This is accomplished by placing the limb upon the double inclined plane. The principal circumstances which demand the attention of the Surgeon in connexion with frac- tures of the shaft of the femur arc : L The ends of the broken bono must be steadily kept upon the same plane and in a line with each other. 2. Care must be taken that no shortening occurs. The extending and counter extending bands should l>e watched and tightened when necessary. 8. The limb, should be placed in a slightly elevated position. 4. It is important to keep as much pressure off the heel as possible in order to prevent sloughing, and ulceration. 5. The perineal band must be carefully watched and care taken to prevent it ironi excoriating the parts beneath. 6. The bandage should not be applied loo speedily, tightly or irregularly, and in compound fractures should be dispensed with. The starch bandage may frequently be employed to great ad- vantage. 7. The bed cloths must be kept oft the fractur- ed limb, lest they disturb the fragments. 8. Passive motion of the neighbouring joints should be undertaken at the end of the twenty eighth day. Fiatiarc of / In Patella. — Causes. — Direct injury, as a fall or blow; indirect violence; and muscular contraction. Symptoms. — In transverse fracture, the upper 388 FRACTURES OF PATELLA. fragment is displaced ; the aspect of the limb is changed ; the limb cannot be extended ; there is some pain, but no crepitation. treatment. — Extend the leg; elevate the foot; bring the fragments together and retain them in apposition by means of adhesive strips; and place the limb upon an inclined plane. Fracture of the libia. — The shaft of the tibia is most frequently broken obliquely at the lower fourth of the bone, by direct or indirect violence. Symptoms. — If the fracture has taken place from above downwards and forwards the fragments ride over one another, the lower fragment being drawn backwards and upwards by the muscles of the calf; while the pointed extremity of the upper fragment projects forwards beneath or through the integu- ment. If the direction of the fracture is the re- verse of this, the pointed extremity of the lower fragment projects forwards, riding over the lower end of the upper one. There is but little crepita- tion, and not much pain. The internal malleolus is most frequently broken off about the centre of that process, in an oblique direction. treatment. — Bend the knee so as to relax the muscles; bring the fragment in apposition; apply adhesive straps from the point of fracture, and form a loop below the foot ; tie a cord to this loop, with a weight attached to it, and pass it over a small wheel at the foot of the bed; when inflam- mation has subsided ; apply the starch bandage and cut off the straps close to the foot. In coin- pound fractures, the same plan may be adopted, taking care to leave the wound uncovered. The FRACTURES OF TIBIA. 389 fracture box, filled with bran may also be employ- ed. An admirable plan is to suspend the leg in a sling reaching from the knee to the foot. The wound should be treated on general principles. Fractures of /he Fibula. — Fractures of the head and shaft of the bone are so readily detected and easily treated that no particular discription is ne- cessary. When the fracture occurs in the inferior fifth of the ,bonc the accident is a more serious one. Causes. Forcible abduction of the foot, such as occurs in falls; and direct violence. Symptoms. — When the fibula alone is broken, there will appear slight eversion of the foot; de- pression at the seat of injury ; and change in the aspect of the joint. When the malleolus is broken off, or when the tibia has given way a short dist- ance above the articulation, the foot seems to be dislocated outwardly; the malleoli are widely se- parated; a deep pression in the line of fracture presents itself; the foot is unusually movable, while its external margin is elevated and its in- ternal depressed; crepitation can be heard; while there is considerable pain, swellingand ecchymosis. Irealment. — The indication is to maintain the foot in a position the reverse of that which is caus" cd by the injury. This is accomplished by Du- puytren's apparatus, which consists of a light wooden splint and a wedged shaped cushion, — the former reaching from the upper third of the leg to about three inches below the sole of the foot, and the latter from the same point to a level with the ankle. Bandage the limb, but do not compress it opposite the site of fracture; stretch the apparatus 390 FRACTURES OF TIBULA. along its inner surface, with the tapering end of the pad upwards ; and secure it first above and then below, carrying the roller around the foot and ankle in such a manner as to turn the internal margin of the foot upwards and inwards. The limb may then be kept extended, or half bent upon a pillow. Attempt passive motion at the end of a week. Both the libia and Fibula may be broken contem- poraneously. If the fracture be transverse, there is no danger of deformity; but if oblique there will be considerable shortening. In oblique fractures, therefore extension and counter extension must be made and persisted in until union has taken place, while the simple fracture box will answer for transverse fractures, provided the great toe is kept constantly on a line with the inner border of the patella. Fractures of the ioot. — The calcaneum may be broken by direct violence. There is always con- siderable contusion and laceration of the soft parts. The signs by which this accident may be determin- ed are a hollow at the heel; a protuberance at the lower and hack part of the leg; and the im- possibility of extending the foot. The fragments should be brought together and a complete relaxa- tion of the muscles of the calf secured, by keeping the leg in a permanently extended condition. In fractures of the other bones there is no displace- ment. Experience teaches that in gunshot wounds of the foot involving a fracture of its bones, there is always danger to lie apprehended, however seeming- ly insignificant the injury. The bones from their FRACTURES OF TARSAL BONES. 391 peculiar conformation, are easily shattered, each fragment becoming the focus of an extensive in- flammation, which speedily produces pus in large qualities. In consequence of the thickness of the fascia 1 , the purulent matter does not readily escape, but burrows in every direction, causing intense pain, and great nervous irritation, and inducing pyaemia with all its frightful consequences. If the ball does not pass entirely through the foot, it should be immediately sought tor, and a counter opening made, if possible, to facilitate the discharge of pus. The endcrmic exhibition of morphia may also be resorted to for the purpose of relieving the pain incident to the wound, of preventing the development of tetanic symptoms, and of securing quietude and sleep to the patient. The foot should be kept in an elevated position until the development of pus, but not longer, and the wound treated on general principles. APPENDIX. 393 & to P-l « CO T 3 ia C3 (N •AUO »— 1 i-H •euopiuadQ CM — < ?C P Si w 2 o a- 'i^'ci •AUG;") i— 1 i—l •SUOU'BJOdQ jo -oji > qo«o f- :^40NI •dl3 U UB[U0JI0 •p.i;ins joy h -p-it'Ii 3TPP!W •d«[j vrepianQ utqq laddfl •pom* lojtf •*M -.nqnsMiQ 3 ft a o S 3 £ w 1-1 H a -< c Pi 3s .". .o r^ ?J ;> •- oo j2 >. £ A -P E\h S2'2«M c?° 1 s 5 ° f c . &| ■r 6 -t! O ^ c -L - APPENDIX. 395 o ■BlflBBp ,,, mn.) .1,1,1 [wjojq j. 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